Every finding on record at Meadow Creek Post-Acute

Based on interview and record review, the facility failed to provide sufficient licensed nursing staff to meet resident needs, as evidenced by the Facility Assessment (a required, facility wide evaluation used to align the specific needs of the resident population with the facility's resources) identifying a required night shift staffing level of one Registered Nurse (RN) and two Licensed Vocational Nurses (LVNs).This deficient practice resulted in enteral (liquid food) feedings being administered late, medications being administered late, and vital signs not being obtained by nursing staff. These failures had the potential to negatively impact residents' health and safety by delaying necessary treatments, monitoring, and identification of changes in condition. Findings:During an interview on 6/11/2026 at 7:11 a.m., with Certified Nurse Assistant (CNA 1), CNA 1 stated her shift was from 6:30 a.m. to 2:30 p.m. She stated she was responsible for nine residents during her shift. CNA 1 stated she felt rushed while providing resident care due to staffing shortages. She stated there were frequent call offs occurring Monday through Sunday on all shifts. CNA 1 stated the residents were high acuity (the measurement of how sick a resident is and the intensity of the nursing care and medical supervision they require) and dependent on staff for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily), incontinence care (personal support provided to residents who cannot control their bladder or bowels), and repositioning. She stated when staff called off, she was assigned ten or more residents.During an interview on 6/11/2026 at 9:39 a.m., with LVN 5, LVN 5 stated she was responsible for 13 residents during her shift. She stated she did not feel able to complete her assignment due to the residents' acuity and the ongoing staff shortages. LVN 5 stated she did not feel she could provide quality care and felt rushed to complete her tasks. She stated the subacute unit ( a specialized care area designed for residents needs of intensive medical, nursing, and rehabilitative support) was short staffed for CNAs, and this occurred daily. LVN 5 stated the staffing shortages caused delays in medication administration, resident assessments, and charting. LVN 5 stated when staffing was inadequate, residents could experience delays in medication administration, delays in repositioning, pain not being addressed in a timely manner, and an increased risk for falls.During a concurrent interview and record review on 6/12/2026 at 7:03 a.m. with the Registered Nurse Supervisor (RNS) 2, the Medication Administration Audit Report dated 6/3/2026 was reviewed, the Medication Administration Audit Report indicated the following:1.Enteral Feed Order Schedule Date: 6/3/2026 11:00 pm/Administration Time indicated- 6/4/2026 1:05 a.m.2.Check blood sugar order schedule: 6/3/2026 11:00 pm/ Administration Time indicated- 6/4/2026 1:04 a.m.3.Enteral Feed Order Schedule Date: 6/3/2026/Administration Time indicated- 6/4/2026 2:41 a.m.4.Oxygen: Monitor oxygen (O2) Saturation (measures blood oxygen level) every shift: Schedule Date: 6/3/2026 11:00 p.m./ Oxygen monitoring indicated 6/4/2026 2:44 amThe RNS acknowledged the enteral feedings, glucose monitoring, and oxygen saturation monitoring were completed late during on 6/3/2026 11 p.m. to 7 a.m., shift. The RNS stated the delays occurred due to the staffing shortage and the number of residents assigned during the shift.The RNS 2 stated she was assigned to the night shift and she works from 11:00 pm to 7:00 am. The RNS 2 stated she was the only licensed nurse assigned to the skilled nursing facility (SNF) during her shift. The RNS 2 stated there were no Licensed Vocational Nurses (LVN's) scheduled for the night shift and stated this staffing pattern has been in place since September 2024. The RNS 2 stated she was informed by the Administrator that this was how the staffing would be assigned. The RNS 2 stated she was not aware of the facility assessment identified the need for one RN and two LVN's for the night shift. The RNS 2 stated she did not notify management regarding the absence of LVN coverage because the facility was not assigning LVN's to the night shift. The RNS 2 stated she was responsible for 47 residents on 6/3/2026, and was responsible for medication administration, enteral feeding administration, blood glucose monitoring, obtaining vital signs, and monitoring residents for changes in condition. The RNS 2 stated she was responsible for approximately 14 residents receiving gastrostomy tube (G tube, a flexible tube inserted through the abdominal wall into the stomach and used to deliver hydration, medications, and nutrition) feeding, and six blood glucose checks during the shift. The RNS 2 stated she was unable to complete all required nursing duties during the shift. The RNS 2 stated at times she was unable to obtain resident's vital signs, medications were administered late, and enteral feedings were administered late. The RNS 2 stated the delays in medication administration and enteral feeding administration were due to the staffing level and the number of residents assigned to her. The RNS 2 stated management was not notified regarding the delayed medication administration or enteral feeding administration and could not explain why management was not notified. The RNS 2 stated the staffing shortage affected her ability to monitor resident. The RNS 2 stated she believes resident's needs were not adequately met during the night shift due to the staffing level and acuity of the residents. The RNS 2 stated inadequate staffing could result in blood glucose abnormalities not being identified timely, inability to monitor residents for changes in condition, pain not being addressed timely, and delayed medication administration. During a concurrent interview and record review on 6/12/2026 at 11:06 a.m., with the Director of Nursing (DON), reviewed the facility's Facility assessment dated [DATE]. The Facility Assessment indicated that the skilled nursing facility (SNF) required one RN and two LVNs for each night shift. The DON acknowledged the Facility Assessment identified the need for one RN and two LVNs. She stated that on 6/3/2026, during the night shift, only one RN was assigned to the SNF. The DON stated she was aware only one RN had worked that night and that no LVNs were scheduled. The DON stated the facility had not evaluated whether resident care would be affected by having only one RN available on the night shift. She stated the medication administration records had not been reviewed to determine whether medication passes were delayed and she was unaware if medications had been administered late because she had not reviewed the records. The DON stated she was also unaware whether treatments or assessments had been delayed because the facility had not evaluated the impact of the reduced staffing. She stated delays may have occurred due to the staffing shortage and believed the absence of the two LVNs contributed to these delays. The DON stated the facility should have provided the two LVNs identified in the Facility Assessment to ensure resident safety, timely medication administration, timely enteral feeding administration, and completion of required monitoring, including vital signs. She stated no safeguards had been implemented to protect residents during the staffing shortage on the night shift and staffing shortages could result in unmet resident care needs and reduced quality of care.During an interview on 6/12/2026 at 1:00 p.m., with the Administrator (ADM), ADM stated the facility decided to staff the night shift with only one Registered Nurse (RN) beginning in September 2025. The ADM stated the facility did not complete an assessment or evaluation before reducing licensed nursing coverage on the night shift. He stated he was unaware that the Facility Assessment identified the need for one RN and two Licensed Vocational Nurses (LVNs) for the night shift. The ADM stated he was unaware that medications and enteral feedings were being administered late during the night shift. He stated the facility had not evaluated the impact of having only one RN assigned on the night shift on resident care needs, including medication administration, enteral feeding administration, monitoring, and other required nursing services. The ADM was unable to provide evidence of any assessment, evaluation, or safeguards implemented to ensure resident needs continued to be met following the reduction in licensed nursing staff coverage.During a review of the facility's policy and procedure (P&P) titled, Facility Assessment, dated 2017, the P&P indicated, A facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day operations. Determining our capacity to meet the needs of and care for our residents during emergencies is included in this assessment.During a review of the facility's P&P titled Staffing, Sufficient and Competent Nursing, dated 2022, the P&P indicated Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment.

Based on observation, interview, and record review, the facility failed to ensure three of five sampled residents (Resident 35, 55 and 68 ) were free of unnecessary physical restraints (any object or device that an individual cannot remove easily which restricts freedom of movement) by failing to:1.Ensure on-going assessment and reevaluation of restraints' continuous use were conducted and documented.2.Ensure less restrictive measures were attempted prior to initiating hand mitten (soft, padded hand covers designed to prevent patients from removing medical equipment) restraints.3.Follow Physician orders to apply the peek-a-boo mitten ( a convenient mesh or cloth inspection flap, that caregivers to quickly check a resident's circulation and skin without having to remove the entire mitten) not a closed mitten restraint.4.Ensure the peek-a-boo mitten manufacturer guidelines were followed.5.Follow the facility's policy and procedure (P&P) titled, Use of Restraints, to ensure the restraint order had an end date.These failures had the potential to place Resident 35, 55 and 68 at risk for unnecessary prolonged use of restraints , impaired blood circulation, skin injuries and entrapment (an event in which a patient is caught, trapped, or entangled).Findings:During a review of Resident 35's admission Record, the admission Record indicated Resident 35 was admitted to the facility on [DATE] with diagnoses including schizophrenia (a long-term brain disorder that affects a person's ability to think clearly, manage emotions, make decisions, and relate to others) and epilepsy (a brain disorder that causes a person to have repeated, unexpected seizures). During a review of Resident 35's Minimum Data Set (MDS- a resident assessment tool) dated 4/27/2026, the MDS indicated Resident 35's cognition (ability to think, understand, learn, and remember) was severely impaired. The MDS indicated Resident 35 was dependent (helper does all the effort) on activities of daily living (ADLs- routine activities such as bathing, dressing, and toileting a person performs daily to care for themselves).During a review Resident 55's admission Record, the admission Record indicated Resident 55 was admitted to the facility on [DATE] with diagnoses including hypertension (HTN- high blood pressure) and quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury).During a review of Resident 55's MDS dated [DATE], the MDS indicated Resident 55's cognition was severely impaired. The MDS indicated Resident 55 was dependent on ADLs.During a review of Resident 68 admission Record, the admission Record indicated Resident 68 was admitted to the facility on [DATE] with diagnoses including HTN and quadriplegia.During a review of Resident 68's MDS dated [DATE], the MDS indicated Resident 68's cognition was severely impaired. The MDS indicated Resident 68 was dependent on ADLs.During an observation on 6/9/2026 at 9:28 a.m., in Resident 55's room, Resident 55 was observed to have a left closed hand mitten restraint.During an observation on 6/9/2026 at 9:28 a.m., in Resident 55's room, Resident 55 was observed to have a left closed hand mitten restraint.During an observation on 6/9/2026 at 10:20 a.m.,, in Resident 35's room Resident 35 was observed to have bilateral (two sides) closed hand mitten restraints.During an interview on 6/11/2026 at 9:42 a.m., with Certified Nurse Assistant (CNA 5), CNA 5 stated when a resident was in restraints, he released the restraints for 15 minutes every two hours but had no place to document that this was done. CNA 5 stated there should be a place to document the two hour restraint releases, so nurses were aware they were being done.During a concurrent interview and record review on 6/11/2026 at 10:16 a.m., with Licensed Vocational Nurse (LVN 7), restraint orders and documentation for Residents 35, 55, and 68 were reviewed. LVN 7 stated there was no documentation from the CNAs indicating the restraints were released every two hours for 15 minutes. She stated the CNAs informed her when they released the restraints, and she would document it herself. LVN 7 stated the restraint orders for Residents 35, 55, and 68 did not contain end dates and there was no documentation showing that least restrictive measures had been attempted before applying the restraints. She stated staff should attempt using a sitter (one to one supervision and observation) before applying restraints.During a concurrent observation and interview on 6/12/2026 at 11:31 a.m., with the Director of Nursing (DON), the DON stated the facility did not use restraints but used peek a boo mittens, which did not enclose the entire hand and allowed the fingers to remain free. The surveyors accompanied the DON to observe the mittens being used for Residents 35, 55, and 68 and showed her that the mittens could fully wrap around the residents' hands. The DON stated she had been unaware the mittens could be used in this manner. She stated the CNAs and licensed nurses released the mittens every two hours for 15 minutes, but the CNAs did not document the releases. The DON stated that if it was not documented, it was not done.The Use of Restraints policy and procedure was reviewed with the DON. The policy stated there should be an end date for hand mitten restraints to ensure reassessment of continued need. The DON stated the facility had not attempted least restrictive measures before applying the mittens, but should have, because the mittens limited movement, could be uncomfortable, and placed residents at risk for psychological distress. The DON stated the restraints for Residents 35, 55, and 68 were used improperly.During a review of the Medline Safety Check Hand Mitts Instruction Sheet, revised 6/23/2020, provided by the DON, the Instruction Sheet indicated, All other least restrictive options must be exhausted prior to restraint application. During a review of the facility's policy and procedure (P&P) titled, Use of Restraints, revised 4/2017, the P&P indicated, When the use of restraints is indicated, the lease restrictive alternatives will be used for the least amount of time necessary. The P&P indicated, Examples of devices that are/may be considered physical restraints include hand mitts. The P&P indicated, Restraint order shall include the type of restraint, and period of time for the use of the restraint.

Based on interview and record review, the facility failed to ensure the following for two of four sampled residents (Resident 35 and Resident 83), including:1.Failed to develop a comprehensive person-center care plan to address Resident 35's restraints.2.Failed to develop a comprehensive person-center care plan for Resident 83's communication.These failures had the potential to negatively affect the delivery of care and services to Residents 35 and 83.Findings:During a review of Resident 35's admission Record, the admission Record indicated Resident 35 was admitted to the facility on [DATE] with diagnoses including schizophrenia (a long-term brain disorder that affects a person's ability to think clearly, manage emotions, make decisions, and relate to others) and epilepsy (a brain disorder that causes a person to have repeated, unexpected seizures).During a review of Resident 35's Minimum Data Set (MDS- a resident assessment tool) dated 4/27/2026, the MDS indicated Resident 35's cognition (ability to think, understand, learn, and remember) was severely impaired. The MDS indicated Resident 35 was dependent (helper does all the effort) on activities of daily living (ADLs- routine activities such as bathing, dressing, and toileting a person performs daily to care for themselves).During a review of Resident 83's admission Record, the admission Record indicated Resident 83 was admitted to the facility on [DATE] with diagnoses including legal blindness, hearing loss, and mutism (inability to speak).During a review of Resident 83's MDS dated [DATE], the MDS indicated Resident 83's cognition was severely impaired. The MDS indicated Resident 83 was dependent on ADLs.During a concurrent interview and record review on 6/12/2026 at 10:15 a.m., with Licensed Vocational Nurse (LVN) 6, reviewed Resident 83's care plan titled Communication Deficit, initiated on 2/26/2026, related to the resident being blind, deaf (inability to hear), and mute (inability to speak). The care plan indicated interventions to monitoring the effectiveness of communication strategies and assistive devices. LVN 6 stated Resident 83 communicated by using sign language (a visual communication system that expresses meaning through hand gestures, facial expressions, and body language rather than spoken words). LVN 6 stated she did not understand everything he communicated. LVN 6 stated she traced words on Resident 83's hands, but not all staff knew how to do this. LVN 6 stated the staff were not following the care plan intervention to monitor the effectiveness of communication strategies.During a subsequent concurrent interview and record review on 6/12/2026 at 10:34 a.m., with LVN 6, reviewed Resident 35's care plan titled Bilateral Hand Mittens, initiated on 3/12/2026, related to the resident pulling life sustaining tubes. The care plan interventions included providing Resident 35 with daily opportunities for restraint free time and physical activity. LVN 6 stated this intervention was not being implemented and the only time Resident 35's restraints were released was every two hours for 15 minutes.During an interview on 6/12/2026 at 12:19 p.m., with the Director of Nursing (DON), the DON stated a care plan was an individualized plan for the resident's care and the interventions were to be followed. The DON stated if staff reported the interventions were not being implemented, then they were not being implemented. The DON stated Resident 83's intervention to monitor the effectiveness of communication strategies was not appropriate because the staff did not know sign language.During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 3/2022, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Based on observation, interview and record review, the facility failed to ensure dependent residents' received timely and appropriate assistance with activities of daily living (ADL- routine activities such as bathing, dressing, and toileting a person performs daily) care by failing to:1.Ensure four of five sampled residents (Resident 4, Resident 19, Resident 27, and Resident 42) fingernails were trimmed and free from accumulation of unknown substance underneath their fingernails.This failure resulted in Resident 4, Resident 19, Resident 27, and Resident 42 fingernails having irregular edges, accumulation of dark brown substances under the fingernails and had the potential to cause infection and impaired skin integrity.2.Ensure one of three sampled residents (Resident 58) was provided with a shower twice a week.This failure resulted in Resident 58 feeling unclean and neglected.3. Ensure Resident 11 received incontinent care in a timely manner.This failure placed Resident 11 at risk for loss of dignity, discomfort, skin irritation, moisture-associated skin damage ([MASD] is an inflammation and erosion of the skin caused by prolonged exposure to moisture), infection, and decreased quality of life. Findings: During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility 7/12/2023 with diagnoses including dementia (a progressive state of decline in mental abilities) and hypertension (HTN- high blood pressure). During a review of Resident 4's Minimum Data Set (MDS- a resident assessment tool) dated 4/21/2026, the MDS indicated Resident 4's cognition (ability to think, understand, learn, and remember) was severely impaired. The MDS indicated Resident 4 was dependent (helper does all the work) on ADLs. During a review of Resident 19's admission Record, the admission Record indicated Resident 19 was admitted to the facility 1/20/2026 with diagnoses including dementia and metabolic encephalopathy (brain dysfunction caused by a chemical imbalance in the body). During a review of Resident 19's MDS dated [DATE], the MDS indicated Resident 19's cognition was severely impaired. The MDS indicated Resident 19 was dependent on ADLs. During a review of Resident 27's admission Record, the admission Record indicated Resident 27 was admitted to the facility 6/6/2025 with diagnoses including cerebral infarction (loss of blood to part of the brain) and HTN. During a review of Resident 27's MDS dated [DATE], the MDS indicated Resident 27's cognition was severely impaired. The MDS indicated Resident 27 was dependent on ADLs. During a review of Resident 42's admission Record, the admission Record indicated Resident 42 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) and anoxic brain damage (happens when your brain does not get oxygen). During a review of Resident 42's MDS dated [DATE], the MDS indicated Resident 42's cognition was severely impaired. The MDS indicated Resident 42 was dependent on ADLs. During a review of Resident 58's admission Record, the admission Record indicated Resident 58 was admitted to the facility on [DATE] with diagnoses including quadriplegia (paralysis from the neck down, including legs and arms, usually due to a spinal cord injury) and attention deficit disorder (ADD- not being able to focus). During a review of Resident 58's MDS dated [DATE], the MDS indicated Resident 58's cognition was intact. The MDS indicated Resident 58 was dependent on ADLs. During an interview on 6/9/2026 at 11:38 a.m., with Resident 58, Resident 58, stated she was supposed to receive two showers a week but does not always get the second one. 1.During a concurrent observation and interview on 6/9/2026 at 2:51 p.m., with Certified Nurse Assistant (CNA) 3, CNA 3 stated the CNAs were responsible for cleaning and trimming resident fingernails. CNA 3 stated it was important to keep the residents' fingernails clean and trimmed to prevent bacteria from building up under their fingernails and prevent the residents from scratching themselves which could lead to wounds. CNA 3 stated Resident 4, 19, 27, and 42's fingernails were long and dirty and should have been cut and cleaned by the CNAs. CNA 3 stated CNAs document whether the residents' fingernails were clean and trimmed on a shower sheet in the shower binder at each nurse's station. During an interview on 6/11/2026 at 8:12 a.m., with the Infection Prevention Nurse (IPN), IPN stated it was important for the residents to have clean and trimmed fingernails because if not it can cause infection if they scratch themselves, having long fingernails can harbor bacteria, and it can affect the resident's dignity. 2.During a subsequent interview on 6/12/2026 at 8:22 a.m., with Resident 58, Resident 58 stated in the last few weeks, she has not been receiving showers regularly and it makes her feel dirty and disgusting. During a concurrent interview and record review on 6/12/2026 at 10:26 a.m., with Licensed Vocational Nurse (LVN) 6, the shower sheets for Resident 58 was reviewed. LVN 6 stated residents should receive eight showers a month, twice a week, and Resident 58 only received three showers for the month of May. LVN 6 stated not showering twice a week could result in Resident 58 feeling sad, upset, dirty, and as her needs were not being met. During a concurrent interview and record review on 6/12/2026 at 12:19 p.m., with the Director of Nursing (DON), the DON stated CNAs were responsible for trimming and cleaning resident fingernails, but any license nurse can do it. The DON stated residents should be showered twice a week. The DON stated having dirty, long fingernails and not receiving showers regularly could affect the residents' dignity because it was their right to receive care. The DON stated having long dirty fingernails could potentially lead to a resident scratching themselves. 3.During a review of Resident 11's admission Record dated 9/3/2025, the admission Record indicated Resident 11 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 11 with a diagnoses including contractures (a permanent tightening of muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) of the bilateral (both) shoulder, anxiety (emotion characterized by feelings of tension, worried thoughts ), dementia (loss of memory, language, problem-solving and other thinking abilities), and Alzheimer's ( an irreversible, progressive brain disorder that slowly destroys memory and thinking skills ). During a review of Resident 11's Care Plan titled Impaired physical functioning and ADL self-care deficit related to the following disease process/medical condition dated 8/2023, the Care plan indicated intervention to keep resident clean and dry. During a review of Resident 11's Care Plan titled Resident has bladder incontinence related to dementia at risk for skin breakdown dated 2/27/2024, the Care Plan indicated interventions including check the resident as required for incontinence, wash, rinse, and dry perineum and change clothing as necessary after incontinence episodes. During a review of Resident 11's History and Physical (H&P) dated 9/4/2025, the H&P indicated, Resident 11 does not have the capacity to understand and make decisions. During a review of Resident 11's MDS dated [DATE], the MDS indicated Resident 11 required substantial/moderated assistance (helper does more than half the effort) for toileting hygiene and was dependent (helper does all the effort) for shower/bathing. During a concurrent observation and interview on 6/11/2026 at 7:11 a.m., with CNA 1, observed Resident 11 in bed wearing an incontinence brief (diaper) containing urine and feces. CNA 1 stated she had begun her shift at 6:30 a.m. and completed rounds at the beginning of her shift to check residents' needs. She stated that, at the time of the observation, she had not yet completed rounds on Resident 11. She could not explain why she had not completed rounds or assessed Resident 11 for incontinent care needs. She stated Resident 11 was depended on staff for ADLs and wore incontinent briefs. She acknowledged the brief appeared to have been soiled for a prolonged period of time and stated, Honestly, the resident should not have been left this way. CNA 1 stated dependent residents required staff assistance with ADLs and incontinent care, and staff were expected to monitor residents and provide care in a timely manner. She stated the facility expected staff to round on residents every two hours and as needed. She further stated that leaving residents soiled for prolonged periods could result in skin irritation, pain, pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure on the skin), and decreased dignity. During an interview on 6/11/2026 at 10:05 a.m., with CNA 2, CNA 2 stated he worked the 10:30 p.m. to 6:30 a.m. shift. He stated Resident 11 was depended on staff for care, including toileting and repositioning. He stated he completed rounds on his assigned residents at the beginning of his shift, every two hours, and as needed. He stated he last provided incontinent care for Resident 11 on 6/11/2026 at 4:00 a.m. He stated residents who experienced prolonged exposure to urine and feces could develop skin damage and pressure ulcers. During an interview on 6/11/2026 at 11:04 a.m., with LVN 4, LVN 4 stated he communicated with the CNAs at the beginning of each shift regarding residents' care needs, including residents who dependent on staff for ADLs and incontinent care. LVN 4 stated he conducted rounds, monitored residents' conditions, and followed up with CNAs to ensure completion of resident care. He stated dependent residents should be checked every two hours and as needed to provide prompt incontinent care that maintains comfort, dignity, and skin integrity. He stated that if a dependent resident remained soiled and incontinent care was not provided timely, the resident could experience skin irritation, MASD, pressure injuries, infection, discomfort, odor, and loss of dignity. LVN 4 further stated delayed ADL and incontinent care could negatively affect the resident's physical well being, comfort, and quality of life. During an interview on 6/12/2026 at 9:53 a.m., with the Director of Nursing (DON), the DON stated she identified residents who required extensive or total assistance with ADLs through shift huddles and shift reports. She stated CNAs were expected to check residents for incontinence every two hours and as needed, and to provide incontinent care when required. She stated the facility did not have an auditing or monitoring process specifically to ensure residents were not left soiled. She stated that when staff found a resident soiled, they were expected to respond immediately and provide incontinent care. The DON stated the expectation for a resident who was dependent on staff for ADL care was the resident received timely and appropriate assistance, including prompt incontinent care, to maintain hygiene, dignity, comfort, and prevent potential complications such as skin breakdown. During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADL), Supporting, revised 3/2018, the P&P indicated, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). The P&P indicated, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. During a review of the facility's P&P titled, Dignity, revised 2/2021, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.

