Every finding on record at Mirage Post Acute

Based on interview and record review, the facility failed to ensure the Advanced Directive (a legal document that lets one state their choices for medical care if they become too sick or hurt to speak for themself)/Physician Orders for Life-Sustaining Treatment (POLST - a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) Acknowledgment form was correctly and accurately dated per facility policy for one of three sampled residents (Resident 2). This failure resulted in discrepancies in Resident 2's medical records. Findings:During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 1/29/2026 with diagnoses including, but not limited to, dementia (a progressive state of decline in mental abilities), furuncle (pus-filled bump) of nose, hypertension (high blood pressure), nontraumatic subdural hemorrhage (blood collecting between the brain and its outer covering).During a review of Resident 2's Minimum Data Sheet (MDS- a resident assessment tool), dated 8/7/2026, the MDS indicated, Resident 2 had a severe cognitive impairment.During a review of Resident 2's POLST form, dated 4/29/2026, the form indicated, the POLST form was prepared on 4/29/2026.During a concurrent interview and record review, on 8/25/2026, at 2:58 PM, with the Assistant Director of Nursing (ADON), Resident 2's Advanced Directive (AD - a legal document indicating resident preference on end-of-life treatment decisions)/POLST Acknowledgement form, dated 4/6/2026 was reviewed. The Acknowledgement form indicated, the POLST form was completed on 4/6/2026. The ADON stated, the Acknowledgment form incorrectly indicated the POLST form was completed on 4/6/2026, not on the correct date of 4/29/2026. The ADON stated the risk the Acknowledgment form incorrectly indicating the date of completion is that it creates a discrepancy of when the form was actually completed.During a review of the facility's policy and procedure (P&P), titled Charting and Documentation, dated 1/27/2026, the policy and procedure indicated, Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

Based on observation, interview, and record review, the facility failed to provide necessary respiratory care (the medical treatment and support for the organs and structures in the body that allow a person to breathe) when oxygen flow rate (measurement of gas volume delivered to person over time period, as liters per minute) was not administered per physician's order for one of three sampled residents (Resident 3). This failure had potential to cause oxygen toxicity (tissue and cell damage caused by breathing molecular oxygen at elevated partial pressures level), respiratory tract (nose, throat, trachea and lung tissues) irritation, and exacerbate the resident's respiratory condition. Findings:During a review of Resident 3's undated admission Record, the admission Record indicated the facility admitted Resident 3 on 8/11/2026, with diagnoses including chronic obstructive pulmonary disease (COPD, a progressive, long-term lung condition that damages the airways and air sacs, making it hard to breathe), pneumonia (infection of the lungs), atrial fibrillation (irregular heart beat in upper chamber of the heart), anemia (low count of red blood cell important for oxygen transport throughout the body), and dementia (progressive decline in mental abilities). During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool), dated 8/17/2026, the MDS indicated Resident 3 had moderate problems with thinking and memory (a condition in which a person has more memory or thinking problems than other people their age). During a review of Resident 3's Physician Order, dated 8/11/2026, the Physician Order indicated to administer oxygen at two liters per minute (L/Min - a unit of measurement) using a nasal cannula (a plastic tube with prongs at the end for nostrils, and connected to a machine that concentrated oxygen from air) for shortness of breath during every shift. During a concurrent interview and record review on 8/20/2026 at 1:06 p.m. with the Assistant Director of Nursing (ADON), Resident 3`s Nursing admission Notes dated 8/11/2026 were reviewed. The ADON stated that according to the Nursing admission Note, Resident 3 was receiving oxygen at two L/Min via nasal cannula. During a concurrent observation and interview on 8/20/2026 at 3:05 p.m. with Registered Nurse (RN) 1, inside Resident 3's room, Resident 3 was observed lying flat in bed, coughing occasionally, with nasal cannula placed under her nose and connected to the oxygen concentrator machine. RN 1 observed the oxygen flow meter indicator (a chamber with a knob to regulate the oxygen flow indicating a range zero to five L/Min) and stated that oxygen for Resident 3 was set at four L/Min. During a concurrent interview and record review on 8/20/2026 at 3:20 p.m. with RN 1, Resident 3`s electronic medical record (EMR) was reviewed. RN 1 stated that the physician order for oxygen indicated to administer oxygen at two L/Min, and Resident 3 currently was on four L/Min. RN 1 looked further through Resident 3's EMR and did not find any documentation of increased oxygen flow rate. RN 1 stated that oxygen must be given to a resident at a set rate ordered by the physician because it is considered medication, and hyperoxygenation (oxygen at higher levels than normal in the lungs) can occur if given at higher flow rates