Based on observation, interview, and record review, the facility failed to ensure staff were trained and competent to meet communication needs for one of three sampled resident (Resident 83).These failures had the potential for the facility not be able to assess the skills necessary to provide nursing services to assure resident safety and to attain or maintain the highest practicable physical, mental, and psychosocial well-being of Resident 83. Findings:During a review of Resident 83's admission Record, the admission Record indicated Resident 83 was admitted to the facility on [DATE] with diagnoses including legal blindness, hearing loss, and mutism (inability to speak).During a review of Resident 83's Care Plan titled Communication Deficit related to being blind, deaf, and mute, initiated 2/26/2026, the care plan indicated Resident 83 had goals to maintain his current level of communication by making sounds and sign language (a visual communication system that expresses meaning through hand gestures, facial expressions, and body language rather than spoken words). The care plan interventions indicated effective strategies such as touch and sign language.During a review of Resident 83's Minimum Data Set (MDS-resident assessment tool) dated 5/18/2026, the MDS indicated Resident 83's cognition (ability to think, understand, learn, and remember) was severely impaired. The MDS indicated Resident 83 was dependent (helper does all the effort) on activities of daily living (ADLs- routine activities such as bathing, dressing, and toileting a person performs daily to care for themselves).During an interview on 6/9/2026 at 10:04 a.m., with Family Member (FM 1), FM 1 stated she was not sure how the staff communicated with Resident 83. FM 1 stated none of the staff had ever asked her how to properly communicate with Resident 83 or brought someone in who could communicate with him.During an interview on 6/11/2026 at 8:03 a.m., with Certified Nurse Assistant (CNA) 4, CNA 4 stated it was difficult to communicate with Resident 83 and that it would have been better for Resident 83 if staff knew how to communicate with him more effectively. CNA 4 stated not being able to properly communicate with Resident 83 could have caused him to feel frustrated.During an interview on 6/11/2026 at 9:13 a.m., with CNA 3, CNA 3 stated the staff had not received training on how to properly communicate with Resident 83. CNA 3 stated it would have been helpful for the staff to receive training because not being able to communicate with Resident 83 could have caused him to feel frustrated when his needs were not being met.During an interview on 6/11/2026 at 4:22 p.m., with the Director of Staff Development (DSD), DSD stated she had begun in-servicing the staff on how to communicate with Resident 83. The DSD stated not being able to communicate with Resident 83 could have caused him to feel that his needs were not being met.During an interview on 6/12/2026 at 7:41 a.m., with Registered Nurse Supervisor (RNS) 2, RNS 2 stated she had learned on her own how to communicate with Resident 83 because the staff had not been educated on how to communicate with him, as he could not hear, speak, or see. RNS 2 stated not being able to communicate with Resident 83 had been frustrating for both the staff and Resident 83, and it would have been helpful to learn how to better communicate with Resident 83.During an interview on 6/12/2026 at 12:19 p.m., with the Director of Nursing (DON), the DON stated the staff should have been educated on how to communicate with Resident 83 because it was important for the resident's care, safety, and dignity. The DON stated the facility was now educating the staff on how to competently communicate with Resident 83 by the DSD.During a review of the facility's policy and procedure (P&P) titled, Dignity, revised 2/2021, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The P&P indicated, The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values, and beliefs. Cross reference F676

Based on interview and record review the facility failed to implement infection control policies and procedures (P&P) when:a. The facility failed to educate and offer the annual influenza ([Flu] highly contagious respiratory infection) vaccine (medications used to prevent diseases usually given by injection or by mouth) to 59 out of 59 licensed practitioners (individual who is licensed or otherwise authorized by a state to provide health care services).b. The facility failed to implement the water management plan (plan that identifies hazardous conditions and steps to take to minimize the growth and spread of bacteria[germs]) thereby affecting 89 out of 89 residents.These failures had the potential to result in staff and residents contracting infectious diseases which can cause serious illness, hospitalization, and death.Findings:a. During a concurrent interview and record review on 6/9/2026 at 12:41 p.m., with the Infection Prevention Nurse (IPN), the facility's 2025-2026 Influenza and COVID-19 Vaccine Tracking Sheet for all staff was reviewed. The IPN stated there was no documented evidence for licensed practitioners' education on benefits and side effects was provided and the offering of 2025 to 2026 Flu vaccine. The IPN stated the roster did not include licensed practitioners and it should include everyone that has direct access to the residents.During a concurrent interview and record review with the IPN on 6/9/2026 at 12:41 p.m., the County of Los Angeles Department of Public Health Order of the Health Officer (HOO), Annual Immunization or masking requirement for healthcare personnel during Respiratory Virus season, revised 10/16/2025 was reviewed. The IPN stated the HOO defined healthcare personnel to include licensed care practitioners, all paid and unpaid employees, contractors, students, volunteers, and emergency services personnel who have direct patient contact or work in the patient care areas.During a review of the facility's P&P titled, Influenza Vaccine, reviewed 10/2022, the P&P indicated all employees will be provided with information regarding the requirement to receive the annual flu vaccine.b. During an interview on 6/9/2026 at 1:14 p.m., with the Maintenance Supervisor (MS), the MS stated he measures water temperatures and at the same time flushes it, quarterly the ice machine was maintained by a third-party company, and there were no other tasks regarding the water management plan. The MS stated there was no documentation of evidence of Water Management Plan implementation or logs.During a concurrent interview and record review on 6/9/2026 at 1:21 p.m. with the IPN, the facility's Water Management Program Water Safety Plan 2026 was reviewed. The IPN confirmed the Plan had tasks and procedures that were not implemented. The IPN stated there was no documented evidence of the performance of tasks outlined in detail in the Water Management Plan.During an interview on 6/9/2026 at 3:27 p.m. with the Director of Nursing (DON), the DON stated licensed practitioners need to be educated and offered the current flu vaccine for resident safety. The DON stated the facility needs to follow water management plan for resident safety.During a review of the facility's Water Management Program Water Safety Plan 2026, the plan indicated: 1. Specific control measures and procedures (actions implemented to eliminate or minimize risks) were provided in the plan.2. All Standard Operating procedures and Protocols were also developed in detail.3. A task planning chart was provided that summarizes control tasks throughout the year. Log sheets/ Verification Forms were provided to help document performance of tasks.4. The plan indicated preventative measures and steps to be performed routinely.

Based on interview and record review the facility failed to educate and offer the 2025 to 2026 COVID-19 ((highly contagious respiratory disease caused by Coronavirus which is transmitted thru coughing, talking, sneezing and touching contaminated surfaces) vaccine (biological preparation to help your body build resistance to specific, harmful diseases) to fifty-nine out of fifty-nine licensed practitioners (individual who is licensed or otherwise authorized by a state to provide health care services).This failure had the potential to result in staff and residents contracting COVID-19 which can cause serious illness, hospitalization, and death.Findings: During a concurrent interview and record review on 6/9/2026 at 12:41 p.m. with the Infection Prevention Nurse (IPN), the facility's 2025-2026 Influenza and COVID-19 Vaccine Tracking Sheet for All Staff' was reviewed. The IPN stated there was no documented evidence licensed practitioners received education on the benefits and side effects of the vaccines or that the 2025-2026 COVID-19 booster vaccine had been offered. The IPN stated the roster did not include physicians and should have included everyone who had direct access to residents.During an interview on 6/9/2026 at 3:27 p.m. with the Director of Nursing (DON), the DON stated licensed practitioners need to be educated and offered the current COVID-19 booster for resident safety.During a review of the facility's Policy and Procedure (P&P) titled, COVID-19 Vaccine, revised 6/22/2022, the P&P indicated all will be provided with information regarding the requirement to receive the COVID vaccine.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 83) was provided an effective means of communication.This failure placed Resident 83 at risk for psychosocial isolation and unmet needs.Findings:During a review of Resident 83's admission Record, the admission Record indicated Resident 83 was admitted to the facility on [DATE] with diagnoses including legal blindness, hearing loss, and mutism (inability to speak).During a review of Resident 83's Minimum Data Set (MDS-resident assessment tool) dated 5/18/2026, the MDS indicated Resident 83's cognition (ability to think, understand, learn, and remember) was severely impaired. The MDS indicated Resident 83 was dependent (helper does all the effort) on activities of daily living (ADLs- routine activities such as bathing, dressing, and toileting a person performs daily to care for themselves).During an interview on 6/9/2026 at 10:04 a.m., with Family Member (FM 1), FM 1 stated she was not sure how the staff communicated with Resident 83. FM 1 stated none of the staff had ever asked her how to properly communicate with Resident 83 or brought someone in who could communicate with him.During an interview on 6/11/2026 at 8:03 a.m., with Certified Nurse Assistant (CNA) 4, CNA 4 stated it is difficult to communicate with Resident 83, and it would be better for Resident 83 if they knew how to better communicate with him. CNA 4 stated not being able to properly communicate with Resident 83 could cause Resident 83 to feel frustrated.During an interview on 6/11/2026 at 9:13 a.m., with CNA 3, CNA 3 stated the staff had not received training on how to properly communicate with Resident 83. CNA 3 stated it would have been helpful for the staff to receive training because not being able to communicate with Resident 83 could have caused him to feel frustrated when his needs were not met.During an interview on 6/11/2026 at 4:22 p.m., with the Director of Staff Development (DSD), DSD stated she had begun in-servicing the staff on how to communicate with Resident 83. The DSD stated not being able to communicate with Resident 83 could have caused him to feel that his needs were not being met.During a concurrent interview and record review on 6/12/2026 at 10:15 a.m., with Licensed Vocational Nurse (LVN) 6, Resident 83' Care Plan titled, Communication Deficit, related to Resident 83 being blind (inability to see), deaf (inability to hear), and mute (inability to speak), initiated 2/26/2026 was reviewed. Resident 83's care plan interventions included monitoring effectiveness of communication strategies and assistive devices. LVN 6 stated Resident 83 communicates by using sign language (a visual communication system that expresses meaning through hand gestures, facial expressions, and body language rather than spoken words) because he was deaf, blind, and mute. LVN 6 stated she does not understand everything Resident 83 communicates to her in sign language. LVN 6 stated she traces words on Resident 83's hands but not everyone knows how to do this.During an interview on 6/12/2026 at 7:41 a.m., with Registered Nurse Supervisor (RNS) 2, RNS 2 stated she had learned on her own how to communicate with Resident 83 because the staff had not been educated on how to communicate with him, as he could not hear, speak, or see. RNS 2 stated not being able to communicate with Resident 83 had been frustrating for both the staff and Resident 83, and it would have been helpful to learn how to better communicate with Resident 83.During an interview on 6/12/2026 at 12:19 p.m., with the Director of Nursing (DON), the DON stated the staff should have been educated on how to communicate with Resident 83 because it was important for the resident's care, safety, and dignity. The DON stated the facility was now educating the staff on how to competently communicate with Resident 83 by the DSD.During a review of the facility's P&P titled, Dignity, revised 2/2021, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The P&P indicated, The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values, and beliefs.Cross reference F726

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 1) received pain medication after reporting a pain level of 5 out of 10 on the pain scale (0 indicating no pain and 10 indicating the worst pain imaginable).This failure resulted in Resident 1 experiencing an increased pain level of 10 out of 10 on the pain scale, and waiting one hour before receiving pain medication.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses of but not limited to atherosclerosis (the buildup of fats, cholesterol and other substances in and on the artery walls) of both legs, claudication (a symptom of muscle pain, cramping, or fatigue typically in the legs) of both legs, type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and neuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet).During a review of Resident 1's History and Physical (H&P), dated 5/26/2026, 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 5/29/2026, the MDS indicated Resident 1 was dependent (helper does all of the effort) on nursing staff for toileting, showering, and dressing. The MDS indicated Resident 1 needed substantial to maximal assistance ( helper does more than half the effort) with oral hygiene and personal hygiene. The MDS indicated Resident 1 needed partial to moderate assistance ( helper does less than half the effort) with sitting up and lying down.During a review of Resident 1's Order Summary, the Order Summary indicated Resident 1 had a physician's order from 6/8/2026 to 6/10/2026 for Hydrocodone-Acetaminophen (a strong prescription combination medication used to manage moderate to severe pain) 5 milligram (mg-uit of measurement) /325 mg, to be administered one tablet through the gastrostomy tube (GT- a soft tube surgically inserted directly into the stomach to administer medication, fluids, and nutrition) every four to six hours for moderate pain rated 4 to 6 and for severe pain rated 7 to 10.During an observation on 6/09/2026 at 10:52 a.m., Resident 1 was lying in bed with necrotic ( dead tissue) left toes wrapped in a gauze dressing. Resident 1 told Licensed Vocational Nurse (LVN) 5, I have pain 5 out of 10 in my left toes. LVN 5 told Resident 1 his pain medication was not due for another hour and offered him an ice pack. Resident 1 declined the ice pack.During a concurrent interview and record review on 6/11/2026 at 2:27 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's Medication Administration Record (MAR) dated 6/2026 was reviewed. The MAR indicated Resident 1 received Hydrocodone/Acetaminophen 5/325 mg on 6/9/2026 at 12:20 p.m. for a reported pain level of 10 out of 10. LVN 1 stated the last time Resident 1 received pain medication before that dose was at 6:15 a.m. on 6/9/2026. LVN 1 stated LVN 5 was supposed to contact the physician to obtain an order allowing an earlier dose of pain medication. LVN 1 stated there was no documentation in Resident 1's record showing the physician was informed of Resident 1's reported pain level of 5. LVN 1 stated Resident 1 would experience increased discomfort, abnormal vital signs (including changes in temperature, blood pressure, pulse, and respiratory rate), and an elevated respiratory rate. LVN 1 stated this could affect pain management because Resident 1's pain level increased from 5 to 10 by the time the scheduled pain medication was due.During an interview on 6/11/2026 at 5:07 p.m. with the Director of Nursing (DON), the DON stated LVN 5 should have assessed the resident and called the physician to report the resident had a pain level of 5 out of 10 and the pain medication was not due for another hour. The DON stated the resident could experience a change of condition or distress, and pain management would be affected if the resident's pain was not relieved.During a review of the facility's policy and procedure (P&P), titled Pain Management, date revised 3/2025, the P&P indicated The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain .If pain has not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated.

Based on observation, interview, and record review, the facility failed to ensure nursing staff administered the correct medication dose as ordered for one of three sampled residents (Resident 41). Resident 41 had a physician's order for Zinc Sulfate (a dietary supplement to replenish an essential element, Zinc) 220 milligrams (mg, unit to measure dose), one tablet daily. Resident 41 was administered four tablets of Zinc 50 mg instead. (One tablet of Zinc Sulfate 220 mg contains 50 mg of elemental zinc.)This deficient practice created the potential for a medication error that could negatively impact the resident's health condition.Findings:During a review Resident 41's admission Record, the admission Record indicated Resident 41 was originally admitted to the facility on [DATE] and recently readmitted on [DATE]. Resident 41's admitting diagnoses included, but not limited to acute post-hemorrhagic (after an internal bleeding event) anemia (low of red blood cells), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (high blood pressure), gastrostomy (a surgical opening through the skin of the abdomen to the stomach), and severe protein-calorie malnutrition (inadequate intake of protein and calories). During an observation on 6/11/2026 at 9:47 a.m., Licensed Vocational Nurse (LVN 3) was observed outside Resident 41's room preparing medications for administration. LVN 3 prepared fifteen (15) medications for Resident 41, including four (4) tablets of Zinc 50 mg. LVN 3 crushed the four zinc tablets and administered them via the resident's gastrostomy tube (G tube, a flexible tube inserted through the abdominal wall into the stomach and used to deliver hydration, medications, and nutrition to individuals who cannot safely consume adequate calories by mouth). During a review of Resident 41's Order Summary dated 6/10/2026 at 8:40 a.m., the order indicated to administer Zinc sulfate 220 mg enterally ( per G-tube) one capsule daily for supplement. LVN 3 gave four tablets of Zinc 50 mg, which equals 200 mg. During an interview and record review on 6/11/2026 at 1:23 p.m., with LVN 3, Resident 41's Order Summary was reviewed. LVN 3 stated she administered four Zinc sulfate 50 mg, which was not the correct dose. During an interview on 6/11/2026 at 3:10 p.m., with LVN 3, LVN 3 stated she was not aware that each Zinc Sulfate 220 mg dose contained 50 mg of elemental zinc. She stated she should have clarified the order when she had a question.During an interview on 6/11/2026 at 3:41 p.m., with the Director of Nursing (DON), the DON stated the drug information indicated Zinc Sulfate 220 mg was equivalent to 50 mg of elemental zinc. The DON stated the facility notified Resident 41's physician, who ordered monitoring of the resident's zinc level and monitoring for potential side effects, since the resident had received four times the prescribed dose (four Zinc 50 mg tablets). The DON stated the possible side effects included nausea and stomach upset. The DON stated nurses should have consulted a supervisor whenever they had a question about a medication order.During a review of the facility policy and procedures (P&P) titled, Administering Medications (revised April 2019), the P&P indicated medications are administered in accordance with prescriber orders. The policy also indicated individual administering medications checks the label three times to verify the right medication and right dosage before giving the medication.

Based on interview and record review, the facility failed to ensure a Licensed Vocational Nurse (LVN 2) did not administer Norco (hydrocodone/acetaminophen, a narcotic pain medication) to one of one sampled residents (Resident 28) when the resident's assessed pain level was 3 out of 10 level on a pain scale rating from zero to ten (pain screening tool using numerical value to assess the level of pain ranging from 0 to 3-mild pain, from 4 to 6- moderate pain, and from 7 to 9-severe pain, and 10- the worse pain possible) and did not meet the criteria established in the pain medication order.This deficient practice had the potential for significant medication errors and/or medication overdose, which could worsen the resident's health condition. Findings:During a review of Resident 28's admission Record, the admission Record indicated Resident 28 was admitted to the facility on [DATE] with diagnoses, including but not limited to hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body), gastrostomy (a surgical opening through the skin of the abdomen to the stomach), and acute respiratory failure with hypoxia (a life-threatening condition where the lungs cannot adequately supply oxygen to the bloodstream).During a review of Resident 28's Physician Order, the order indicated hydrocodone/APAP (Norco) 5/325 milligram (mg-unit of measurement) dated 3/22/2026, give one tablet via gastrostomy tube (G tube, a flexible tube inserted through the abdominal wall into the stomach and used to deliver hydration, medications, and nutrition every six hours as needed for moderate pain ( scores 4-6) and severe pain (7-10).During a concurrent interview and record review on 6/10/2026 at 3:03 p.m., with Licensed Vocational Nurse (LVN 1), Resident 28's electronic Medication Administration Record (eMAR)was reviewed. LVN 1 stated Resident 28 received one dose of Norco on 6/10/2026 at 7 a.m., and that the documented pain level at the time was 3.During a concurrent interview and record review on 6/10/2026 at 3:05 p.m., with LVN 2, Resident 28's pain assessment was reviewed, the record showed a total score of 3: the resident demonstrated facial grimacing (facial expression of discomfort) ( score 2) and tense body language (score 1). LVN 2 stated Resident 28 was non verbal and the resident's pain level was assessed using the Pain Assessment in Advanced Dementia ([PAINAD] a 5-item observational tool used to evaluate pain in patients who cannot verbally communicate ) Scale. LVN 2 stated the PAINAD section in the electronic health record allowed nurses to select the appropriate descriptions of the resident's physical behaviors, each corresponding to a score of 1 or 2, and the system automatically totaled the score.During an interview on 6/10/2026 at 3:08 p.m., with LVN 1, LVN 1 stated Resident 28's documented pain level on 6/10/2026 for the morning dose was 3, which was below the parameter, or pain level criteria, established in the order; therefore, the resident should not have received the Norco. LVN 1 stated a pain score of 1 to 3 reflected mild pain, not moderate or severe pain.During a concurrent interview and record review on 6/10/2026 at 3:18 p.m., with the Director of Nursing (DON), Resident 28's eMAR was reviewed. The DON stated Resident 28 received one dose of Norco on 6/9/2026 with a documented pain level of 2, and one dose of Norco on 6/10/2026 with a documented pain level of 3. The DON stated nurses should not administer the medication when the resident's pain level does not meet the pain level required by the physician's order. During an interview on 6/11/2026 at 3:54 p.m., with DON, the DON stated administering a higher dose of a narcotic than needed could increase the resident's risk of addiction and lead to adverse effects.During a review of the facility policy and procedures (P&P) titled, Administering Medications (revised April 2019), the P&P indicated medications are administered in accordance with prescriber orders.

Based on observations, interviews, and record reviews, the facility failed to store one of forty residents (Resident 66) frozen meals in a freezer set at zero (0) degrees Fahrenheit ( F-unit of measurement) or below and the facility failed to ensure food items in the residents' refrigerator were labeled with the residents' names and not expired.These failures had the potential to result deterioration of food quality changes in texture, and loss of nutrient. Using expired food items increases the risk of bacterial growth which can cause foodborne illness (illness cause by food contaminated with bacteria, viruses, parasites, or toxins) such as nausea, vomiting (throwing up), and diarrhea (loose stool).Findings: During a review of Resident 66's admission Record, the admission Record indicated Resident 66 was admitted to the facility on [DATE] with a diagnosis including end stage renal disease (ESRD - irreversible kidney damage), type 2 diabetes (disorder characterized by difficulty in blood sugar control and poor wound healing) , severe protein calorie malnutrition (condition caused by extreme lack of both protein and calories in the diet).During a review of Resident 66's Minimum Data Set ([MDS] a resident assessment tool), dated 4/23/2026, the MDS indicated Resident 66's cognition (ability to think, understand, learn, and remember) was intact. The MDS indicated Resident 66 independently eats. During a review of Resident 66's Physician Order, dated 11/27/2025 at 2:17 p.m., indicated a Regular diet.During a concurrent observation and interview on 6/09/2026 at 9:40 a.m. with Licensed Vocational Nurse (LVN) 1, in the staff lounge, it was observed and LVN 1 confirmed the following observations in the residents refrigerator: a. freezer temperature was 10 F and there were food items that belonged to Resident 66 (frozen meals)b. opened, half used Perrier bottle with no resident name and no open date.c. used and unlabeled cup which was dirty and stained with red color in the cup d. texas hot sauce bottle with no resident namee. ketchup bottle with no resident name and expired on 4/28/2026f. mustard bottle with no resident name and expired 2025g. second mustard bottle expired 8/13/2025During an interview on 6/9/2026 at 9:58 a.m. with the Infection Preventionist Nurse (IPN), the IPN stated staff needed to store residents' food at the correct temperatures. The IPN stated staff needed to ensure there were no dirty items or expired food in the residents' refrigerators. The IPN stated food items needed to be labeled with the residents' names. The IPN stated these practices helped prevent the growth of food borne bacteria. During an interview on 6/9/2026 at 3:27 p.m., with the Director of Nursing (DON), the DON stated the freezer temperature needed to be 0 F or below, so food would not spoil. The DON stated expired foods need to be discarded to prevent food poisoning.During a review of the facility's policy and procedure (P&P) titled, Procedure for Refrigerated Storage, 2023. the P&P indicated the freezer temperature should be 0 degrees Fahrenheit or lower. During a review of the facility's P&P titled Food brought by Family/ Visitors, revised 3/2022, the P&P indicated the nursing staff will discard perishable foods on or before use by date. The P&P indicated the containers will be labeled with the resident's name and use by date.

Based on observation, interview and record review the facility failed to ensure one of one sampled resident (Resident 6) received respiratory tracheostomy (a surgical procedure that creates an opening in the neck and directly into the windpipe [trachea])suctioning (a critical medical procedure used to clear the trachea and lower airway of mucus, saliva, blood, or vomit when a person cannot cough effectively) every two hours as order.This failure had the potential to lead to Resident 6 experiencing respiratory distress (medical emergency characterized by difficulty breathing and low oxygen levels).Findings:During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses of but not limited to acute respiratory failure, aphasia (a disorder that makes it difficult to speak), type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), transient ischemic attack (a temporary blockage of blood flow to the brain) and pressure ulcer/injury Stage IV (wound that penetrate all layers of skin exposing muscles, tendons [tissue that unites a muscle with a bone] cartilage {tissue that lines a joint}, and bones caused by prolonged pressure on the skin)During a review of Resident 6's History and Physical (H&P), dated 5/16/2026, the H&P indicated Resident 6 had fluctuating capacity to understand and make decisions.During a review of Resident 6's Minimum Data Set (MDS- a resident assessment tool), dated 6/1/2026, the MDS indicated Resident 6 was dependent (helper does all the effort) on nursing staff for oral hygiene, toileting, showering, dressing, rolling from left to right and transferring. The MDS indicated Resident 6 received respiratory therapy, oxygen therapy, suctioning, and tracheostomy care. During a review of Resident 6's Order Summary, the Order Summary dated 5/15/2026 indicated for respiratory tracheostomy suctioning for airway clearance (therapies used to loosen and mobilize thick, sticky mucus from the lungs) as needed every two hours.During an observation on 6/09/2026 at 10:07 a.m. in Resident 6's room, Resident 6 lay in bed with a tracheostomy tube (a curved plastic or metal catheter inserted into a surgically created opening in the windpipe) in place. Resident 6 exhibited loud, audible lung sounds, was coughing, and appeared flushed with red skin coloration.During an observation on 6/9/2026 at 10:11 a.m., with Licensed Vocational Nurse (LVN) 8 knocked on Resident 6's door, entered the room, looked at Resident 6, and then walked out. At the time of the observation, Resident 6 laying on his left side and was coughing.During an observation on 6/9/2026 at 10:19 a.m., with Certified Nursing Assistant (CNA) 5, CNA 5 entered Resident 6's room and told Resident 6 We will fix you up.During an observation on 6/9/2026 at 10:26 a.m., with Certified Nursing Assistant (CNA) 5 donned a gown and gloves and stated he would clean Resident 6. CNA 5 closed the curtains, and Resident 6 continued to cough with audible lung sounds.During an observation on 6/9/2026 at 10:31 a.m., the wound care nurse was at Resident 6's bedside preparing to perform a dressing change.During an interview on 6/11/2026 at 3:45 p.m. with the Respiratory Therapist (RT), the RT stated his responsibilities included managing residents' airways, providing tracheostomy care, and suctioning the residents every two hours.During a concurrent interview and record review on 6/11/2026 at 3:57 p.m. with the Respiratory Therapist (RT), Resident 1's Medication Administration Audit Report, dated 6/11/2026, was reviewed. The Medication Administration Audit Report showed that Resident 6 was scheduled for tracheostomy suctioning on 6/9/2026 at 10:00 a.m. and did not receive suctioning until 12:22 p.m., over two hours later. The RT stated residents were suctioned every two hours around the clock and the registered nurse supervisors could also perform suctioning. The RT stated nursing staff were expected to inform him of any audible lung sounds, visible coughing, redness, cyanosis (a bluish or purplish discoloration of the skin, lips, or nail beds), or any signs of respiratory distress. The RT acknowledged that he did not suction the resident at 10:00 a.m. and did not perform suctioning until 12:22 p.m.During an interview on 6/11/2026 at 5:06 p.m. with the Director of Nursing (DON), the DON stated it was unsafe for a resident to miss being suctioned because the resident could experience respiratory distress. The DON stated residents needed to be suctioned to keep their airways clear.During a review of the facility's policy and procedure (P&P), titled Suctioning the Lower Airway (Endotracheal [ET] or Tracheostomy Tube), date revised 10/2010, the P&P indicated, The purpose of this procedure is to remove secretions, maintain a patent airway, and prevent infection of the lower respiratory tract.During a review of the facility's P&P titled, Job description Respiratory Therapist, dated 1/2010, the P&P indicated, .Performs chest physical therapy treatments involving percussion, postural drainage (technique that uses gravity to clear mucus from the lungs), and suctioning, in order to mobilize secretions and mucus in the lungs and to clear airway blockage in the respiratory system.

Based on observation, interview, and record review, the facility failed to date food brought in from an outside source and placed in a refrigerator used to keep residents' food for one out of three residents (Resident 1). This deficient practice resulted in the inability to determine the date Resident 1's food was placed in the refrigerator had the potential to cause Resident 1 food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food, as well as toxins).Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 had a diagnosis including metabolic encephalopathy (brain dysfunction resulting from a disruption in the body's chemical processes). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 5/16/2026, the MDS indicated Resident 1 had severe cognitive impairment (memory and thinking problems). The MDS indicated Resident 1 was not assessed for the ability to perform toileting hygiene due to medical conditions or safety concerns.During an observation of a refrigerator used to store resident's food, located in the employee lounge, on 5/31/2026 at 9:26 a.m., a bag of food was found inside the residents' refrigerator. The bag of food was labeled with Resident 1's name but without a date. Inside the bag there were multiple undated food items: five containers of soup, cheese in a zip lock bag, and a macaroni dish. During an interview on 5/31/2026 at 9:42 a.m., the Infection Preventionist Nurse (IPN) stated residents' food stored in the residents' refrigerator should be labeled with the resident's name and date it was placed in the refrigerator to prevent food borne illnesses, and food left longer than three days should be thrown away. During a review of the facility's Policy and Procedure (P/P) titled Food Brought by Family/Visitors dated 3/2022. The P/P indicated food brought by family/visitors will be labeled with the resident's name, the item, and use by date.

Based on observation, interview and record review, the facility failed to ensure the door to the front entrance of the facility was secured after business hours (7:30 p.m. - 8 a.m.) This deficient practice resulted in the door to the front entrance of the facility being left open and unlocked by wedging a surgical mask between the door and the door frame, disabling the door's locking mechanism. This deficient practice placed residents' who resided in the facility at risk for acts of theft and harm by unauthorized individuals entering the facility and elopement (resident leaves facility without supervision).Findings: On 5/31/2026 at 6 a.m., upon entering the facility to conduct a complaint investigation, the front door to the entrance to the facility was observed with a surgical mask wedged between the door and the door frame, used to keep the door open by not allowing the locking mechanism to engage. There was no one observed monitoring the entrance to the facility. During a review of the facility's undated list of Residents Who Wander Around the Facility, the list of Residents Who Wander Around the Facility indicated two Residents were listed. During a review of the facilities Census dated 5/30/26 at 6:04 a.m., the Census indicated there were 88 residents who resided in the facility. During an interview on 5/31/2026 at 6:15 a.m., the Registered Nurse Supervisor (RNS) stated the front door should be locked after 7:30 p.m., and opened at 8 a.m. The RNS stated everyone's safety was at risk when the front door was not locked, anyone off the street could walk into the facility. During an interview on 5/31/2026 at 7:51 a.m., the housekeeper stated the front entrance was left open with a surgical mask because it was easier for staff in the morning to get into the facility. The housekeeper stated it was not safe for anyone in the facility when the front entrance was not locked because anyone could walk into the facility. During an interview 5/31/2026 at 12:57 p.m., the Administrator (ADM), stated the facility's front door should be locked after hours (7:30 p.m. - 8 a.m.) to ensure everyone's safety inside the facility. The front door's lock should not have been disabled by placing a surgical mask between the door and the door frame. The ADM stated a resident could elope, and people who were not authorized to enter the facility could enter the building without knowledge of the facility staff. During a review of the facility's Policy and Procedure (P&P) titled Safety and Supervision of Residents dated 7/2017, the P&P indicated he facility strives to make the environment as free from accident hazards as possible. 1. The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly. 2. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment.

Based on interview, and record review, the facility failed ensure a physician for one of three sampled residents (Resident 1) responded to facility staff phone calls or contacted the facility's Medical Director when Resident 1 reported symptoms of pain and burning during urination As a result of this deficient practice, Resident 1's evaluation, diagnosis, and treatment were delayed. This deficient practice placed Resident 1 at risk for worsening symptoms/infections and had the potential to turn into sepsis (a life-threatening response to an infection).Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 had a diagnosis of a urinary tract infection ([UTI] an infection in the bladder/urinary tract). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 5/16/2026, the MDS indicated Resident 1 had severe cognitive impairment (memory and thinking problems). The MDS indicated Resident 1 was not assessed for the ability to perform toileting hygiene due to medical conditions or safety concerns. During a review of Resident 1's SBAR ([situation, background, assessment, recommendation] a communication tool used by healthcare workers when there is a change of condition among the residents) dated 5/26/2026 and timed at 7 p.m., the SBAR indicated Resident 1 reported pain and burning during urination. The SBAR indicated the physician was notified on 5/26/2026 at 10:53 p.m. During a review of Resident 1's Alert Charting, dated 5/27/2026 and timed at 1:45 a.m., and 3:30 p.m., the Alert Charting indicated Resident 1 was still waiting for orders (for UTI) this was endorsed to the next shift for follow up. During a review of Resident 1's Physician's Orders, dated 5/27/2026 and timed at 3:55 p.m., the Physician's Orders indicated to collect urine for a urinalysis (a laboratory test that examines the physical, chemical, and microscopic properties of urine), and culture and sensitivity ([C&S] a laboratory test that grows bacteria or fungi from a patient's sample to identify the specific germ causing an infection and determine which antibiotics or medications will effectively treat it) with a straight catheter (a thin, flexible, hollow tube inserted into the bladder through the urethra to drain urine) as indicated. During a review of Resident 1's Nurses Notes, dated 5/28/2026 and timed at 12:58 p.m., the Nurses Notes indicated the facility received a call from the laboratory (lab) indicating Resident 1's UA/C&S required recollection due to incomplete labeling. During a review of Resident 1's Lab Results Report, dated 5/29/2026, the Lab Results Report indicated another UA/C&S was collected on 5/29/2026 at 12:06 a.m. During a review of Resident 1's Physician's Orders, dated 5/29/2026 and timed at 6:45 a.m., the Physician's Orders indicated to give Resident 1 Cephalexin (an antibiotic, closely related to penicillin, an allergic reaction to penicillin could trigger a reaction to Keflex) oral capsule 500 milligrams ([mg] metric unit of measurement, used for medication dosage and/or amount) three times a day for UTI symptoms x five days. During a review of Resident 1's Nurses Notes, dated 5/29/2026 and timed at 7:40 a.m., the Nurses Notes indicated Resident 1 was allergic to penicillin ([PCN] an antibiotic). Resident 1's physician was notified, Cephalexin was discontinued and endorsed to the next shift for an alternative medication. During a review of Resident 1's Lab Results Report, dated 5/29/2026 and timed at 10:03 a.m., the Lab Results Report indicated Resident 1 was positive for leukocytes (specialized cells of the immune system that protect the body from infections, diseases, and foreign invaders) and bacteria in the urine. During a review of Resident 1's Physician's Orders, dated 5/29/2026 and timed at 10:48 a.m., the Physician's Orders indicated to give Resident 1 Macrobid (an antibiotic) oral capsule 100 mg twice a day for UTI symptoms x five days. During a review of Resident 1's Medication Administration Record (MAR), dated 5/2026, the MAR indicated Resident 1 received her first dose of Macrobid oral capsule 100 mg on 5/29/2026 at 5 p.m. (2 days and 22 hours after symptoms of burning and urination were first reported on 5/26/2026 at 7 p.m.). During an interview on 5/29/2026 at 10:18 a.m., Licensed Vocational Nurse (LVN) 1 stated on 5/26/2026 at 7 p.m., during the medication pass, Resident 1 complained of burning and pain when she urinated. LVN 1 stated she called Resident 1's physician in the evening (5/26/2026) and in the morning (5/27/2026) but he did not respond. LVN 1 stated she endorsed Resident 1's complaint to the 11 p.m. to 7 a.m. shift. LVN 1 stated she did not know to call the Medical Director.During an interview on 5/29/2026 at 12:37 p.m., Registered Nurse (RN) 1 stated on 5/27/2026 she called Resident 1's physician via phone and then she texted him, but the physician did not respond until 3:55 p.m., after her third attempt. The physician instructed her to collect Resident 1's urine for a UA/C&S. RN 1 stated she tried to collect urine from Resident 1 but she refused. RN 1 stated she received a call from the pharmacy on 5/29/2026 at 7:30 a.m., stating Resident 1 was allergic to Cephalexin and to notify Resident 1's physician. RN 1 stated she notified the physician of Resident 1's allergy to PCN and obtained a new order for Macrobid 100 mg capsule twice daily. During an interview on 5/29/2026 at 1:40 p.m., the Director of Nursing (DON) stated when the physician did not respond to the nurses calls following one to three attempts within an hour, they should have contacted the Medical Director. The DON stated a delay in treating Resident 1's UTI placed her at risk of becoming septic and 24 hours was a reasonable expectation to begin treatment. During a review of the facility's Policy and Procedure (P/P) titled Acute Condition Changes dated 3/2018, the P/P indicated the nursing staff will contact the physician based on the urgency of the situation and the attending physician or practitioner will respond in a timely manner to notification of problems or changes in condition and status. The nursing staff will contact the medical director for additional guidance and consultation if they do not receive a timely or appropriate response.

Based on interview, and record review, the facility failed to administer medication as prescribed by a physician for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1 receiving medication prescribed for a 9 a.m., administration time, but it was not administered until 10:32 a.m. This deficient practice had the potential to cause a delayed therapeutic effect.Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnoses including cord compression (occurs when pressure is applied to the spinal cord [a long tube-like bundle of nerve tissue that extends from the brain stem down to the lower back], blocking the nerve signals between the brain and the rest of the body), cervical disc disorder (a group of conditions affecting the cushioning discs between the vertebrae [one of the bones that make up the spinal column] in the neck) with myelopathy (an injury, inflammation, or dysfunction of the spinal cord), and hypertension ([HTN] high blood pressure). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 5/10/2026, the MDS indicated Resident 1 was cognitively intact (had the ability to think and reason). During a review of Resident 1's Physician's Orders dated 5/17/2026, the Physician's Orders indicated the following: 1. Epclusa (medication used to treat chronic Hepatitis C [a bloodborne viral infections that causes liver inflammation and damage]) 400-100 milligrams ([mg] metric unit of measurement, used for medication dosage and/or amount), one tablet one time a day at 9 a.m., for hepatitis. 2. Theophylline (medication used to prevent and treat wheezing shortness of breath and chest tightness caused by lung diseases like asthma, chronic bronchitis, and emphysema), ER (extended release) 200 mg, one tablet one time a day at 9 a.m., for lung disease. 3. Baclofen (a muscle relaxant) 10 mg, 1 tablet three times a day, at 9 a.m., 1 p.m., and 5 p.m. 4. Losartan Potassium (used to treat HTN) 50 mg, one time a day for HTN. During a review of Resident 1's Medication Administration Audit Report (MAAR) dated 5/17/2026, the MAAR indicated Resident 1 received the following medications at 10:32 a.m., instead of 9 a.m., as prescribed. 1. Epclusa 400-100 mg2. Theophylline ER 200 mg3. Baclofen 10 mg4. Losartan Potassium 50 mg During an interview on 5/26/2026 at 10:25 a.m., Licensed Vocational Nurse (LVN) 1 stated medications were to be administered one hour before or one hour after their scheduled time, and if a medication could not be given on time, the physician should be notified for a late administration order. During an interview on 5/26/2026 at 10:47 a.m., with the Director of Nursing (DON), and a concurrent review of Resident 1's MAAR, the MAAR indicated Epclusa, Theophylline, Baclofen and Losartan Potassium were administered to Resident 1 on 5/17/2026 at 10:32 a.m. The DON stated medications can be administered one hour before or one hour after the scheduled time, LVN 2 administered Resident 1's 9 a.m., medications late. The DON stated if a medication was anticipated to be late, the physician must be called for a late medication order to prevent a subtherapeutic (ineffective dose to treat a disease or condition) or a toxic dose (an amount that can cause adverse or dangerous side effects). During review of facility's P/P titled Administering Medications dated 4/2019, the P/P indicated medications are to be administered within 1 hour of their prescribed time.

Based on interview and record review, the facility failed to ensure Registered Nurse (RN) 1 accurately documented a prescribed treatment for one of three sampled residents (Resident 1) on the Medication Administration Record ([MAR] a daily documentation record used by a licensed nurse to document medications and treatments) when she irrigated (flush out medical device with fluid) Resident 1's indwelling catheter (thin, flexible, hollow tube inserted into the bladder to drain urine, typically into a collecting bag) with normal saline ([NS] a solution of salt and water) on 2/15/2026. This failure resulted in incomplete and inaccurate documentation for Resident 1, which prevented the facility from determining the amount of irrigating solution instilled through the indwelling catheter and verifying the corresponding drainage output relative to urine output. This failure had the potential to negatively impact Resident 1's health and non-continuity of care. Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnoses including aphasia (a disorder that makes it difficult to speak), respiratory failure (serious condition where the lungs cannot properly supply oxygen to the blood) and neuromuscular dysfunction (lack of bladder control caused by damage to the nerves, spinal cord, or brain) of the bladder.During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 12/20/2025, the MDS indicated Resident 1's cognition (ability to register and recall information) was severely impaired and was dependent (helper does all the effort, resident does none of the effort to complete the activity) on staff for all activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 1's Physician's Orders, dated 2/1/2026, the Physician's Orders indicated an as-needed (PRN) order was received to irrigate Resident 1's indwelling catheter irrigation with 60 milliliters ([mL] small unit of volume) of normal saline for catheter clogging. During a review of Resident 1's initial Change of Condition ([COC] a document indicating a significant change in condition), dated 2/15/2026, indicated nursing interventions done as follows, cold NS irrigation to indwelling catheter with clear to amber color return.During a review of Resident 1's MAR, dated 2/15/2026, there was no documentation indicating RN 1 documented that she irrigated Resident's indwelling catheter on 2/15/2026. During an interview on 4/14/2026 at 12:10 p.m., the Quality Assurance (QA) Nurse stated based on her review of Resident 1's Medical Records, there was no documentation indicating irrigation of NS was administered to Resident 1 on 2/15/2026. The QA nurse stated all treatments and medications should be documented timely and accurately in the resident's chart to ensure everyone on the care team knows exactly what's been done. The QA Nurse stated when records are clear and correct, the next nurse knows exactly what was given, when it was given, and why.During a telephone interview on 4/14/2026 at 3 p.m., RN 1 stated she could not remember how much NS she used to irrigate Resident 1's indwelling catheter on 2/15/2026 and could not recall the amount of drainage or urine that resulted from the irrigation. RN 1 stated it is important to chart accurately at the time of care so Resident 1's medical record clearly communicates the resident's care to all staff.During an interview on 4/14/2026 at 4:10 p.m., the Director of Nursing (DON) stated all licensed nurses must document medications and treatments immediately after administering them. The DON stated that all incomplete documentation can lead to medication errors and inaccurate communication between team members which may ultimately harm the resident. The DON stated based on her review of Resident 1's Medical Records, she could not determine the amount of NS used to irrigate Resident 1's indwelling catheter on 2/15/2026 or the amount of irrigation output which leads to an incomplete assessment of Resident'1 condition.During a review of the facility's policy and procedure (P&P) titled, Catheter Irrigation, Open System, revised 10/2010, the P&P indicated the following information is to documented in the resident medical record, the date and time the procedure was performed, the name and title of the individual who performed the procedure, the amount of solution used to irrigate, the amount returned as drainage and the amount of urine drained and the signature and title of the person recording the data.During a review of the facility's P&P titled, Charting and Documentation, revised 7/2017, the P&P indicated: the following information is documented in the resident medical record, medications administered, treatments or services performed, documentation in the medical record will be objective, complete and accurate.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident) hair was cut. This deficient practice resulted in Resident 1's hair being cut unevenly when the Beautician ([NAME]) 1 did not finish cutting Resident 1's hair. This deficient practice had the potential to negatively affect Resident 1's self-esteem and emotional wellbeing. Findings: During a review of Resident 1's admission Record (Face Sheet) the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] and readmitted [DATE]. Resident 1 had diagnoses including unspecified hypotension (low blood pressure), anemia (a condition where the body does not have enough healthy red blood cells), and schizoaffective disorder (a mental disorder that can affect thoughts, mood and behavior).During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 3/7/2026, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired and was dependent on staff for activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's Situation, Background, Assessment, Recommendation ([SBAR] a communication tool used by healthcare workers when there is a change in condition among the residents) and initial Change of Condition/Alert Charting and Skilled Documentation dated 3/6/2026 and timed at 11:42 a.m. The SBAR indicated Resident 1 was found by Certified Nurse Assistant (CNA) 1 with short uneven hair on the right side of her head. The SBAR indicated Resident 1 was asked if she received a hair cut in the last couple of days or weeks, and Resident 1 stated she received a haircut last month. [NAME] 1 was asked by Social Service Director (SSD) and Charge Nurse (unknown) if she had given Resident 1 a haircut in the prior month. The SBAR indicated [NAME] 1 stated she attempted to give Resident 1 a haircut last month (2/2026) and was unsuccessful due to Resident 1 being noncompliant as she was moving around too much. During a review of a Written Statement signed and dated 3/6/2026, [NAME] 1 indicated on 2/16/2026, she tried to cut Resident 1's hair, but Resident 1 did not allow it, so she ended up only cut one side. During a concurrent observation and interview on 3/20/2026 at 4:15 p.m. with Resident 1, in Resident 1's room, Resident 1 was observed lying in bed with the right top and right side of her hair was observed very short. Resident 1's left side of her hair was observed significantly longer. Resident 1 was not able to describe why her hair was uneven.During a telephone interview on 3/23/2026 at 1:30 p.m. with the [NAME] 1, [NAME] 1 stated she wrote the statement on 3/6/2026 indicating she cut Resident 1's hair but was unable to complete the haircut because Resident 1 was moving too much. [NAME] 1 stated that when a resident is difficult to work with, she will typically ask a nurse or another staff member for assistance; however, on 2/16/2026 she did not ask staff for assistance and Resident 1 was left with an incomplete and uneven haircut. [NAME] 1 stated that residents have the right to look and feel good about themselves and acknowledges she should not have left Resident 1 before ensuring her haircut was complete and her appearance was acceptable. During an interview on 3/23/2026 at 2:30 p.m. with Registered Nurse (RN) 1, RN 1 stated he and Charge Nurse (unknown) were alerted by CNA 1 indicating Resident 1's hair was short. RN 1 stated he went to assess Resident 1; he did see that her hair was uneven. RN 1 stated [NAME] 1 told him the last time she tried to cut Resident 1's hair was on 2/16/2026 but could not complete the job due to the resident moving too much. During an interview on 3/23/2026 at 2:40 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 3/6/2026 at 12 p.m. she went to assess Resident 1, and she saw that the right side of the hair was much shorter than the left side. LVN 1 stated she asked Resident 1 what happened, and stated the resident was unable to tell her. LVN 1stated it is important for a resident to look their best and it is our job to make sure that they do because it is a matter of the resident's dignity.During an interview on 3/23/2026 at 4:00 p.m. with Social Services Director (SSD), SSD stated on 3/6/2026, the [NAME] 1 informed her that she was unable to complete Resident 1's haircut on 2/16/2026 and did not charge the facility because the service was not completed. The SSD stated that [NAME] 1 left the facility without notifying the staff. The SSD stated on 3/6/2026, she asked [NAME] 1 if she could correct Resident 1's haircut as her hair was uneven. The SSD stated that residents' hair should be styled and presentable. During an interview on 3/20/2026 at 4:15 p.m. with the Director of Nursing (DON), the DON stated dignity is an important part of quality care and if she knew sooner that Resident 1's hair was uneven, [NAME] 1's supervisor should have been notified.During a review of the facility's policy and procedure (P&P) titled, Dignity, dated 2/2021, the P&P indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life and feelings of self-worth and self- esteem. The P&P indicated residents are treated with dignity at all times.

Based on interview and record review the facility failed to follow its policy and procedure (P&P) titled Safety and Supervision of Residents, which indicated proper resident supervision was a key part of maintaining safety, when a visitor (Family Member [FM] 2), known to pose a safety risk, was unsupervised in the facility for one of three sampled residents (Resident 1).The facility failed to ensure:1) Family Member (FM) 2, who had documented evidence of providing Resident 1 with illicit substances (drugs that are prohibited by law due to their potential for abuse, addiction, and harm) at the current facility and previous facility, was not allowed to visit Resident 1 without staff's supervision on 2/27/2026.2) Facility staff supervised FM 2's visit on 2/27/2026 rather than FM 1, who was asked to supervise the visit.These deficient practices resulted in Resident 1 becoming unresponsive, with hypoxia (condition when the body does not get enough oxygen), bradypnea (abnormally slow breathing rate), and altered mental status (change in a residents' baseline consciousness). Resident 1 required emergency administration of Narcan (emergency treatment for known or suspected drug overdose) and transfer to the General Acute Care Hospital (GACH) for evaluation and treatment on 2/27/2026.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE]. Resident 1's diagnoses included psychoactive substance abuse (the harmful or use of substances [alcohol, illicit drugs, prescription medications] that change how a person thinks, feels, or behaves), respiratory failure (when the lungs cannot adequately supply oxygen to the blood), chronic kidney disease (CKD- kidneys are permanently damaged and cannot properly filter waste and extra fluid from the blood), ventilator (a medical device to help support or replace breathing) and gastrostomy tube (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach).During a review of Resident 1's previous facility Progress Note dated 10/15/2025, the Progress Note indicated Resident 1 was briefly altered today (3rd episode in several days), occurs only during FM 2's visits. The Progress Note indicated the nurse suspects possible outside substance exposure.During a review of Resident 1's previous facility Progress Note dated 11/2/2025, the Progress Note indicated suspected drugs provided to Resident 1 by FM 2.During a review of Resident 1's previous facility Progress Note dated 11/3/2025, the Progress Note indicated, positive urine drug screen (UDS- laboratory test used to detect the presence of drugs in a person's urine) reflecting barbiturates (sleep inducing drug), and the suspected drugs provided by FM 2.During a review of Resident 1's IDT Meeting Notes dated 11/7/2025, the Notes indicated the IDT addressed concerns from Resident 1's previous facility stay, that FM 2 had been placed on supervised visits at the previous facility due to suspected drugs provided to Resident 1 by FM 2.During a review of Resident 1's Respiratory Therapy (specialized healthcare field focused on treating and managing residents with breathing problem) Notes dated 1/30/2026, the RT Note indicated FM 1 expressed concerns regarding FM 2 visiting Resident 1 and stated FM 1 did not trust FM 2. The RT Note indicated FM 1 believed FM 2 was giving Resident 1 something that could affect Resident 1's breathing.During a review of Resident 1's RT Notes dated 2/5/2026, the RT Notes indicated after FM 2 left, Resident 1' s ventilator began alarming, Resident 1 was noted to have an altered level of consciousness (medical emergency representing any deviation from a normal, alert waking state) and was breathing at a rate of four breaths per minute ( normal breathing ranges from 12 to 20 breaths per minute). The RT Note indicated Resident 1 became more arousable after aggressive stimulation (forceful or intense approach to stimulation).During a review of Resident 1's Physician Progress Note dated 2/26/2026, the Physician's Progress Note indicated there was a suspicion that Resident 1 may have been using drugs besides the one's prescribed to Resident 1 due to her altered mental status.During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 2/27/2026, the MDS indicated Resident 1 cognition (ability to think, understand, learn, and remember) was intact. The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort) with activities of daily living (ADLs- activities such as bathing, dressing, and toileting a person performs daily).During a review of Resident 1's Nurse's Note dated 2/27/2026, the Nurse's Note indicated Resident 1's ventilator was alarming and Resident 1 was noted to have altered responsiveness, bradypnea, hypoxia, and pinpoint pupils (black, circular opening in the center of the eye that remain very small, even in bright light). The Nurse's Note indicated Resident 1 received Narcan (a life-saving medication that rapidly reverses opioid [strong pain medicine] overdose). The Nurse's Note indicated Resident 1 responded to the Narcan when Resident 1 became responsive and stable. The Nurse's Note indicated FM 1 was overheard stating Resident 1 may have taken something, and handed the ADM a clear box containing a powdery substance. The Nurse's Note indicated Resident 1's room belongings were gathered and a white powdery substance and straw wrapped with a napkin were found. During a review of Resident 1's Paramedic Run Sheet dated 2/27/2026, the Paramedic Run Sheet indicated Resident 1's family admitted to giving Resident 1 some sort of narcotic (drug used for pain relief and inducing sleep) substance causing patient to overdose. The Paramedic Run Sheet indicated Resident 1's family stated FM 2 and a drug dealer (individual involved in the illegal sale of illicit substance) have visited Resident 1 at the facility before, and both (FM 2 and drug dealer) have given Resident 1's drugs.During a review of Resident 1's GACH Emergency Department Provider Note Room dated 2/27/2026 at 5:11 p.m., the Note indicated Resident 1 presented to the emergency department for drug overdose (excessive, dangerous amount of a substance is consumed). The Note indicated Resident 1 was visited by FM 1 when found unresponsive. The Note indicated facility staff were called and noted Resident 1 to be apneic (breathing stop) with pinpoint pupils. The Note indicated facility gave Resident 1 Narcan 4 milligram (mg-unit of measurement) intramuscular (IM-injection to the muscle) and Resident 1 woke up and was responsive. Resident 1 was visited by FM 2 or drug dealer, likely given substances. Resident 1 did defecate (pass stool) herself and has been slightly combative.During a review of Resident 1's GACH Psychiatric Consult Note dated 2/28/2026 at 1:09 p.m., the Psychiatric Consult Note indicated, Resident 1 was found by FM 1 and facility staff on 2/27/2026 to have pinpoint pupils. Facility staff gave Narcan 4 mg and Resident 1 became responsive. The Note indicated per FM 1, FM 2 and a drug dealer provides Resident 1 with drugs. The Psychiatric Consult Note indicated Resident 1 reported accidental overdose on medication.During an interview on 3/3/2026 at 8:15 a.m., with the Administrator (ADM), the ADM stated FM 2 was restricted to supervised visits starting 2/26/2026 because he had previously interfered with Resident 1's care (unknown date). The ADM stated on one occasion, FM 2 arrived at the facility at 3:00 a.m. and was banging on the front door, which led the facility to limit his visiting hours and require supervision. The ADM stated that on 02/27/2026, he instructed FM 1, who was at Resident 1's bedside with FM 2, to supervise FM 2 due to FM 2's history of providing illicit substances to Resident 1.During an interview on 3/3/2026 at 11:10 a.m., with FM 1, FM 1 stated she had a feeling Resident 1 was on something because she knew the types of drugs she used in the past and Resident 1 kept nodding off (unintentionally falling into a light sleep). FM 1 stated prior to Resident 1 being transferred to GACH on 2/27/2026, Resident 1 handed her a box with a white powdered substance inside but did not indicate where she got it. FM 1 stated on 2/27/2026 the ADM asked her to monitor FM 2 during a bedside visitation.During an interview on 3/3/2026 at 11:25 a.m. with FM 3, FM 3 stated FM 2 was asked to leave the previous facility in October or November of 2025 because he was suspected of giving Resident 1 something that caused Resident 1 to exhibit unusual behavior. FM 3 stated the previous facility conducted a urine test, on Resident 1 which was positive for some drug (unknown). FM 3 stated she did not know what specific drug the urine test detected.During an interview on 3/3/2026 at 12:31 p.m. with Certified Nurse Assistant (CNA) 1, CNA 1 stated FM 2 was placed on supervised visits because he tried to bring unauthorized items (alcohol) into the facility. CNA 1 stated facility staff should be responsible for supervising FM 2's visits and no other family members, as family members could potentially be involved if inappropriate items (alcohol) were being brought in.During a concurrent interview and record review on 3/3/2026 at 12:53 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated FM 2 was placed on supervised visits because he would bring drinks to Resident 1 even though Resident 1 was not allowed to eat or drink anything. LVN 1 stated on 1/14/2026 she observed a beer inside a clear bag that FM 2 had brought into the facility. FM 2's visits should have been supervised only by facility staff to ensure family members did not provide unauthorized items to Resident 1.During an interview on 3/4/2026 at 9:55 a.m. with Respiratory Therapist (RT) 1, RT 1 stated on 2/27/2026 at approximately 4:00 p.m., she responded to Resident 1's ventilator alarm and found Resident 1 difficult to arouse. RT 1 stated she suspected Resident 1 had consumed something (alcohol or drugs), and FM 1 told RT 1 Resident 1 had consumed something.During an interview on 3/4/2026 at 1:00 p.m. with the Director of Nursing (DON), the DON stated facility staff, not FM 1, should have supervised FM 2 during his bedside visit on 2/27/2026 for the safety of Resident 1. The DON stated the incident on 2/27/2026 could have been avoided if all visitors had been supervised by facility staff, as FM 2 appeared suspicious, agitated, and restless at the time of the event (2/27/2026).During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, dated 7/2017, the P&P indicated, Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify specific accident hazards or risks for individual residents. Resident supervision is a core component of the systems approach to safety.

Based on interview and record review, the facility failed to ensure a resident, who used a ventilator (a machine used in healthcare to assist or perform breathing for a patient who cannot breathe adequately on their own), had a functional limitation in range of motion ([ROM] the direction a joint can move to its full potential) to both her upper and lower extremities (arms and legs) and required a two person physical assist with bed mobility, including turning and repositioning, did not sustain a facial injury for one of three sampled residents (Resident 2). The facility failed to: 1. Ensure Certified Nurse Assistant (CNA) 2 did not turn and reposition Resident 2 by herself, without assistance, placing Resident 2 on the tubing of a ventilator circuit (a system of tubes connecting a ventilator). 2. Ensure CNA 2 followed the facility's Policy and Procedure (P/P) titled, Repositioning revised on 5/2013, which indicated .use two people while tuning or moving the resident in bed. 3. Ensure CNA 2 followed the facility's P/P titled, Safety and Supervision of Residents, revised 7/2017, which indicated .resident safety, supervision, and assistance to prevent accidents are facility wide priorities. The care team shall target interventions to reduce individual risks related to hazards in the environment. These deficient practices resulted in Resident 2 sustaining a skin tear (a traumatic wound caused by friction when the upper layer of the skin becomes torn from the underlying layers) with minimal bleeding to her left upper lip, measuring 0.3 centimeters ([cm] a unit of measurement) x 0.1 cm x 0.1 cm.Findings: During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cerebrovascular accident ([CVA] stroke, loss of blood flow to a part of the brain), diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing), dependency on a ventilator and residing on the facility's Sub Acute Unit (a medical care setting for Residents who need more intensive care than a standard nursing home). During a review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool) dated 7/22/2025, the MDS indicated Resident 2's cognitive (thought process) skills for daily decision making were severely impaired. The MDS indicated Resident 2 had a functional limitation in ROM to her bilateral (both) upper extremities (arms), her bilateral lower extremities (legs) and was dependent (helper does all of the effort, resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity) when rolling left and right. During a review of Resident 2's 48 Hour Baseline Care Plan dated 3/21/2025, the Care Plan indicated Resident 2 needed a two-person physical assist for bed mobility and was totally dependent on all aspects of self-care. During a review of Resident 2's Nurses Progress Note dated 9/5/2025, the Nurses Progress Note indicated Resident 2 had a skin tear to her left upper lip measuring 0.3 cm x 0.1 cm x 0.1 cm with a peri wound (the area of skin immediately surrounding an open wound) discoloration and minimal bleeding. During a review of Resident 2's Situation, Background, Assessment, Recommendation ([SBAR] a communication tool used by healthcare workers when there is a change of condition among the residents) dated 9/5/2025, the SBAR indicated Resident 2 was lying on her ventilator circuit while being cleaned by CNA 2, sustaining a skin tear on her left upper lip. During a review of Resident 2's Physicians Order Summary dated 9/5/2025, the Physicians Order Summary indicated to apply Vitamin A&D Ointment (a skin protectant that helps soothe, moisturize, and protect minor skin irritations) topically (applied directly to the skin) to the skin tear on Resident 2's upper lip every shift for 14 Days. During a telephone interview on 9/9/2025 at 10:47 a.m., Resident 2's Family Member (FM) 1 stated she received a phone call on 9/5/2025 from a Licensed Vocational Nurse (LVN 1) notifying her that Resident 2 sustained a cut on her face. FM 1 stated she asked LVN 1 how Resident 2 got the cut on her face because Resident 2 was unable to move her hands, LVN 1 could not tell her what happened. FM 1 stated later that day she received a phone call from the facility's Administrator (ADM) informing her that upon investigation he determined that CNA 2, when repositioning Resident 2, placed Resident 2 on top of her ventilator circuit on her left side, which caused Resident 2 to sustain an injury to her face. During an interview on 9/9/2025 at 12:11 p.m., the Treatment Nurse (LVN 1) stated on 9/5/2025, she entered Resident 2's room to perform a wound treatment to Resident 2 and observed her lying on her left side. LVN 1 stated following the wound treatment, she and CNA 2 turned Resident 2 on her back, that's when they both noticed blood on Resident 2's face and on her ventilator circuit. LVN 1 stated Resident 2 required a two-person assist for care and CNA 2 should have gotten another person to assist her when turning Resident 2 in bed. During an interview and on 9/10/2025 at 9:52 a.m., the Director of Staff Development (DSD) stated nurses who work on the Sub-Acute Unit, upon hire, they were instructed not to turn or reposition any of the residents by themselves. During an interview on 9/10/2025 at 11:52 a.m., the Respiratory Therapy Manager (RTM) stated nurses who work on the Sub-acute Unit should turn and reposition residents using two people and make sure the ventilator circuit tubing is not on the resident's face or head. During an interview and on 9/10/2025 at 3:48 p.m., the Director of Nursing (DON) stated the nursing staff were trained on how to prevent accidents or injuries by using a two-person assist while turning or repositioning residents. During a review of the facility's Policy and Procedure (P/P) titled, Repositioning revised on 5/2013, the P/P indicated repositioning is critical for a resident who is immobile or dependent upon staff for repositioning. The P/P indicated to. use two people while tuning or moving the resident in bed. During a review of the facility's P/P titled, Safety and Supervision of Residents, revised 7/2017, the P/P indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety supervision and assistance to prevent accidents are facility wide priorities. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision.

Based on interview and record review, the facility failed to ensure the resident, who was assessed as being at risk for falls, did not fall and sustained multiple lacerations (a cut refers to a skin wound) required hospitalization and suturing (stitches that holds wound edges together) for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure Certified Nurse Assistant (CNA 1) asked another staff to assist transferring Resident 1 from a shower chair back to bed via a mechanical lift in attempt to remove linen and the sling from the lift underneath the resident while the resident was positioned too close to the edge of bed. 2. Ensure Resident 1's care plan titled, Self-care performance deficit included how staff will transfer the resident between surfaces to prevent falls. These deficient practices resulted in Resident 1 falling from a bed when CNA 1 was removing a mechanical lift sling and linen from a bed underneath the resident on 7/26/24. Resident 1 sustained two lacerations on the scalp (head), one on the right side of the head and another on the front of the head (unspecified location) and the right arm skin tear. On 7/26/24 at 12:15 p.m., Resident 1 was transferred to a General Acute Care Hospital (GACH), where the resident underwent suturing of lacerations and was admitted to the GACH's telemetry unit (unit for cardiac [heart] monitoring) for further evaluation and treatment. As of 8/7/2024, Resident 1 remains at the hospital. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including hemiplegia (paralysis of one side of the body), hemiparesis (weakness of one side of the body) following cerebral infarction (damage to the brain from interruption of its blood supply), type 2 diabetes mellitus (a condition in which the body fails to process sugar correctly), unspecified dementia (loss of memory, language, problem-solving and other thinking abilities) and limitation of activities due to disability. During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care-screening tool) dated 5/21/2024, the MDS indicated Resident 1 had severely impaired cognitive (ability to think, understand, learn, and remember) skills for daily decision making. The MDS indicated Resident 1 was dependent (helper does all the effort, assistance of two or more helpers is required for the resident to complete the activity) on staff for transfer between surfaces and all activities of daily living (ADLs) including dressing, personal hygiene, oral hygiene, toileting, and showering. The MDS indicated Resident 1 was incontinent (inability to control bladder and bowel functions) of urine and bowel and had a history of falls with injuries. The MDS did not indicate the resident's need for mechanical lift. During a review of Resident 1's History and Physical (H&P) dated 12/20/23, the H&P indicated Resident 1 had no capacity to make decisions. During a review of Resident 1's care plan titled Resident at risk for fall related to poor safety awareness, cognitive loss, and behavior of getting up unassisted, putting legs by the edge of the bed dated 5/21/2024, the care plan indicated the resident was recognized as risk for falls. The care plan goal for Resident 1 was to minimize episode of falls through the next review date of 9/7/2024. The Care Plan interventions included to provide extensive staff assistance to Resident 1 with getting in and out of bed and to conduct frequent visual check. During a review of Resident 1's care plan titled Self-care performance deficit dated 5/21/24, related to impaired function and mobility, cognition, diagnosis of dementia, and depression (persistent feeling of sadness and loss of interest in activities) indicated staff will assist Resident 1 with ADLs as needed. The care plan did not include information about mechanical lift for resident's transfer between surfaces or what staff approach would be During a review of Resident 1's Nurses Progress Note dated 7/26/24, the Nurses Progress Note indicated Resident 1 fell on [DATE] at 9:20 a.m., while CNA 1 was transferring the resident from shower chair to bed by using a mechanical lift by herself. The Nurses Progress Notes indicated Resident 1 was totally dependent on staff and required two-persons assistance with care. The Nurses Progress Note indicated Resident 1 sustained a bump on the forehead, skin tear on the right arm, and laceration on the right side of the head. The Nurses Progress Note indicated 911 (a phone number used to contact emergency services) was called and the resident was transferred to the GACH on 7/26/2024 at 12:15 p.m. During a review of Resident 1's GACH report titled History of Present Illness (HPI), the HPI indicated Resident 1, was being helped after shower to transfer back to bed when he fell from the bed to the floor and hit his head. The HPI indicated Resident 1 sustained two lacerations to his scalp which were repaired with sutures (a stitch or row of stitches holding together the edges of a wound) by emergency department (ED) physician. During a review of Resident 1's GACH report titled Clinical Impression, the report indicated Resident 1 had a head injury, fall after getting a shower, pneumonia (an infection of the lungs), and acute respiratory failure (caused by a disease or injury that affects the breathing) with hypoxia (low levels of oxygen). The Clinical Impression report indicated Resident 1's, lacerations were treated/repaired, oxygen three liter per minute ([L/min]-unit of oxygen flow measurement) via nasal cannula (a thin, small flexible tubes placed into nostrils that delivers oxygen) and antibiotic (medication to treat infection) was ordered for Resident 1. The Clinical Impression report indicated Resident 1 was admitted to the telemetry unit for further evaluation and treatment. During an interview on 8/7/24 at 12: 46 p.m., CNA 1 stated she had a high workload and responsibilities that included residents' hygiene care, residents' feeding, bathing, ambulation (walking) assistance, and monitoring the resident's vital signs. CNA 1 stated she was attempting to transfer Resident 1 by using a mechanical lift from a shower chair to the bed after the resident was showered. CNA 1 stated she was intended to change the bed linens. CNA 1 stated when she lowered the lift's sling down the resident was positioned closed to the edge of the bed so when she was removing the sling and bed linen underneath the resident, the resident's leg slipped, causing him to fall. CNA 1 stated Resident 1 landed on the floor, resulting in a head injury and a skin tear on the arm. CNA 1 stated given how busy the facility's staff were, and her having assigned nine residents to care for with three of nine residents needed a shower on 7/26/2024, she felt she could not request an assistance from other staff to transfer Resident 1 to bed. CNA 1 stated Resident 1 needed a two-person assistance due to his weight and his total dependance on staff for assistance with all transfers. CNA 1 stated Resident 1's fall was avoidable if she had asked a second person to assist her with use of mechanical lift to transfer Resident 1 to bed. During an interview on 8/7/24 at 2:06 p.m., the Licensed Vocational Nurse (LVN 1) stated she was passing medications when the incident (Resident 1's fall) happened on 7/26/2024. LVN 1 stated a Restorative Nursing Assistant (RNA 1) summoned her to go to Resident 1's room. LVN 1 stated when she walked in Resident 1's room, the resident was on the floor and was bleeding from his head and a skin tear on his right arm. LVN 1 stated CNA 1 was removing Resident 1 linen and the sling from a mechanical lift underneath the resident when she rolled Resident 1 over that was when the resident fell . LVN 1 stated CNA 1 should have had an assistance from another staff to place Resident 1 back to bed as Resident 1 was very tall. LVN 1 stated Resident 1 fall was avoidable if CNA 1 had another staff to assist her with Resident 1 transfer to bed. During an interview on 8/7/24 at 3:09 p.m., the Occupational Therapist ([OT 1] a professional who provides services to increase and/or maintain a person's ability to participate in everyday life activities) stated Resident 1 required a two-persons assistance during care. The OT 1 stated CNAs and licensed staff were instructed to use two-persons assistance during Resident 1 transfers between surfaces as Resident 1 was a high risk for fall. The OT 1 stated Resident 1's fall could have been avoided if the resident had not been positioned so close to the edge of the bed, especially given his size. OT 1 stated when the resident shifted his body weight, he was too near the edge of the bed, which led to the fall. OT 1 stated for transfers Resident 1 required a mechanical lift with the assistance from two persons . During an interview on 8/7/24 at 4 p.m., the Administrator (ADM) stated on 7/26/2024 Resident 1 was transferred out to the GACH due to injuries related to his fall. The ADM stated Resident 1's fall was avoidable because if CNA 1 had used two persons assistance to transfer the resident back to bed, the resident would not have fallen. During a review of facility's policy and procedures (P&P) titled Falls Management dated 5/26/2021, indicated Residents will be assessed for fall risk as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. During a review of facility's P&P titled Safe Lifting and Movement of Residents dated 7/2017 indicated Nursing staff in conjunction with the rehabilitation staff, shall assess individual resident's needs for transfer assistance on an ongoing basis, staff will document resident's transferring and lifting needs in the care plan, such assessment shall include resident's preferences for assistance, resident's mobility (degree of dependency), resident's size, weight bearing ability, and the resident cognitive status.

Based on observation, interview, and record review, the facility failed to ensure six of ten sampled residents (Residents 1, 6, 8, 9, 11 and 12), who were receiving [CONDITION(S)] treatments (a life-support treatment that uses a special machine to filter harmful wastes, salt, and excess fluid from your blood) at their bedside, were provided the care and services consistent with the facility ' s policies and procedures (P&P), professional standards of practice, and the contract between the facility and the [CONDITION(S)] provider. The facility failed to ensure: 1. The [CONDITION(S)] provider licensed nurses initiated and terminated the [CONDITION(S)] treatment by connecting the residents ' [CONDITION(S)] access through a central venous catheter ([CVC] flexible tube [catheter] that is placed into a large vein above the heart) for Resident 1 to 6, 8, 9, 11, 12. 2. A Certified Hemodialysis Technicians 1,2,3,4 ([CHT] health care professional trained in the operation of a [CONDITION(S)] machine under RN supervision) were not connecting the residents to the [CONDITION(S)] machine through CVC including flushing the central line with Saline(mixture of salt and water) and [MEDICATION(S)] (substance that slows the formation of blood clots) as per facility ' s contractual agreement with the [CONDITION(S)] provider. 3. The assigned [CONDITION(S)] Registered Nurse (RN) conducted an ongoing assessment of the residents ' condition while the residents were receiving hemodialysis treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. [CONDITION(S)] RNs were not leaving dialyzed residents unmonitored, while the residents were receiving the [CONDITION(S)] treatment, to attend other residents needing an emergency care. 5. The facility had a formal assignment schedule for contracted [CONDITION(S)] staff prior to the start of their shift to conduct the hemodialysis treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] 6. To have an ongoing communication and collaboration with the contracted [CONDITION(S)] company regarding [CONDITION(S)] care and services to the facility ' s residents. These deficient practices placed [CONDITION(S)] residents at high risk for acute and chronic problems including bleeding from CVC, infection at the access site, malfunction or clogging of the CVC , [CONDITION(S)] [CONDITION(S)](disorder in which red blood cells [type of cell in the blood carries oxygen] are destroyed faster than they can be made) manifested by chest pain and/or back pain, shortness of breath, localized burning and pain in [CONDITION(S)] access ([site in the body allows blood to travel through soft tubes to the [CONDITION(S)] machine], [CONDITION(S)] (abnormal heart beat), [CONDITION(S)] (too much potassium in the blood), and an acute decrease in the hematocrit (test showing amount of red blood cells in the body) and death. Findings: During a record review of the facility census dated 9/19/2022, the census indicated there were 42 residents residing at the sub-acute area, 11 residents were receiving hemodialysis in house. Among 11 residents receiving hemodialysis four residents were on contact isolation and seven were residing on the facility ' s non-isolation area. Ten residents out of 11 ( Resident 1, 2,3,4,6,7,8,9,1112)residents receiving hemodialysis had CVC access site for [CONDITION(S)], and one resident had an arteriovenous fistula access ([AVF] a connection that's made between an artery and a vein for [CONDITION(S)] access). A. During a review of Resident 1 ' s Admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission record indicated Resident 1's [CONDITION(S)] access site, PermaCath (type of catheter used for short-term [CONDITION(S)] treatment), was located on the right upper chest and hemodialysis was to be done in-house four days per week for two hours on Monday, Tuesday, Thursday, and Friday. During a review of Resident 1 ' s Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 5/15/2022, MDS indicated the resident ' s cognitive (the ability to understand or to be understood by others) skills for daily decisions making were intact and the resident required from extensive assistance with two persons physical assistance from staff for activities of daily living (ADL) including bed mobility, eating, toilet use. The MDS indicated the resident was totally dependence on staff for dressing and personal hygiene. The MDS indicated, Resident 1 was receiving [CONDITION(S)] care in house. During a review of Resident 2 ' s Admission Record, indicated Resident 2 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission record indicated Resident 2 ' s PermaCath [CONDITION(S)] access site located on the left upper chest and the resident was receiving hemodialysis in-house five days a week for two hours on Monday, Tuesday, Wednesday, Thursday, and Friday. During a review of Resident 2 ' s MDS dated [DATE], MDS indicated the resident was able to understand and was understood by others. The MDS indicated Resident 2 was totally depended on staff for ADL including bed mobility, dressing, and personal hygiene and needed extensive assistance with eating and toilet use. The MDS indicated Resident 2 was receiving hemodialysis in house. During a review of Resident 3 ' s Admission Record (AR), the AR indicated Resident 3 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The AR indicated the resident's PermaCath [CONDITION(S)] access site was on the right upper chest and hemodialysis was conducted in house five days a week for two hours Monday through Friday. During a review of Resident 3's admission notes (AN) dated 9/12/2022, the AN indicated Resident 3 was alert, nonverbal, unable to follow command, and was able to make eye contact. During a review of Resident 3 ' s physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 6 ' s Admission Record, the Admission Record indicated Resident 6 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission record indicated Resident 3's PermaCath [CONDITION(S)] access site was on the right upper chest and the resident was receiving hemodialysis in-house five days a week for two hours Monday through Friday. During a review of Resident 6's MDS dated [DATE], the MDS indicated the resident ' s cognitive skills for daily decisions making were severely impaired and the resident was totally depended on staff for ADL, including bed mobility, eating, toilet use, dressing, bathing, and personal hygiene. The MDS indicated, Resident 6 was receiving hemodialysis care in-house. During a review of Resident 6 ' s physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . The PO indicated Resident 6 was on contact isolation precaution due to exposure to a roommate with pending [MEDICATION(S)] Auris results. During a review of Resident 8 ' s Admission Record, the AR indicated Resident 8 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The AR indicated resident's PermaCath [CONDITION(S)] access site was located on the right upper chest and hemodialysis was provided in-house five days a week for two hours Monday through Friday. During a review of Resident 8's MDS dated [DATE], the MDS indicated the resident ' s cognitive skills for daily decisions making were severely impaired. The MDS indicated Resident 8 was totally depended on staff for ADL including bed mobility, eating, toilet use, bathing, dressing and personal hygiene. The MDS indicated Resident 8 was receiving hemodialysis care in house. During a review of Resident 9 ' s Admission Record (AR) , the AR indicated Resident 9 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The AR indicated Resident 9 ' s PermaCath [CONDITION(S)] access site was located on the right upper chest and that hemodialysis was done in-house five days a week for two hours on Monday through Friday. During a review of Resident 9's MDS, dated [DATE], the MDS indicated the resident ' s cognitive skills for daily decisions making were severely impaired and Resident 9 was totally depended on staff for ADL including bed mobility, eating, toilet use, dressing, bathing, and personal hygiene. The MDS indicated Resident 9 was receiving hemodialysis care in house. During a review of Resident 11 ' s Admission Record (AR) , the AR indicated Resident 11 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The AR indicated Resident 11 ' s PermaCath [CONDITION(S)] access site was located on the left upper chest and the resident was receiving hemodialysis in-house five days a week for two hours Monday through Friday. During a review of Resident 11's MDS, dated [DATE], the MDS indicated the resident ' s cognitive skills for daily decisions making were severely impaired and the resident was totally depended on staff for ADL including bed mobility, eating, toilet use, dressing, bathing, and personal hygiene. The MDS indicated Resident 11 was receiving [CONDITION(S)] care while resided at the facility. During a review of Resident 12 ' s AR, the AR indicated Resident 12 was admitted to the facility on [DATE] and re admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The AR indicated Resident 12 ' s PermaCath [CONDITION(S)] access site was located on the left upper chest and the hemodialysis was done in-house five days a week for two hours Monday through Friday. During a review of Resident 12's MDS dated [DATE], the MDS indicated Resident 12 ' s cognitive skills for daily decisions were moderately impaired. The MDS indicated Resident 12 was totally depended on staff for ADL including bed mobility, eating, toilet use, bathing, dressing, and personal hygiene. The MDS indicated Resident 12 was receiving [CONDITION(S)] care while resided at the facility. During a concurrent observation and interview on 9/19/2022 at 4:15 a.m., CHT 3 was observed setting up the [CONDITION(S)] machine to be used for hemodialysis treatment. CHT 3 stated, he was assigned to initiate hemodialysis treatment on Resident 1and Resident 3 who were on contact isolation together in one a room. During a concurrent observation and interview on 9/19/2022 at 4:35 a.m., CHT 4 was observed setting up the [CONDITION(S)] machine to use for [CONDITION(S)] treatment on Resident 2 and Resident 4. Resident 2 ' s room and Resident 4 ' s room were adjacent to each other and both residents were on contact isolation. CHT 4 stated he was assigned to initiate hemodialysis on both residents on contact isolation and at the same time on additional two resident who were in a different room. CHT 4 stated he was starting the hemodialysis treatment from cleaning the assigned residents CVC. At the same time CHT 4 was observed attaching the cartridge at the machine. CHT 4 stated, he needed to prime (system for preparing [CONDITION(S)] fluid from [MEDICATION(S)] fluid concentrate) the machine. Then CHT 4 was observed to start preparing the medical supplies needed to clean and change the dressing for Resident ' s 4 CVC. During an interview on 9/19/2022 at 5:55 a.m., CHT 1 stated he was allowed to initiate and terminate [CONDITION(S)] treatments using the CVC in the facility because [CONDITION(S)] machines used here were home hemodialysis machines. CHT 1 stated that he connects the [CONDITION(S)] tubing from the [CONDITION(S)] machine to the CVC. During an interview on 9/19/2022 at 5:56 a.m., CHT 2 stated she was allowed to initiate and terminate [CONDITION(S)] treatments using the CVC without any problems. CHT 2 stated she was capable to do that and she has been doing this job for almost [AGE] years now. During an interview on 9/19/2022 at 6:10 a.m., Resident 1 stated she was left unattended during [CONDITION(S)] treatment. Resident 1 stated that she uses the call light to call [CONDITION(S)] staff if she does not feel good. Resident 1 stated it was CHT 3 who always initiates the hemodialysis treatments and CHT 3 is the one who helps her in case she needs help. During an interview on 9/19/2022 at 6:30 a.m., Resident 4 stated that sometimes he was left by himself during [CONDITION(S)] treatment. During an interview on 9/19/2022 at 5:55 a.m., CHT 1 stated [CONDITION(S)] staff was not supposed to leave residents alone and unattended during ongoing [CONDITION(S)] treatment at any time. During an interview on 9/19/2022 at 7:08 a.m., [CONDITION(S)] RN 1 stated the CHT's were trained on how to use the hemodialysis machines and how to connect the dialyzed resident to the [CONDITION(S)] machine through the CVC including dressing change. [CONDITION(S)] RN 1 stated at the facility CHT ' s were allowed to initiate and terminate residents ' [CONDITION(S)] treatments through CVC and do a dressing change to CVC site. [CONDITION(S)] RN1 stated that CHT cleans the CVC site, change the dressing, flush the CVC with [MEDICATION(S)] or Saline Solution. During an interview on 9/19/2022 at 10:21 a.m., the DON stated CVC care and assessment done by the [CONDITION(S)] RN at the facility. The DON stated, she was not sure if the LVN was allowed to flush and check CVC patency(condition of being open ). The DON stated, based on my knowledge of nursing scope of practice, only RN could assess, touch, and care for CVC. The DON added, CVC is a tube connected to the heart, so it was a high risk for infection, [CONDITION(S)] or even death if not properly cleaned, assess, access and cared by a trained licensed nurse. During a concurrent observation of Resident 4's [CONDITION(S)] treatment termination and interview with CHT 3 on 9/20/2022 at 7:49 a.m., CHT 3 was observed turning off the [CONDITION(S)] machine. CHT 3 was observed setting up supplies for cleaning the CVC siteon top of disposable pad. CHT 3 observed placing the disposable pad on top of Resident 2's chest. CHT 3 observed placing on top of disposable pad two10 cubic centimeter [(cc) a unit of volume measurement] syringes filed with a solution, not covered tip. CHT 3 observed flushing Resident 2 ' s CVC ' s red line with 10 cc of Normal Saline solution then Heflushed it with [MEDICATION(S)] (anticoagulant [blood thinner] that prevents the formation of blood clots) 2000 units then recapped the syringe. CHT 3 observed to repeat the same procedure with the CVC ' s blue line. Then CHT 3 was observed wrapping both CVC lines ?catheters with gauze. Concurrently with the observation, CHT 3, stated he will not change the CVC dressing because he did change it before starting the treatment. During a review of Resident 4's [CONDITION(S)] Flowsheets for September 2022, the Flowsheets indicated CHT 3 initiated and terminated [CONDITION(S)] treatments on the following days: 9/20/2022, 9/19/2022, 9/16/2022, 9/15/2022, 9/14/2022, 9/13/2022, 9/12/2022, 9/9/2022, 9/8/2022, 9/7/2022, 9/6/2022, 9/5/2022 and 9/2/2022, through the right [MEDICATION(S)] (relating to an artery or vein which serves the neck anatomical location) PermaCath [CONDITION(S)] access. During a concurrent interview on 9/20/2022 at 10:02 a.m., and a review of the facility ' s [CONDITION(S)] contract dated 07/25/2022, [CONDITION(S)] RN 1 stated that the contract indicated that only licensed nurses may initiate [CONDITION(S)] treatment at the facility. According to the contract Personnel who initiate and discontinue [CONDITION(S)] resident [CONDITION(S)] treatments will be the RN, Licensed Practical Nurse (LPN), or the LVN, depending on whether [CONDITION(S)] resident is receiving HHD [ home hemodialysis] or peritoneal [CONDITION(S)] (PD), and meets the practice requirements in the state in which he or she is employed. A trained facility staff member such as a nurse aide or trained caregiver may monitor the [CONDITION(S)] resident for a duration of the resident ' s treatment, but initiation and discontinuation of treatments will only be performed by the supervising nurse. B. During a review of the facility ' s floor plan map, the floor plan map indicated rooms for Resident 1, 2, 3 and 4, who were on contact isolation related to C-Auris infection and were receiving [CONDITION(S)], located at the front of the facility ' s building. However, rooms of Resident 5, 6, 7, 8, 9, 11, and 12 who were receiving [CONDITION(S)], were located on sub-acute area at the back side of the facility. During an observation on 9/19/2022 at around 5:55 a.m., CHT 3 and CHT 4 were observed going in and out from Resident 1, 2, 3 and 4 during ongoing hemodialysis on all four residents to check on Residents 1, 2, 3 and 4. During a concurrent observation and interview on 9/19/2022 at 6:22 a.m., CHT 2 stated, she was the one who stays with the residents during the hemodialysis treatment. CHT 2 stated that RN 1 and RN 2 have their own residents receiving ongoing [CONDITION(S)] treatment as well. CHT 2 stated, if there would be an emergency RN 1 would leave her assigned dialyzed residents and would attend to CHT ' s residents. CHT 2 stated she, tries her best to manage and capable to troubleshoot if needed. CHT 2 stated she was the unit coordinator of all scheduled CHT working on 9/19/2022. CHT 2 stated she goes around and checks all CHTs ' and helps everyone on both clean side and on the isolation side of the facility. During an interview on 9/19/2022 at 7:08 a.m., [CONDITION(S)] RN 1 stated when she was the only [CONDITION(S)] RN working at the facility, she usually stayed on sub-acute area at the back side of the facility and CHTs ' stayed at the front area of the facility to care for Residents 1,2, 3, and 4 .[CONDITION(S)] RN 1 stated she was assigned to tow residents in the same room. [CONDITION(S)] RN 1 stated the CHT ' s were monitoring their assigned dialyzed residents. [CONDITION(S)] RN 1 stated in the event of emergencies with any dialyzed resident who is being administered [CONDITION(S)] treatment by CHTs, the CHT will alert her of emergency. The [CONDITION(S)] RN 1 stated, in the emergency or during breaks, another [CONDITION(S)] staff RN or CHT covers for her to monitor her assigned dialyzed residents. The [CONDITION(S)] RN 1 stated that during time when her colleagues monitoring her residents they must care for their assigned dialyzed residents as well. The [CONDITION(S)] RN 1 stated, the staff who is monitoring for her during breaks or possible emergency, have to monitor at the same time a total of four dialyzed residents located in different rooms and therefore, the dialyzed residents are not being continuously visualized/monitored. The [CONDITION(S)] RN 1 stated because RNs have their own residents with ongoing [CONDITION(S)] the expected ongoing RN assessments of residents receiving [CONDITION(S)] is not provided. During an interview on 9/19/2022 at 7:43 a.m., CHT 2 stated [CONDITION(S)] staff to resident ratio was one [CONDITION(S)] staff per two residents (1:2) except during staff breaks. During breaks one staff covers four residents for 30 minutes. During an observation of CHT 3 on 9/20/2022 from 6:22 a.m. to 6:56 a.m., the following was observed: 1. None of the [CONDITION(S)] staff continuously visually monitored Resident 2 during ongoing hemodialysis treatment from 6:31 a.m. to 6:34 a.m. and from 6:44 a.m. to 6:56 a.m. 2. None of the [CONDITION(S)] staff continuously visually monitored Resident 4 during ongoing hemodialysis treatment from 6:25 a.m. to 6:31 a.m., from 6:34 a.m. to 6:38 a.m., and from 6:44 a.m. to 6:56 a.m. During an interview on 9/20/2022 at 6:57 a.m., CHT 3 stated he was assigned to Resident 2 and Resident 4. CHT 3 stated he was monitoring at the time Resident 2 and Resident 4, who were dialyzed in different rooms. CHT 3 stated he typically sits in the hallway and goes to the dialyzed resident ' s room to check on the resident whenever the [CONDITION(S)] machine will alarm or would make a sound. CHT 3 stated he started Resident 2's treatment at 5:30 a.m. and Resident 4's treatment at 5:50 a.m. CHT 3 stated he cannot visually monitor both residents at the same time because their doors were not even facing each other. During an interview on 9/20/2022 at 7:24 a.m., the [CONDITION(S)] RN 1 stated they had 10 residents with ongoing [CONDITION(S)] at this time and their shift started at 4:30 a.m. The [CONDITION(S)] RN 1 stated all staff was running around and busy with their own residents. The [CONDITION(S)] RN 1 stated CHT 3 had two residents assigned that were in two different rooms making continuous visualization of the residents impossible. The [CONDITION(S)] RN 1 stated both [CONDITION(S)] treatments for Residents 2 and Resident 4 should not be conducted at the same time if the residents were in different rooms. The [CONDITION(S)] RN 1 stated on 9/20/2022 [CONDITION(S)] RN1 and [CONDITION(S)] RN2 were assigned to work on the sub-acute unit side. The [CONDITION(S)] RN stated, if emergency would occur the [CONDITION(S)] RN 2 could watch four residents from 2 separate rooms without direct visualization or assessment while receiving [CONDITION(S)]. Then the [CONDITION(S)] RN 1 handles the emergency on the other facility ' s side with the residents on contact isolation. C. During a concurrent interview and review of handwritten [CONDITION(S)] staff assignment on 9/20/2022 at 7:36 a.m., the [CONDITION(S)] RN 1 confirmed CHT 1 was assigned to Resident 5 and 6, who were in different rooms, and both hemodialysis treatments were ongoing at the same time. The [CONDITION(S)] RN 1 stated this assignment was unacceptable because CHT 1 could not visualize both residents at the same time as both were in two different rooms. The [CONDITION(S)] RN 1 sated the residents during [CONDITION(S)] treatment need to be continuously monitored because complications like high or low blood pressure, bleeding, or change in condition during hemodialysis may occur. The [CONDITION(S)] RN 1 stated it was unacceptable for staff not to have a visual of the residents during [CONDITION(S)] treatment continuously and not to have an ongoing RN assessment to ensure resident safety. According to the [CONDITION(S)] staff assignment for 9/20/2022 CHT 1 was assigned to provide hemodialysis to Resident 5 and 6 who were in different rooms and CHT 3 was assigned to provide hemodialysis to Resident 2 and 4 who were in different rooms. On 9/20/2022 at 7:45 a.m., during a concurrent interview and review of Resident 2's [CONDITION(S)] Flowsheet dated 9/20/2022, CHT 3 confirmed that on 9/20/2022 at 7:00 a.m., Resident 2 had an emergency. CHT 3 stated Resident 2's blood pressure went down to 88/47 and he administered to the resident 100 cc of Normal Saline (NS) solution and the resident ' s blood pressure normalized (normal ranges 100-140/60-80), thus the emergency was resolved. CHT 3 stated he has not had a chance to notify the [CONDITION(S)] RN 1 of Resident 2 ' s change of condition ([COC] sudden clinical deviation from a resident's baseline in physical, cognitive, behavioral, or functional status). According to Resident 2's [CONDITION(S)] Flowsheet on 9/20/2022 at 7:00 a.m., the resident ' s BP was 88/47, 100 cc of NS was given to Resident 2, and Ultra Filtration ([UF] the removal of fluid from a resident) was stopped. During an interview on 9/20/2022 at 8:01 a.m., the [CONDITION(S)] RN 1 stated she was unaware of the emergency when Resident 2 ' s blood pressure dropped down to 88/47. The [CONDITION(S)] RN 1 stated, CHT 3 had not chance to let her know. During a concurrent interview with [CONDITION(S)] RN1 on 9/20/2022 at 8:36 a.m. and record review of Hemodialysis Resident ' s (Resident 1,2,3,4,5,6,8,9,11,12) flowsheets for 9/20/2022 it indicated treatment started 4:25 a.m. and last treatment ended at 7:50a.m. [CONDITION(S)] RN1 stated that no continuous visual monitoring and assessment for those Resident that are receiving [CONDITION(S)]. On 9/20/2022 at 8:52 a.m., during a concurrent interview and review of [CONDITION(S)] communication logs dated 9/13/2022 for Residents 4, 1 ,2, 6,8, 9 and 10, the [CONDITION(S)] RN 1 confirmed there was no continuous visual monitoring of the residents during ongoing [CONDITION(S)] documented due to short staffing they had on those days. The [CONDITION(S)] communication logs indicated: 1. Resident 4 started [CONDITION(S)] treatment at 7:30 a.m. and stop treatment at 9:35 a.m., 2. Resident 1 has no start treatment time and end treatment time, 3. Resident 2 started [CONDITION(S)] treatment at 5:25 a.m. and stop treatment at 7:35 a.m. 4. Resident 6 started [CONDITION(S)] treatment at 4:25 a.m. and stop treatment at 6:25 a.m. 5. Resident 8 started [CONDITION(S)] treatment at 4:30 a.m. and stop treatment at 6:30 a.m. 6. Resident 9 started [CONDITION(S)] treatment at 4:35 a.m. and stop treatment at 6:35 a.m. 7. Resident 10 started [CONDITION(S)] treatment at 6:00 a.m. and stop treatment at 8:00 a.m. During an interview on 9/20/2022 at 8:54 a.m., the [CONDITION(S)] RN 1 stated three residents, Residents 6, 8, and 9 had their [CONDITION(S)] treatment started with five minutes interval of start time with the same primary care nurse, the [CONDITION(S)] RN 2. The [CONDITION(S)] RN 1 stated it was impossible to assess residents with a five-minute interval start time. The [CONDITION(S)] RN 1 stated, if it was documented it means it happened. During an interview on 9/20/2022 at 9:07 a.m., the [CONDITION(S)] RN 2 stated he just started working two weeks ago and that he is still learning the process. The [CONDITION(S)] RN 2 stated the dialyzed residents needed close monitoring because the residents at the skilled nursing facilities have a lot of medical co-morbidities (presence of two or more diseases or medical conditions in a patient) and their condition may change at any time during [CONDITION(S)] treatment. The [CONDITION(S)] RN 2 added he was not aware Resident 2 had a change of condition. During an interview on 9/20/2022 at 9:36 a.m., the DON stated a continuous assessment of each resident receiving [CONDITION(S)] was vital due to their co-morbidities and multiple medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the policy titled Patient policy manual [CONDITION(S)] dated 01/2022, indicated onsite supervision of [CONDITION(S)] by a trained and qualified caregiver whenever a resident is receiving hemodialysis (HD) in the Congregate Home facility. A qualified/trained [CONDITION(S)] caregivers are present in the room and maintain direct visual contact with the resident receiving HD throughout the entire duration of the treatment. The policy indicated that the RN is always present in the facility when residents are being treated. A review of the facility ' s policies and procedures (P&P) dated 09/2010 titled End- Stage Renal Disease, Care of a Resident, the P&P indicated that resident with [CONDITION(S)] will be cared for according to currently recognized standards of care. During a review of the contract Addendum to the coordination of services agreement dated 2/1/2022, the contract indicated that RN provided by the [CONDITION(S)] agency must ensure onsite supervision of [CONDITION(S)] treatment by a trained RN whenever a resident is receiving HD at the facility. The supervising RN must constantly be present on-site at facility and immediately available to respond to concerns or emergencies that may occur during a [CONDITION(S)] patients ' treatment. The supervising RN must be present in the general area where the resident is receiving [CONDITION(S)] and readily available. D. During an interview on 9/19/2022 at 4:40 a.m., the [CONDITION(S)] RN 1 stated, the schedule contains names of three CHT ' s and a [CONDITION(S)] RN 2. The [CONDITION(S)] RN 1 stated they did not have a divided set assignment with the residents ' names per [CONDITION(S)] staff, date, and time of [CONDITION(S)] treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The [CONDITION(S)] RN 1 stated that today she receives an update email that a new admitted resident needs to be dialyzed. She further added that, one of the [CONDITION(S)] resident was transferred to the hospital last weekend. On 9/19/2022 at 6:55 a.m., during a concurrent interview and review of the monthly staffing schedule for the month of September 2022, the [CONDITION(S)] RN 1 stated the schedule was just given to her last Friday on 9/16/2022. The [CONDITION(S)] RN 1 stated, there were discrepancies in the time. She stated they usually start at 3:15 a.m., and CHT 4 was on vacation first two weeks of September. She stated today (9/19/22) was the CHT 4 ' s first day back from vacation. The [CONDITION(S)] RN 1 added that a clear/ divided staffing schedule was the best way to verify who was assigned to monitor residents that has ongoing [CONDITION(S)]. During a review of the September 2022 [CONDITION(S)] staffing schedule, the schedule indicated two RNs and three CHTs were assigned to start at 3:30 a.m. and end at 12:00 p.m., the schedule did not include specific room assignments. During an interview on 9/19/2022 at 10:45 a.m., the DON stated she has been requesting additional RNs from the [CONDITION(S)] agency. The DON further added that adequate staffing will not compromise residents care or treatment. The DON also stated the facility staff helps and respond if there is an emergency, but it would be still different if they would be well experienced [CONDITION(S)] nurses. A review of the facility ' s P&P dated 10/2017 titled Staffing indicated the facility would provide sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. E. During an observation of Resident 1 ' s ongoing hemodialysis, on 9/19/2022 at 6:36 a.m., the resident observed vomiting. Resident 1 informed [CONDITION(S)] staff she did not feel good. During an interview on 9/19/2022 at 9:56 a.m., the [CONDITION(S)] RN 1 stated the facility, and the [CONDITION(S)] staff have a good communication. The [CONDITION(S)] staff provides assign license nurse the Communication Sheet at the end of each treatment. She added that plan of care was necessary for collaboration of each team member on residents ' goal and interventions to provide a good quality of care. During a review of Resident 1 ' s nursing progress notes (NPN) dated 9/19/2022, the NPN indicated Resident 1 ' s treatment was terminated early due to Resident ' s complain of chest pain and refusal to continue hemodialysis treatment. The facility RN made aware. During an interview on 9/20/2022 at 8:36 a.m., the [CONDITION(S)] RN1 stated yesterday (9/19/2022) Resident1 had an episode of vomiting and a chest pa

Based on interview and record review, the facility's nursing staff failed to conduct a thorough neurological assessment (a group of tests that help in determining if the functioning of the nervous system is impaired) and demonstrate a knowledge base by responding to the seriousness of what an abnormal neurological assessment entailed. They failed to adhere to its policy regarding a change of condition (COC) and use professional judgement to transfer a resident as an emergency via 911 (emergency services) for one of two sampled residents (Resident A). Resident A sustained a [MEDICATION(S)] head trauma ([BHT] any injury to the face, skull, or brain as a result of [MEDICATION(S)] force, or penetrating trauma) with other injuries and had a COC after falling from a gurney while being transported to a [CONDITION(S)] center for a hemodialysis treatment (a medical procedure to remove fluid and waste products from the blood and to correct electrolyte [minerals in the body that balance the amount of water in the body] imbalances). Resident A returned to the facility, over 6 hours later, and was assessed to have a wound on the top of her head, a bruise on the right side of her face and was noted to not be in her usual state of alertness. Resident A's neurological assessment did not indicate the size of Resident A's pupils. (cross referenced to F580). This deficient practice of the licensed nursing staff not understanding the relevance of Resident A's abnormal neurological assessment and the immediate need for emergency services to be called resulted in a delay in diagnosis, care, and treatment. Resident A remained in the facility for another three hours after returning from the [CONDITION(S)] center assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident A was pronounced deceased the next day on [DATE] at 8:15 a.m. On [DATE] at 4:10 p.m., a system failure was identified due to the facility's licensed nursing staff failure to accurately document, assess, and evaluate Resident A's abnormal neurological assessment and call for emergency service. 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 causes serious injury, harm, impairment, or death to a resident) was declared under F726. The facility's Administrator (ADM) and the Director of Nurses (DON) were notified of the serious non-compliance that threatened residents' health and safety. On [DATE] at 4:35 p.m., the facility submitted an acceptable plan of action (POA) and the DON was notified the IJ was lifted after onsite verification and confirmation to ensure the POA was implemented per interview and record review as follows: 1. A nurse practitioner in-serviced and demonstrated the relevance and importance of a neurological assessment. All licensed nurses on duty on [DATE] were in-serviced and the nurse managers demonstrated competency. The Nurse Managers who were trained by the nurse practitioner will complete a competency in-service for licensed nurses on other shifts. This competency will continue until [DATE] and will be completed upon hire and yearly. Nurses on leave will complete a competency evaluation upon return to work. 2. Five neurological assessment forms of residents who required a neurological assessment was reviewed by the DON and no deficient practice was found. 3. Competency assessment will be completed for all licensed nurses upon hire, yearly and as needed. 4. Licensed Nurses employee files will be reviewed every six months by the director of staff development (DSD) or designee for completion of competencies for neurological assessment starting [DATE]. If any deficiency is found immediate correction will be made by the DSD or designee and the licensed nurse will complete the competency form. Findings: A review of Resident A's Admission Records indicated Resident A was originally admitted to the facility on [DATE] and last readmitted on [DATE]. Resident A had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident A's Minimum Data Set (MDS), a resident assessment and care-screening tool, dated [DATE] indicated Resident A's cognitive (thought process) skills for daily decision-making were severely impaired. Resident A was totally dependent on the nursing staff for transferring and all her activities of daily living ([ADLs] task such as eating, bathing, dressing, grooming and toileting). Resident A required an extensive assistance for bed mobility, was non-ambulatory and was incontinent (inability to control) both bowel and bladder functions. The MDS indicated Resident A had no episodes of falls in the previous six months. A review of an Event Report dated [DATE] indicated Resident A had a witnessed fall by a vendor's staff at the facility outside the building. The sequence of events are as follows: 6:11 a.m. - Resident A picked up by a transportation company via a gurney accompanied by two EMTs ([emergency medical technician] a specially trained medical technician certified to provide basic emergency services) and one RT] ([respiratory therapist] a certified medical professional who specializes in providing healthcare for the lungs). 6:20 a.m. - A facility's vendor staff witnessed Resident A fall with her gurney to the ground in the facility's driveway leading to the parking lot. The EMTs declined taking Resident A back into the facility for an assessment and proceeded to transfer Resident A to the [CONDITION(S)] center. 7:48 a.m. - Communication with [CONDITION(S)] center indicated Resident A was noted with a right elbow bruising and a scratch on the right side of her face. The physician at the [CONDITION(S)] center was made aware and ordered an x-ray to the right elbow upon Resident A's return to the facility. 12:20 p.m. - Resident A back to the facility, with eyes closed and noted with a hematoma to her right forehead and right temporal-parietal (where the bones in the skull meet) area and a small hematoma on the right elbow. 1 p.m. - Resident A's attending physician (Physician 1) was notified of the fall with an abrasion to the right temporal parietal area, bruise on the right forehead and right elbow. Order obtained to transfer Resident A to a GACH. Phone call made to a transportation company with and ETA (estimated arrival time) of 60 minutes. 2:50 p.m. -A basic transportation company arrived and advised that Resident A be transferred by ACLS ([advanced cardiac life support] emergency transportation) 3:09 p.m. - 911 was called 3:18 p.m. - 911 (emergency transportation) arrived at the facility 3:20 p.m. - Resident A transferred to the GACH via 911 [DATE] at 1:08 p.m. - The facility was informed that Resident A expired from a subdural hematoma ([SDH] usually caused by a head injury strong enough to burst blood vessels and cause blood to pool and push on the brain). A review of a text message sent to Physician 1 by RN 1, dated [DATE] and timed at 1:38 p.m., eight hours after Resident A's fall, indicated the following: Hello, on (Resident A), it was reported that she fell on the ground with the gurney on her way to the ambulance for her [CONDITION(S)] earlier. We didn't get to assess the patient as she was taken to the [CONDITION(S)]. The hemodialysis physician gave an order to do an x-ray on the right arm as she fell on her right side. She also has abrasion on her right temporal parietal area and a bruise on her right frontal and right arm. and she's not as responsive as her usual state. Can we send her out for further evaluation? According to the text (no time indicated), Physician 1 responded yes. RN 1 then text Physician 1, (no time indicated) which hospital doc? Physician 1 responded at 2:38 p.m., with the name of the GACH where he wanted Resident A to be transferred. A review of Resident A's Neurological Assessment, dated [DATE] indicated at 12:20 p.m., 12:45 p.m., 1 p.m., 1:15 p.m., 2:15 p.m., and 3:15 p.m., Resident A's right pupil was non-reactive (no response to light) and her left pupil was sluggish (slow response to light). The Neurological Assessment indicated the size of Resident A's pupils were not documented. A review of an article titled, The Neurological Wake-up Test, published by the National Center for Biotechnology Information on [DATE] indicated intense clinical monitoring is an integral part of the management or traumatic brain injury (TBI) patients. Neurological worsening, commonly defined as a decrease of two or more points on the motor component of the Glasgow Coma Scale score ([GCS]- a method of evaluating the level of consciousness and overall status of the central nervous system; score ranging from ,d+[DATE]), may occur rapidly and is associated with a poor outcome in traumatic brain injury. Clinical deterioration may be caused by, e.g., ongoing hemorrhage or increased brain swelling. In addition, information from these neurological examinations may prove important in clinical decision-making, and lead to improved patient outcome. The components of the neurological examination used for monitoring can vary depending on the clinical situation, although assessment of the level of consciousness, neurological motor function, and assessment of pupillary size and reactivity is a minimal requirement. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 71/ A review of Resident A's GACH emergency room (ER) records, dated [DATE] indicated the following: Neuro: Resident A's GCS ([Glasgow coma score] - a method used to determine a patients conscious state ranging from ,d+[DATE]) was 3 (comatose [unresponsive] Eyes: right pupil fixed at 5 millimeters ([mm=unit of measurement] normal is ,d+[DATE] mm in bright light to ,d+[DATE] mm in the dark) and left pupil fixed at 3 mm A review of Resident A's chest CT ([computed (computerized) tomography] an X-ray image made using a computer) indicated there was a non-displaced right lateral (outside) fifth rib fracture (broken bone). A review of Resident A's head CT indicated there was a large right subdural hematoma measuring up to 31 mm ([millimeter] unit of measurement) with a 22 mm of leftward midline shift (the brain shifts beyond the center line of the brain; normally caused by a traumatic event involving the brain or head ) and a severe right and left herniation (a potentially deadly side effect of very high pressure within the skull that occurs when a part of the brain is squeezed across structures within the skull). The CT scan of the head indicated the herniations caused entrapment of the left temporal horn (a part of the brain) and an extension of subdural hemorrhage. A review of Resident A's GACH discharge summary, dated [DATE] and timed at 10:44 a.m. indicated the resident presented to the ER after a fall and was found to have a massive SDH with a midline shift. Resident A's family decided to withdraw care. All treatment was withdrawn in the ER according to the Summary Discharge note. Resident A was pronounced deceased on [DATE] at 8:15 a.m. On [DATE] at 10:47 a.m., during an interview, and subsequent interviews at 11:09 a.m. and 3:30 p.m., Registered Nurse 1 (RN 1) stated she assessed Resident A upon arrival from the [CONDITION(S)] center and noted a bruise to the right side of her forehead that was larger than a quarter, an abrasion with redness to the resident's right temporal parietal area of her head and a bruise to her right elbow that was larger than a quarter. RN 1 stated she was not able to gauge the size of the injury to Resident A's right temporal parietal area because the resident's hair covered it. RN 1 stated a neurological assessment was done but stated she did not document the size of Resident A's pupils. RN 1 stated she remembered Resident A's right pupil was larger than the left. RN 1 stated she was aware that non-reactive, sluggish pupils were not normal but stated Resident A had neurological deficits because of her condition and she (RN 1) did not know Resident A's neurological baseline. RN 1 stated she contacted Resident A's attending physician via text message letting him know about Resident A's fall, the two bruises to the head and elbow. RN 1 stated she did not report the results of the abnormal neurological assessment to Resident A's physician. RN 1 stated Resident A's physician responded via text message telling her to transfer Resident A to a GACH for evaluation. RN 1 stated when she contacted the transportation company to request a transfer for Resident A and was told they would arrive in approximately an hour RN 1 stated she did not think to call 911. RN 1 stated when the basic ambulance transportation company arrived, and saw the extent of Resident A's injuries they refused to transport Resident A and 911 was called. On [DATE] at 3:05 p.m., during an interview, Resident A's physician (Physician 1) stated he was contacted by the facility and made aware that Resident A had head injuries after a fall. Physician 1 stated he instructed the nurse who contacted him to transfer the resident to a GACH, later he was told the EMTs would not take Resident A to the GACH, they call 911 and sent her out via ambulance. Physician 1 stated he was first contacted when Resident A returned from her [CONDITION(S)] appointment (1 p.m.), he was not contacted when Resident A fell in the morning. Additional attempts to contact Physician 1 were unsuccessful. A review of the facility's policy and procedure (P/P), revised in [DATE] and titled Competency of Nursing Staff indicated all nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by State Law. The P/P also indicated a list of skill competencies and techniques required for the nurse at the facility to care for the residents that included Identification of changes in condition and critical thinking. The P/P provided an example, which stipulated LPNs and RNs were trained for and evaluated on managing and reporting pertinent findings to the providers. A review of an undated facility's P/P titled, Change of Condition indicated to ensure proper assessment and follow-through for any resident with a change of condition. The P/P indicated a change of condition was a sudden or marked difference in a resident's: bruises, skin condition (e.g., swelling or discoloration). All changes of condition in a resident shall be handled promptly. The physician shall be called promptly. In cases of emergency changes in the condition of a resident, the following actions are options. The nurse may dial 911 if necessary.

Based on interview and record review, the facility's staff failed to notify a resident's (Resident A) primary physician (physician 1) immediately (approximately seven hours passed before Resident A's physician was notified of her fall) when Resident A fell from a gurney, hit her head and developed neurological changes (results from injury or changes to the functioning of the brain, spine or nerves). The facility failed to adhere to their change of condition (COC) policy and procedure that stipulated in the case of an emergency 911 may be called for one of two sampled residents (Resident A). Resident A fell hitting the ground while being transported by two EMTs ([emergency medical technician] a person specially trained and certified to administer basic emergency services to victims of trauma or acute illness) to a [CONDITION(S)] center for hemodialysis treatment (a medical procedure to remove fluid and waste products from the blood and to correct electrolyte imbalances). Resident A sustained [MEDICATION(S)] head trauma ([BHT] any injury to the face, skull, or brain as a result of [MEDICATION(S)] force, or penetrating trauma), multiple bruises and hematomas (a collection of blood outside of blood vessels). Resident A returned to the facility six (6) hours later an assessment indicated a wound on the top of the resident's head, a right facial bruise and the resident was noted to not be in her usual state. A neurological assessment (a group of tests that help in determining if the functioning of the nervous system is impaired) was conducted indicating Resident A's right pupil was non-reactive (no response to light) and her left pupil was sluggish (slow response to light). This deficient practice resulted in a delay in care and services for over nine (9) hours after Resident A had a fall and sustained BHT with an intracranial bleed (life-threatening emergency with acute bleeding inside the skull or brain), right 5th rib fracture (broken bone), and multiple bruises. Resident A was transferred to a general acute care hospital (GACH), three hours after her abnormal neurological assessment, for evaluation and treatment and was diagnosed with a subdural hematoma ([SDH] a type of bleeding in which a collection of blood-usually associated with a traumatic brain injury-gathers between the inner layers surrounding the brain). Resident A was pronounced deceased at the GACH the next morning on [DATE] at 8:15 a.m. On [DATE] at 4:10 p.m., the Administrator (ADM) and the Director of Nursing (DON), were notified that an Immediate Jeopardy ([IJ], a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called for the facility's failure to notify Resident A's physician immediately of a COC resulting in a delay in diagnosis, care and treatment (Cross Reference F726). The ADM and DON were informed of the seriousness of the deficient practice and other residents' health and safety being threatened. On [DATE] at 4:35 p.m., the facility submitted an acceptable plan of action (POA) and the DON was notified the IJ was lifted after an onsite verification and confirmation was made to ensure the POA was implemented per interview and record review as follows: 1. All licensed nurses will be in-serviced beginning [DATE] to report to the resident's attending or alternate physician when an unusual occurrence happens. If the attending physician does not respond within 15 minutes, call the medical director. In an emergency they will call 911 then notify the physician. 2. Five residents were identified with falls, incidents and/or unusual occurrences their charts were review by the DON. No discrepancies were identified. 3. During the daily stand up meeting, beginning [DATE], falls and incidents will be discussed, and charts will be reviewed by Medical Records and the DON for deficient charting, physician notification and physician response. Any negative findings will be reported and corrected immediately and reported monthly at the QA meeting. 4. The Quality Assurance Nurse, Medical Records and the DON will be responsible for monitoring of resident's falls and incidents, prompt physician notification and response. Findings: A review of Resident A's Admission Records indicated Resident A was originally admitted to the facility on [DATE] and last readmitted on [DATE]. Resident A's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident A's Minimum Data Set (MDS), a resident assessment and care screening tool, dated [DATE] indicated Resident A's cognitive skills (thought process) for daily decision-making was severely impaired. The MDS indicated Resident A was totally dependent on staff for transferring and completion of activities of daily living ([ADLs] task such as eating, bathing, dressing, grooming and toileting). The MDS indicated Resident A required an extensive assist for bed mobility and was non-ambulatory and incontinent (unable to control) of both bowel and bladder functions. According to the MDS, Resident A had no episodes of falls in the last six months. A review of an Event Report dated [DATE] indicated Resident A had a witnessed fall outside the building. The sequence of events was as follows on [DATE]: 6:11 a.m. - Resident A picked up by a transportation company via a gurney accompanied by two EMTs and one RT ([respiratory therapist] a certified medical professional who specializes in providing healthcare for the lungs). 6:20 a.m. - A facility's [CONDITION(S)] technician witnessed Resident A fall with her gurney to the ground in the facility's driveway leading to the parking lot. The EMTs declined taking Resident A back into the facility for an assessment and proceeded to transfer Resident A to the [CONDITION(S)] center. 7:48 a.m. - Communication with [CONDITION(S)] center indicated Resident A was noted with right elbow bruising and a scratch on the right side of her face. The physician at the [CONDITION(S)] center was made aware and ordered an x-ray to the right elbow upon Resident A's return to the facility. 12:20 p.m. - Resident A back to the facility, with eyes closed and noted with a hematoma to her right forehead and right temporal-parietal (where bones in the skull meet) area and a small hematoma on the right elbow. 1 p.m. - Resident A's attending physician was notified of the fall with an abrasion to the right temporal parietal area, bruise on the right forehead and right elbow. Order obtained to transfer Resident A to a GACH. Phone call made to a transportation company with and ETA (estimated arrival time) of 60 minutes. 2:50 p.m. -A basic life support transportation (non-emergency transport) company arrived and advised that Resident A be transferred by ACLS ([advanced cardiac life support] emergency transport) 3:09 p.m. - 911 was called 3:18 p.m. - 911 arrived at the facility 3:20 p.m. - Resident A transferred to the GACH via 911 [DATE] at 1:08 p.m. - The facility was informed that Resident A expired from a subdural hematoma. A review of Resident A's Neurological assessment dated [DATE] indicated at 12:20 p.m., 12:45 p.m., 1 p.m., 1:15 p.m., 2:15 p.m., and 3:15 p.m., Resident A's pupils were assessed, the right pupil was non-reactive and the left pupil was sluggish. The Neurological Assessment did not indicate the size of Resident A's pupils. A review of Resident A's GACH emergency room (ER) records, dated [DATE] indicated the following: Neuro: Resident A's GCS ([Glasgow coma score] - a method used to determine a patients conscious state ranging from ,d+[DATE]) was 3 (comatose [unresponsive] Eyes: right pupil fixed at 5 millimeters ([mm=unit of measurement] normal is ,d+[DATE] mm in bright light to ,d+[DATE] mm in the dark) and left pupil fixed at 3 mm A review of Resident A's CT ([computed (computerized) tomography] an X-ray image made by using a computer) of the chest without contrast (a dye used to help highlight the areas of the body being examined) indicated a non-displaced (a bone that is cracked but maintains its proper position) right lateral (outside) fifth rib fracture (broken bone). A review of Resident A's head CT indicated there was a large right subdural hematoma measuring up to 31 mm ([millimeter] unit of measurement) with a 22 mm of leftward midline shift (the brain shifts beyond the center line of the brain; normally caused by a traumatic event involving the brain or head ) and a severe right and left herniation (a potentially deadly side effect of very high pressure within the skull that occurs when a part of the brain is squeezed across structures within the skull). The CT scan of the head indicated the herniations caused entrapment of the left temporal horn (a part of the brain) and an extension of subdural hemorrhage. A review of Resident A's GACH discharge summary, dated [DATE] and timed at 10:44 a.m. indicated the resident presented to the ER after a fall and was found to have a massive SDH with a midline shift. Resident A's family decided to withdraw care. All treatment was withdrawn in the ER according to the Summary Discharge note, Resident A was pronounced deceased on [DATE] at 8:15 a.m. On [DATE] at 10:47 a.m., during an interview and subsequent interviews at 11:09 a.m. and 3:30 p.m., the same day, Registered Nurse 1 (RN 1) stated Resident A was not alert and oriented but would often open her eyes but could not follow movement. RN 1 stated she was aware or Resident A's fall and report from the [CONDITION(S)] center that Resident A sustained a scratch to the side of the face, a bruise to the elbow and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN 1 stated she assessed Resident A on arrival to the facility from the [CONDITION(S)] center and saw a right facial bruise on the forehead that was larger than a quarter, an abrasion with redness to the right temporal parietal area and a bruise to the right elbow that was larger than a quarter. RN 1 stated she was not able to gauge the size of the injury to Resident A's right temporal parietal area because the resident's hair covered it. RN 1 stated a neurological assessment was done upon Resident A's arrival to the facility. RN 1 stated she did not document the size of Resident A's pupils but remembers the right pupil was larger than the left one. RN 1 stated she was aware that non-reactive, sluggish pupils were not normal findings and should be reported. RN 1 stated she contacted Resident A's attending physician (1 p.m.) via text message letting him know about Resident A's fall, the two bruises to her head and elbow. RN 1 stated she did not report the results of the abnormal neurological assessment to Resident A's physician. RN 1 stated Resident A's physician responded via text message telling her to transfer Resident A to a GACH for evaluation. RN 1 stated when she contacted the transportation company to request a transfer for Resident A and was told they would arrive in approximately an hour RN 1 stated she did not think to call 911. RN 1 stated when the basic ambulance transportation company arrived, and they saw the extent of Resident A's injuries they refused to transport Resident A and 911 was called. On [DATE] at 12:10 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated a neurological assessment was done as soon as Resident A arrived back to the facility. LVN 1 stated Resident A would normally open her eyes when touched and noted Resident A was having a hard time opening her eyes but stated she thought it was because Resident A was tired after [CONDITION(S)] and did not think much of it. LVN 1 stated Resident A's right pupil was non-reactive, her left pupil was sluggish and smaller than the right pupil and the right pupil was fixed (a large pupil that is completely unresponsive to light). LVN 1 stated the results of the neurological assessment should have been considered as an emergency, especially after Resident A sustained a head injury and 911 should have been called. LVN 1 stated she reported to the RN supervisor (RN 1) that Resident A's physician should be called to get an order to transfer the resident. LVN 1 stated they did not initially call 911. On [DATE] at 3:05 p.m., during an interview, Resident A's physician stated he was contacted by the facility and made aware that Resident A had head injuries after a fall. Physician 1 stated he instructed the nurse who contacted him to transfer the resident to a GACH, later he was told the EMTs would not take Resident A and they sent her to a GACH after contacting 911 via an ambulance. Resident A's physician stated he was first contacted when Resident A returned from her [CONDITION(S)] appointment (1 p.m.), he was not contacted when Resident A fell in the morning. Additional attempts to contact Physician 1 were unsuccessful. On [DATE] at 4:30 p.m., during a telephone interview, a representative from the basic transportation company, who was initially dispatched to transfer Resident A to a GACH on [DATE], stated when the EMTs arrived at the facility Resident A had a report of a fall. The representative stated Resident A was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The representative stated the EMTs decided to call 911. A review of a text message sent to Physician 1 by RN 1, dated [DATE] and timed at 1:38 p.m., eight hours after Resident A's fall, indicated the following: Hello, on (Resident A), it was reported that she fell on the ground with the gurney on her way to the ambulance for her [CONDITION(S)] earlier. We didn't get to assess the patient as she was taken to the [CONDITION(S)]. The hemodialysis physician gave an order to do an x-ray on the right arm as she fell on her right side. She also has abrasion on her right temporal parietal area and a bruise on her right frontal and right arm and she's not as responsive as her usual state. Can we send her out for further evaluation? According to the text (no time indicated), Physician 1 responded yes. RN 1 then text Physician 1, which hospital doc? (no time indicated) Physician 1 responded at 2:48 p.m., with the name of the GACH where he wanted Resident A to be transferred. A review of an undated facility's policy and procedure (P/P) titled, Change of Condition indicated to ensure proper assessment and follow-through for any resident with a change of condition. A change of condition is a sudden or marked difference in a resident's: bruises skin condition (swelling or discoloration). All changes of condition in a resident shall be handled promptly. In cases of emergency changes in the condition of a resident, the following actions are options. The nurse may dial 911 if necessary.

Based on observation, interview, and record review, the facility failed to follow its policy on abuse and ensure two of four residents (Residents 1 and 3) were protected from being roughly handled and abused by a facility staff member (CNA 1) during care. This deficient practice resulted in Resident 1 and 3 being rough handled and physically abused. Resident 1 sustained a bruise to the right hand and mental anguish to both Resident's 1 and 3. Findings: On 11/21/17 at 2:17 p.m., during an interview, the Director of Nursing (DON) stated an investigation was being conducted regarding a physical abuse incident between Certified Nursing Assistant 1 (CNA 1) and Resident 1. A review of Resident 1's Admission Face Sheet indicated the resident was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. ([MEDICAL CONDITION]) blood flow to a part of the brain is stopped either by a blockage or the rupture of a blood vessel) [MEDICAL CONDITION] disease (disease of the blood vessels that supply the brain) affecting the left side. A review of Resident 1's quarterly Minimum Data Set (MDS), a resident assessment and care screening tool, dated 11/16/17, indicated Resident 1 had no memory problems, and no impaired decision-making, was able to make needs known and understand others. Resident 1's Brief Interview of Mental Status (BIMS) score was 14 (BIMS score 9-15 means interviewable). According to the MDS, Resident 1 was assessed as requiring extensive assistance with bed mobility, transferring, locomotion on and off the unit, as well extensive assistance with personal hygiene. A review of a progress note, dated 11/17/17 and timed at 7 p.m., indicated Resident 1 complained of pain to the right hand and shoulder. According to an assessment, the right hand was discolored blue/green measuring 3x3 centimeter (cm) with complaint of right hand and shoulder pain to touch with movement. The progress report, indicated Resident 1 informed staff that CNA 1 assisted her out of bed and into the wheelchair, by grabbing her right hand pulling her up in a fast motion. Resident 1 told CNA 1 she was being rough. A review of a Situation, Background, Assessment, Recommendation ((SBAR) communication tool used between licensed nurses) communication form, dated 11/17/17, indicated Resident 1 reported pain to the right hand and right shoulder. Resident 1 informed staff that CNA 1 assisted her out of bed and into the wheelchair by grabbing her right hand pulling her up in a fast motion. On 11/21/17 at 2:30 p.m., during an observation, Resident 1 had a purple discoloration on top of the right hand. On 11/21/17 at 2:31 p.m., during an interview, Resident 1 stated, I was using the commode, and I needed assistance to get into the wheelchair to finish my morning care before breakfast. She (CNA 1) told me to stand, I am old and I cannot stand. She (CNA 1) told me, so my back hurts, you can stand for a moment and she then pulled me by the hand and it pulled up to my shoulder. I had a lot of pain and she (CNA 1) squeezed my hand hard while pulling it. I am very upset and I am scared. On 11/21/17 at 3:40 p.m., a review of a hand written declaration written by Resident 2, indicated I noticed a bruise on the right wrist of my friend (Resident 1) and she began to tell me how a CNA (CNA 1) was rough handling her and hurt her shoulder and bruised her wrist. She said the CNA was rude, disrespectful, and very argumentative. A review of Resident 2's Admission Face Sheet indicated the resident was admitted to the facility on [DATE]. Resident 2's [DIAGNOSES REDACTED]. A review of Resident 2's quarterly MDS, dated [DATE], indicated Resident 2 had no memory problems, no impaired decision-making, and was able to make needs known and understand others. Resident 2's BIMS score was 15. According to the MDS, Resident 2 was assessed requiring limited assistance in bed mobility, transferring, locomotion on and off the unit, supervision with eating and limited assistance with personal hygiene. On 11/21/17 at 4:08 p.m., during an interview, the Director of staff development (DSD) stated, Upon reviewing her (CNA 1) employee file I realized another resident (Resident 3) reported an allegation against her (CNA 1) as well. The other resident (Resident 3) accused her (CNA 1) of hitting him in the arm during care. A review of a confidential report, dated 8/24/17 indicated Resident 3 reported CNA 1 for an alleged physical abuse. The report indicated Resident 3 told the facility's staff that he did not want CNA 1 to continue to care for him due to her rough handling. The confidential report indicated that CNA 1 hit Resident 3 during care on 8/23/17. On 11/22/17 at 10:04 a.m., during an interview, Resident 3 stated, She (CNA 1) was changing me, pushing, and pulling me so rough I told her please not to be so rough, then she socked me in my left arm. I was so mad and insulted. She hit me with a closed fist and thinks she can get away with it. I do not want her to hit anyone else. A review of Resident 3's Admission Face Sheet indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 3's [DIAGNOSES REDACTED]. A review of Resident 3's quarterly MDS dated [DATE], indicated Resident 3 had no memory problems, no impaired decision-making, was able to make needs known and understand others with a BIMS score of 12. According to the MDS, Resident 3 was assessed as being totally dependent with bed mobility, transferring, and locomotion on and off the unit, as well as being totally dependent with personal hygiene. A review of a care plan titled, Allegations against Staff dated 8/23/17 identified Resident 3's concern of making allegations of inappropriate treatment by staff, stating CNA (CNA 1) punched his left forearm. The goals included no physical interactions with the staff member and no more allegations against the staff member (CNA 1). The staff's approach included to perform skin/ body assessment and handle resident gently at all times. On 11/22/17 at 9:06 a.m., during an interview, the MDS nurse stated, The Resident (Resident 1) is able to stand with assistance, usually with a walker because she has paralysis on the left side with weakness on the right side. 11/22/17 at 11:25 a.m., during an interview, Resident 4 stated, The CNA (CNA 1) could be a little more patient during care, she needs training. She can be very abrupt and rough with care, I reported her before to the charge nurse. Nothing was done. A review of Resident 4's Admission Face Sheet indicated the resident was admitted to the facility on [DATE]. Resident 4's [DIAGNOSES REDACTED]. A review of Resident 4's Admission MDS, dated [DATE], indicated Resident 4 had no memory problems, no impaired decision-making, was able to make needs known and understand others with a BIMS score of 13. According to the MDS, Resident 4 was assessed requiring extensive assistance with bed mobility, transferring, locomotion on and off the unit, with eating and with personal hygiene. On 12/5/17 at 3:56 p.m., during an interview, the Director of Human resources stated, The CNA (CNA 1) was terminated because of residents' complaints. On 12/5/17 at 4:05p.m., during an interview, the DON stated, I reviewed this case and the other case of her (CNA 1) hitting another resident (Resident 3). HR (Human resources) has discharged the CNA (CNA 1), she said she was sorry and I explained to her, that with older residents she needs to be gentle during resident care. A review of CNA 1's employee file indicated date of hire was 4/20/17. CNA 1 completed Elder and Dependent adult abuse training on 4/27/17. A review of a corrective action notice, dated 8/23/17, indicated CNA 1 was suspended due to an allegation of physical abuse of Resident 3. A review of a corrective action notice, dated 11/17/17, indicated CNA 1 was suspended due to an allegation of physical abuse of Resident 1. A review of a corrective action notice, dated 11/27/17, indicated CNA 1's date of termination was 11/27/17. A review of the facility's undated policy titled Abuse Prevention program indicated residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This included but was not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the residents' symptoms.

Based on interview and record review, the facility failed to follow its policy and procedure and a resident's plan of care to notify the physician when a resident had a change of condition to ensure that the necessary care and services were provided for one of three sampled residents who had a change in condition (Resident 1). Resident 1, who refused to eat and take medications, was heard and seen moaning in pain, but was not assessed nor was the change of condition reported to the resident's physician and responsible party . These deficient practices of the facility not adequately assessing and not reporting Resident 1's change of condition (C[NAME]) resulted in a delay in diagnosis, treatment, and services for the resident. Resident 1 was later found unresponsive and pronounced deceased by the paramedics. Findings: A review of Resident 1's closed record Admission Face Sheet indicated the resident was initially admitted to the facility on [DATE] and last re-admitted on [DATE], after receiving blood [MEDICAL CONDITION] in the general acute care hospital (GACH). Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), an assessment and care screening tool, dated [DATE], indicated Resident 1 was able to make needs known and had the ability to understand and be understood. The MDS indicated Resident 1 required extensive assistance of a one-person physical assist with activities of daily living ((ADLS) routine activities of life). According to the MDS, the resident's Brief Interview for Mental Status (BIMS) score was 14 (score of ,[DATE] means interviewable). A review of Resident 1's physician's orders [REDACTED]. full treatment for [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED].(S/S) of infection. The orders also stipulated to document and refer to the physician if needed, per protocol. A review of Resident 1's care plan titled, At Risk for Complications Secondary to receiving [MEDICAL TREATMENT], dated [DATE], indicated the staff interventions included to assess the resident, evaluate for pain, numbness/tingling, redness, drainage and/or any signs and symptoms (S/S) of infection of the left upper arm site, and notify the physician and the resident's representative for any C[NAME]. A review of a nurses' written note, by Licensed Vocational Nurse 2 (LVN 2), dated [DATE], and timed at 10:30 a.m., indicated Resident 1 went out for [MEDICAL TREATMENT] treatment that day transported by a medical van. The nurses' note indicated Resident 1 was alert and oriented to person, place and time, coherent and able to make needs known. No complaints of pain and/or acute distress. Resident 1's pre-[MEDICAL TREATMENT] vital sign were, blood pressure ,[DATE] mm/hg (Normal Reference Range (NRR) ,[DATE]), temperature was 98.9 degrees Fahrenheit (F) (NRR 97XXX,[DATE].5 °F), pulse was 78 beats a minute (NRR ,[DATE] beats per minute (bpm)), respirations was 18 breaths (NRR ,[DATE] per minute), and 0 pain from a scale of ,[DATE], (0 as no pain, and 10 being severe pain). The nurses' note for post-[MEDICAL TREATMENT] did not indicate Resident 1's vital signs, pain assessment and/or left arm site assessment upon returning to the facility. A review of LVN 1 electronic nurses' note, dated [DATE], and timed at 10:54 p.m., indicated on 12//,[DATE] at 3:15 p.m. (late entry (L/E)), the resident was in the bed awake, alert to staff, verbally able to make needs known. Resident 1 had no complaints of pain, discomfort, no signs and symptoms of acute distress. At 4 p.m., on the same day, Resident 1 was up in a wheelchair, alert, oriented to person, place, and time. According to the L/E nurses' note, the resident was doing exercises with the physical therapist (PT) in PT room, no complaints of pain or discomfort was observed and tolerated the task well. At 5 p.m., on the same day, Resident 1 was back in bed asleep, responsive to tactile (touch) stimuli, no signs or symptoms of pain or distress, respiration was even and unlabored. No shortness of breath, vital signs was B/P ,[DATE], temperature was 97.2 F, pulse was 60 bpm, and respirations was 16 breaths a minute. The blood sugars checked and no hypo/[MEDICAL CONDITION] noted. Resident 1 refused to eat dinner. At 7 p.m., on [DATE], the note indicated Resident 1 was in bed, alert, oriented to staff, responsive to all tactile stimuli, no signs or symptoms of pain or distress, all needs met at that time. At 7:30 p.m., on [DATE], the note indicated the resident had pain, while in bed, moaning out loud. LVN 1 asked the resident if he had pain, but the resident did not respond. According to the note, LVN 1 repositioned the resident, but did not recheck the resident's vital signs, blood sugar levels, and/or call the physician. At 7:55 p.m., on [DATE], 25 minutes later, on the same day, the note indicated Resident 1 was found in bed unresponsive, without any vital signs, and Code Blue was called (used to indicate a patient requiring resuscitation or in need of immediate medical attention, such as CPR). CPR was started by the facility's respiratory therapist. 911 was called and the paramedics arrived, assessed Resident 1, and pronounced the resident deceased at 8:06 p.m. At 8:10 p.m. on [DATE], Resident 1's physician and family member were notified of the resident's death. There was no documented evidence Resident 1's physician or family were made aware of the resident's change in condition prior to expiring. On [DATE] at 10:35 a.m., during an interview, Resident 1's roommate, Resident 2 stated Resident 1 looked good that morning ([DATE]), before he left for his [MEDICAL TREATMENT] treatment. Resident 2 stated Resident 1 started moaning after the dinner tray pass and he was concerned about Resident 1's moaning. Resident 2 stated he started yelling for help to get the nurses to come and help his roommate. Resident 2 stated when the nurses finally came he yelled and cursed at them. On [DATE] at 10:58 a.m., during a concurrent interview and record review, the Director of Staff Development (DSD) stated certified nursing assistants are supposed to report any change of condition of the residents. On [DATE] at 11:40 a.m., during an interview, the acting Director of Nurses (DON) stated LVN 1 did not call Resident 1's physician about the resident's C[NAME] during the time the resident was moaning and unresponsive to LVN 1 questions and should have. On [DATE] at 12:29 p.m., during a telephone interview, Certified Nursing Assistant 1 (CNA 1) stated he was assigned to Resident 1 on [DATE] on the 3 p.m.-11 p.m. shift. CNA 1 stated Resident 1 was sleeping at the start of the shift (3 p.m.). At approximately 5:10 p.m., on [DATE], CNA 1 stated he informed LVN 1 that Resident 1 did not eat dinner and was moaning. On [DATE], at 11:40 a.m., during an interview, Registered Nurse 1 (RN 1) stated if there was a change in a resident's condition, such as moaning, it needed to be communicated to the resident's physician and family. RN 1 stated the charge nurse on duty should have been assessing Resident 1's vital signs and reported to the RN Supervisor and the physician immediately. At 11:45 p.m., on [DATE], during an interview, RN 2 stated any resident's change of condition should be assessed by the charge nurse, which included taking vital signs and notifying the physician about the change of condition right away. RN 2 stated it was important to identify, recognize and report the resident's change of condition, because it can lead to a delay in treatment and interventions, which can result in injury or death to the resident. On [DATE], at 12:05 p.m., during a telephone interview, LVN 1 stated she performed an end of shift rounds with outgoing LVN 2 from the 7 a.m.-3 p.m. shift. At 7 p.m., on [DATE], LVN 1 stated Resident 1 was still in bed. At 7:30 p.m., on [DATE], LVN 1 stated Resident 1 was in bed moaning out loud. LVN 1 stated she asked Resident 1 if he was in pain, but the resident did not respond to the question. LVN 1 stated she did not take the vital signs or inform Resident 1's physician about the change of condition, but should have. At 7:55 p.m., on [DATE], LVN 1 stated Resident 1 was found unresponsive, without vital signs and code blue was called. CPR was started by the respiratory therapist and 911 called. LVN 1 stated once paramedic arrived, Resident 1 was pronounced deceased at 8:06 p.m. At 8:10 p.m., LVN 1 notified the physician and responsible party of Resident 1's death. LVN 1 stated she did not notify the physician prior to the death of Resident 1. On [DATE] at 12:35 p.m., during a telephone interview, Resident 1's physician (Physician 1) stated he was notified about Resident 1's death. When asked if he was notified about the resident's change of condition prior to his death, Physician 1 replied, I do not know, I do not remember. On [DATE] at 12:14 p.m., during an interview, Licensed Vocational Nurse 2 (LVN 2) stated Resident 1 came back from [MEDICAL TREATMENT] at approximately 2:15 p.m., on [DATE]. LVN 2 stated she asked to check the resident's blood pressure, but Resident 1 refused and became agitated. LVN 2 stated she did not re-attempt to check the resident's vital signs or check the bruit (abnormal sound heard through a stethoscope (medical instrument used to listen to one's heart or lungs)) and thrill (vibrating sensation felt on the skin) on the arteriovenous shunt (passageway that allows blood to flow directly from an artery to a vein). At 4:35 p.m., LVN 2 stated she saw Resident 1 with two physical therapists walking in the hallway. LVN 2 stated she did not report to physician about Resident 1's refusal of an assessment with yelling and screaming. LVN 2 stated if a resident was unresponsive and not responding, the pulse and blood pressure should be checked and the RN supervisor and the physician should also be notified. On [DATE] at 3:30 p.m., during an interview with LVN 1, stated the Resident 1's roommate yelling was what that got her attention. LVN 1 stated that Resident 1 refused dinner, refused all medications, but she did not report it to Resident 1's physician. LVN 1 stated, Resident 1 did not speak, just shook his head. On [DATE] at 7:30 p.m., LVN 1 stated that CNA 1 told her that Resident 1 was moaning, not responding at the time when she repositioned the resident but did not notify Resident 1's physician. Resident 1's physician was not notified about the change of condition at 7:30 p.m., when LVN 1 ask Resident 1 if he was in pain, and Resident 1 did not respond. LVN 1 stated she did not report to the RN Supervisor on duty. LVN 1 read and reviewed own documentation entered on [DATE] at 10:54 p.m., and LVN 1 stated Resident 1 had a change of condition at 7:30 p.m., and should have reported it to the physician, taken the resident's vital signs and called 911. LVN 1 stated, It is important to identify and recognize Resident 1's condition because it could have saved his life. A review of the facility's undated policy and procedure titled, Care of the [MEDICAL TREATMENT] Resident, indicated that Resident 1 was to be monitored for infection or clotting of the access site. The nursing staff were to monitor for swelling, pain, redness, or drainage of the shunt and monitor bruit as ordered. A review of the facility's undated policy and procedure titled, Vital Signs, indicated vital signs will be taken on admission, weekly and as needed due to change of condition. A review of the facility's Charge Nurse/Licensed Vocational Nurse Job Description indicated nurses were responsible for monitoring vital signs, pre/post -[MEDICAL TREATMENT] assessment, assessment and interventions related to changes of patient condition, such as changes of level of condition, confusion, and pain management. The job description indicated the nurses should monitor the behavior, identify and assess emergency medical situations and provide appropriate interventions as indicated. A review of the Paramedics' Care Report Summary, dated [DATE], indicated the paramedics were called at 7:58 p.m. and arrived on the scene at 7:59 p.m. The paramedics' Narrative History indicated the following: Male found in [MEDICAL CONDITION] asystole (no heart beat), breathing absent, skin condition is dry with lividity (dark purple discoloration of the body and can also be referred to as Livor Mortis or Post Mortem Hypostasis (key factors that are used when estimating the time of Death)), the resident (Resident 1) determined dead at 8:07 p.m. A review of Resident 1's death certificate, signed by the physician on ,[DATE] /18, indicated the resident expired on [DATE] with the cause of death as [MEDICAL CONDITION] (a sudden, sometimes temporary, cessation of function of the heart). A review of the facility's policy, titled, Change in Condition, dated 2000, indicated under Purpose was to assure that appropriate care and documentation occurs when residents experience a change of condition. Under Procedure, it indicated to assess the resident's condition: limited movement, neurological checks for injuries such as falls, pain, swelling, bruising, discoloration, vital signs. The policy indicated to notify the Attending Physician promptly, notify the family, document what, where, symptoms, assessment, treatment notifications. Under What is a Change of Condition, it indicated that any sudden or marked change in vital signs, behavior (change to: lethargy, agitated, anxiety, refusing care, no-responsive), appetite (refusing meals, decreased appetite), Complaints (nausea, vomiting, dizziness), and/or changes in level of consciousness or functioning.

Based on interview and record review, the facility failed to assess the continued need for one to one staff supervision from the acute hospital and implement interventions to prevent the risk for falls at admission for one of two sampled residents (Resident 1). This deficient practice resulted in Resident 1's fall on [DATE] at 5:10 p.m., 24.5 hours after his admission to the facility, causing a jolt to Resident 1's head when his right shoulder landed on the floor of the facility's hallway. This deficient practice led to a decline in Resident 1's neurological status and the resident was subsequently transferred to an acute care hospital via [DATE] paramedics, 25 hours after the fall. Resident 1 had a new hemorrhage in his right occipital lobe (the posterior part of the brain located at the back of the head) and was placed under hospice care (a compassionate care for people facing a life-limiting illness or injury) due to no meaningful recovery was expected. Resident 1 passed away at home under hospice care 20 days after being discharged from the acute hospital. (Cross refer to F157, F279, and F309) Findings: A review of Resident 1's Face Sheet (admission record) indicated Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 1's history and physical examination [REDACTED]. The HPE indicated that Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Physical Restraint Review, dated [DATE], indicated that Resident 1 had poor safety awareness, poor sitting balance, gait dysfunction (abnormal manner of walking), and aggressive behavior. The Physical Restraint Review indicated that Resident 1 will have a tab alarm (a sensor device applied to the bed or chair that creates an alarming sound when the resident gets up while in bed or chair). A review of a facility's document titled, Resident 1's Fall Risk Evaluation, dated [DATE], indicated the resident had a total fall risk assessment score of 15, which indicated that Resident 1 was a high risk for potential falls. The Fall Risk Evaluation form indicated a prevention protocol should be initiated immediately and documented in the care plan. A review of Resident 1's Physician Orders, dated [DATE] and timed at 4:30 p.m., indicated to administer to the resident enteric coated (tablet film coatings designed to be resistant to stomach acid) aspirin 81 milligrams (mg) orally, and quetiapine (an antipsychotic medication for mental illness) 12.5 mg twice a day orally for psychosis manifested by recurrent outbursts of anger and 12.5 mg every 6 hours as needed for psychosis manifested by aggressive behavior towards staff. The physician ordered the tab alarm to be placed and monitored in the resident's wheelchair and bed. A review of a facility document titled Interdisciplinary Team Conference Record, dated [DATE], indicated an IDT meeting was conducted for Resident 1's Complex medical condition at risk for decline, fall, and unavoidable change in condition. The IDT record indicated that Resident 1 was placed on a one on one sitter (one staff supervises one resident at all times) and had physical restraints while in the acute hospital; the resident had a [DIAGNOSES REDACTED]. The IDT record indicated that appropriate care plans were developed to assist with Resident 1's needs, safety, and level of care, including placement of tab alarm while in the wheelchair. A review of Resident 1's Licensed Nurses Progress Notes, dated [DATE] and timed at 2:40 p.m., indicated Resident 1 needed to be monitored at all times due to being a high risk for fall. A review of Resident 1's Licensed Progress Notes, dated [DATE] and timed at 3 p.m., indicated that Resident 1 was seen sitting in the wheelchair with a certified nursing assistant or CNA (whom the facility was unable to identify) and a family member (Fam 1). At 5:05 p.m., Resident wheel himself to the laundry room door. At 5:10 p.m., according to the laundry personnel (LS), Resident 1 asked him if he could let him in. LS turned around and walked two steps (away from the resident), the resident then stood up from his wheelchair and then slowly fell back. Resident 1's wheelchair moved back, then the resident fell on the floor, hit his head, but it's not hard. LVN 1 went to check the resident, there was no injury noted, no bump on his head, and no redness. The resident denied any pain or discomfort. A review of Resident 1's Licensed Nurses Progress Notes, dated [DATE] and timed at 2:30 p.m., indicated that Resident 1 had refused to eat breakfast and lunch, and had been sleeping the whole day. Resident 1 was responding to painful stimuli only. Resident 1 had an elevated blood pressure of ,[DATE] millimeters per mercury or mm/hg (the normal range is ,[DATE] mm/hg), body temperature of 100.2 degrees Fahrenheit (normal range is 98.6 to 99 Fahrenheit), pulse rate of 109 beats per minute (the normal range is 60 to 100 beats per minute), and shallow respirations of 23 breaths per minute (normal range is 12 to 20 breaths per minute). The attending physician was notified and he ordered laboratory blood tests. At 6 p.m., the progress note indicated the facility sent Resident 1 to the emergency room for a change in his level of consciousness (a measurement of a person's arousability and responsiveness to stimuli from the environment). The vital signs during the time of transfer were ,[DATE] mm/hg (BP), 102.1 degrees Fahrenheit (body temperature), and 106 beats per minute (pulse). A review of Resident 1's Physician Telephone Orders, dated [DATE] and timed at 5:30 p.m., indicated to send the resident to the emergency room for evaluation of change in level of consciousness. A review of Resident 1's general acute care hospital (GACH) records titled, Emergency/Urgent Care, dated [DATE], indicated Resident 1 was seen at the emergency room at 6:08 p.m., with vital signs that included ,[DATE] mm/hg (BP), 106 beats per minute (heart rate), and 18 breaths per minute (respiratory rate). There was no temperature recorded. Resident 1's Computed Tomography (special x-ray tests that produce cross sectional images of the body) result taken from the acute hospital, on [DATE] and timed at 9:35 p.m., indicated that compared to Resident 1's previous CT examination taken and recorded on [DATE], there was a new area of hemorrhage in Resident 1's right occipital lobe. The hemorrhage measured 2.9 centimeters (cm) in width and 2.9 cm in length, and 1.9 cm in height. A review of Resident 1's Discharge Summary from the GACH, dated [DATE], indicated that the neurologist recommended no surgical intervention. The summary indicated, Resident 1 offered no meaningful recovery and was accepted to hospice. Resident 1 was subsequently discharged to home on hospice care on [DATE]. A review of Resident 1's hospice records, titled Discharge Transfer Summary Report [REDACTED]. A review of Resident 1's Certificate of Death, dated [DATE], indicated that the resident's immediate cause of death was end stage cerebrovascular accident. The resident died at his home. During a telephone interview, on [DATE], at 2:35 p.m., Fam 1 stated that on [DATE], before Resident 1 was admitted to the facility, she toured the facility with the admission coordinator (AC 1). Fam 1 stated she communicated to AC 1 about Resident 1's fall risk and need for one on one direct staff supervision. Fam 1 stated that on [DATE], around 5 p.m., she was getting ready to leave the facility and wanted to tell the staff not to leave Resident 1 alone in the wheelchair because he would fall. Fam 1 stated she left Resident 1 with a certified nursing assistant (unable to recall name) before she went to the Nursing Station. During the telephone interview, Fam 1 stated she watched the video footage of the facility camera on [DATE], at around 12 p.m. with the Administrator and the video footage showed How the people (facility staff) were just passing by him (Resident 1). A review of the facility document titled, Marketing Communication Log, dated [DATE], indicated that Resident 1's ETA (estimated time of arrival to the facility) was at 4 p.m. on [DATE]. The behavior, restraint, and comment portion of the Marketing Communication Log was left blank. There was no documented evidence that the admissions coordinator, prior to Resident 1's admission to the facility, had communicated to the licensed staff, Resident 1's behavior and need for one to one staff supervision as indicated in the acute hospital record. Concurrently, during an interview, on [DATE], at 9:50 a.m., the admission coordinator (AC 1) stated the marketing staff that visited Resident 1 at the hospital prior to facility admission is no longer employed in the facility. During an interview, on [DATE], at 9:50 a.m., AC 1 stated he could not remember talking to Fam 1 about Resident 1's fall risk and need for one on one direct staff supervision. AC 1 stated it was the previous director of nursing (DON 1) that reviewed the medical records of Resident 1 from the acute care hospital prior to admission in the facility. AC 1 stated that it was a standard practice of the facility to know the fall risk of a resident prior to admission to the facility because they could not accept a resident that required a sitter. During an interview, on [DATE], at 10:30 a.m., a registered nurse (RN) 2 stated that she could not find documented evidence in Resident 1's medical records that a care plan for high risk for falls and the use of a tab alarm in bed and wheelchair was developed prior to Resident 1's fall incident on [DATE], at 5:10 p.m. RN 2 stated that the prevention protocol indicated in the Fall Risk Evaluation form included application of a tab alarm device, use of floor mats at bedside, and frequent monitoring. RN 2 stated she did not know if the facility had a documented preventive protocol for falls. There was no documented evidence that a care plan was initiated for Resident 1's high risk for falls upon admission to the facility and before the actual fall on [DATE]. During an interview, on [DATE], at 1:25 p.m., a licensed vocational nurse (LVN 1) stated that on [DATE], Fam 1 communicated to LVN 1 that Resident 1 needed a sitter (one on one staff supervision) because the resident had a sitter in the acute care hospital due to Resident 1 would try to get up, would not ask for assistance, and fall. LVN 1 stated he notified DON 1 of what Fam 1 had told him. LVN 1 stated DON 1 stated they would try to look for a sitter. LVN 1 stated he did not know what happened after he notified DON 1. There was no documented evidence that the facility had conducted an assessment of Resident 1's need for one-on-one staff supervision (sitter). During an interview, on [DATE], at 1 p.m., Fam 1 stated that she spoke with the ER physician and was asked if Resident 1 had a recent fall. Fam 1 stated that the ER physician told her that for a resident who recently had a stroke, even just a mild jolt can cause a brain bleed, and it does not matter if the resident did not hit his head that hard at all. During a telephone interview, on [DATE], at 4:48 p.m., RN 1 stated that he remembered seeing Resident 1 that day (on [DATE]) wheeling his wheelchair in the facility's hallway. RN 1 stated that prior to the fall incident, a facility staff (unable to recall whom) placed Resident 1 that day (on [DATE]) in front of the nursing station to be monitored by facility staff. RN 1 was asked if he knew that Resident 1 was at high risk for falls. RN 2 stated, Everybody here was at risk for falls. But Resident 1 was able to propel his own wheelchair. A review of the facility's security video footage, on [DATE] at 10:45 a.m., in the presence of the facility's administrator, DON 2, Fam 1, AC 1, and medical records supervisor (MRS 1) showed Resident 1 was wheeled by a CNA (unidentified) in front of the nursing station and then the CNA left the resident alone on [DATE], at 5:04 p.m. Fam 1 was observed facing the Nursing Station with her back facing Resident 1. Resident 1 was wearing socks and a pair of long pajamas with the hem extending to the middle part of the resident's foot. The video footage showed Resident 1 was independently propelling his wheelchair after being left alone in front of the Nursing Station. At 5:10 p.m., Resident 1 propelled his wheelchair in front of the laundry room, which was 34 feet from the Nursing Station; the resident stood up from the unlocked wheelchair and fell backwards.The facility's security video camera showed a jolt to Resident 1's head when his right shoulder landed on the floor, which prevented the head from hitting the floor. A review of an undated facility policy and procedure titled Admissions, indicated The admission coordinator would conduct preadmission interviews as appropriate with the representative of the facility from which the patient (resident) is being transferred, usually by telephone. The policy indicated that the director of nursing services or administrator would review the admission inquiries to ensure that the facility admits only those residents for whom it can provide adequate care. A review of the facility policy and procedure titled Fall Risk Assessment Identification and Reduction, dated ,[DATE], indicated that the Resident at risk for falls shall have a care plan that identifies the risk factors for that individual resident and appropriate interventions based on the individual risk factors. The facility nursing staff and/or the IDT shall update the residents' plan of care accordingly to reduce the risk of further occurrences of a fatal or related incident.

Based on observation, interview, and record review, the facility failed to accurately assess urine characteristics and report findings to the physician, as stipulated in the facility's policy and the residents' plan of care for two of seven sampled residents (Residents 1 and 7) who had indwelling urinary catheters (flexible plastic tubes used to drain urine from the bladder). These deficient practices resulted in a delay in [DIAGNOSES REDACTED]. Resident 1 was transferred to a general acute care hospital (GACH) in respiratory distress (difficulty breathing) and was diagnosed upon admission to the GACH with a urinary tract infection ([MEDICAL CONDITION], an infection involving any part of the urinary system, including urethra, bladder, ureters, and kidney) [MEDICAL CONDITION] (a serious medical condition caused by an overwhelming immune response to infection). Resident 7 did not receive an antibiotic treatment for [REDACTED]. Resident 7 had another U/A (urine analysis), after 15 days of the first U/A and C/S ((culture sensitivity) a culture test identifies bacteria or fungus that caused an infection, and a sensitivity test identifies the antibiotic that best treat the illness or infection), possibly being contaminated. The facility initially did not want to repeat the UA and C/S because they stated Resident 7 was asymptomatic, but once the UA and C/S was repeated it was positive for bacteria. This delayed Resident 7's [DIAGNOSES REDACTED]. Findings: a. A review of Resident 7's Admission face sheet indicated Resident 7 was initially admitted to the facility on [DATE], and was re-admitted on [DATE]. Resident 7's [DIAGNOSES REDACTED]. A review of Resident 7's Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 4/20/16, indicated Resident 7 was totally dependent on staff for all care and was not able to verbalize needs. A review of a nurse's note dated 5/7/16, and timed at 6 p.m., indicated Resident 7's FM 1 requested a U/A with a culture and sensitivity test (a culture test identifies bacteria or fungus that caused an infection and the sensitivity test identifies the antibiotic that best treat the illness or infection). A nursing note, dated 5/11/16, and timed at 6 p.m., indicated Resident 7's preliminary U/A results had a large amount of blood, but indicated that Resident 7 was asymptomatic (no symptoms). A review of the Nurses Catheters Notes, dated from 4/1/16 to 4/30/16, and notes from 5/23/16 to 5/27/16, indicated Resident 7's urine was yellow, had no sediment, or no foul smelling urine. A review of Resident 7's care plan titled, Possible UTI with chronic sedimentation, dated 5/16/16 indicated to Monitor urine for sediment (particles that may be indicative of an infection), cloudiness, odor, blood tinge, and amount and report to MD for any of those symptoms. During an observation accompanied by a registered nurse (RN 1) on 5/25/16 at 3:28 p.m., Resident 7 was lying in bed and had an indwelling urinary catheter. The urine in the tubing and catheter bag had sediment and a strong foul odor permeating in the room. During a concurrent interview, RN 1 confirmed that there was sediment in Resident 7's urine tube and that there was a strong foul urine smell permeating the room. RN 1 stated, Sediment, fever, bad odor, and blood in the urine are all signs and symptoms of a urine infection. On 5/25/16 at 3:28 p.m., during an interview, while at the Resident 7's bedside, FM 1 stated that she had requested a urinalysis (U/A) test to check for infection, because there was a strong urine odor and a lot of sediment with blood in the tubing in Resident's 7's catheter. A review of Resident 7's laboratory results titled, Laboratory urinalysis, culture and sensitivity report, dated 5/13/16 indicated multiple organisms ' isolated probable contaminant, repeat culture if indicated. During a concurrent interview, on 5/25/16 at 3:38 p.m., RN 1 and LVN 3 stated that the C/S was not repeated because The resident was asymptomatic. After the interview, LVN 3 stated that she called the physician assistant ((PA) a healthcare professional who provides healthcare within the medical model as part of a team with physicians), who then ordered to repeat the C/S. On 5/25/16 at 4:45 p.m., during a telephone interview, Resident 7 's PA stated Resident 7 was asymptomatic per nursing assessments. The PA stated Resident 7 was receiving cranberry supplements (used to prevent UTI) and he would wait for the C/S results. A review of Resident 7's U/A & C/S results, dated 5/27/16, twenty days after Resident 7's FM 1 requested the U/A and C/S, indicated it was positive for [DIAGNOSES REDACTED] pneumoniae, a type of gram-negative bacteria that can cause different types of healthcare-associated infections, including pneumonia, bloodstream infections, and wound or surgical site infection. The record also indicated a handwritten note by a nurse (unidentified nurse) on the U/A & C/S result, No new orders, the resident (Resident 7) is asymptomatic. A review of Resident 7 's CBC (completed blood count), dated 5/31/16, the WBC (white blood cells (indicative of an infection if elevated)) results were 11.40 H ((high) normal reference range 4.0-11.0). The CBC lab result also indicated a handwritten note by a nurse (unidentified nurse) on the result page, on ATB (antibiotic) already. A review of Resident 7's physician orders, dated 5/28/16, indicated an order for [REDACTED]. in [DIAGNOSES REDACTED]. b. On 5/25/16 at 2:35 p.m., during an interview, the director of nursing (DON) stated Resident 1 was admitted to the facility on [DATE] with an indwelling catheter and did not have a urine infection. The DON stated Resident 1 was transferred to a GACH on 1/1/16 for difficulty in breathing. A closed review of Resident 1's Admission face sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. and subcutaneous tissues; middle skin area)). A review of the Resident 1's Minimum Data Set (MDS) a resident assessment and care screening tool, dated 12/21/15, indicated Resident 1 required an extensive assistance for daily activities and was not able to verbalize needs. A review of a licensed nurses' progress note, dated 12/14/15, and timed at 7:48 p.m., upon admission to the facility, indicated Resident 1's indwelling catheter was draining clear yellow urine. A review of the nurses' Treatment Catheter Notes, dated from 12/14/15 to 12/31/15, indicated Resident 1's urine was clear and did not have any presence of urine sediment, mucus, blood, and/or urine foul odors. A review of Resident 1's care plan titled, Foley catheter (name of an indwelling urinary catheter), dated 12/14/15, indicated Resident 1 was at risk for urinary tract infection [MEDICAL CONDITION] and the staff 's interventions included to Monitor urine for color and clarity (clearness). A review of Resident 1's nurses note, dated 1/1/16, indicated Resident 1 was in respiratory distress (difficulty in breathing) with an elevated heart rate. The facility called 911 and Resident 1 was transferred to the GACH. A review of Resident 1 's GACH records, dated 1/1/16, indicated Resident 1's [DIAGNOSES REDACTED]. Resident 1's white blood cell ((WBC) indicative of an infection) was up to 39,700 upon admission to GACH (normal reference range 4,500-11,000 WBC per microliter). Resident 1 was treated with an antibiotic [MEDICATION NAME] 3.375 grams via intravenous (IV (into the vein)), an antibiotic (used only to treat or prevent infections that are proven or strongly suspected to be caused by bacteria). Resident 1's GACH nurse's note, dated 1/1/16, and timed 10:35 p.m., indicated Resident 1's urine specimen collected was cloudy. A review of Resident 1's GACH's laboratory report, dated 1/1/16, and timed at 11:50 p.m., indicated the following UA results; yellow cloudy urine and positive for bacteria. The C/S results dated 1/2/16, and timed at 7:10 a.m., indicated it was positive for Proteus Mirabillis (a rod-shaped bacterium found in putrid meat, abscesses, and fecal material responsible for complicated UTIs that sometimes causes bacteremia (bacteria in the blood)). According to the National Institute of Health, the signs and symptoms of UTI included, but not limited to fever, urine that smells bad or looks cloudy or reddish in color, and pain during urination at <https://www.nlm.nih.gov/medlineplus/urinarytractinfections.html> According to an article titled, WBC Count, a high number of WBCs may be due to infections, most often those caused by bacteria. (<https://www.nlm.nih.gov/medlineplus/ency/article/ 3.htm>). The facility's policy and procedure revised on October 2014 and titled, Foley Catheter Care, indicated for the staff to report any signs and symptoms of infection, suspected obstruction and/or retention, significantly reduced output to the attending physician.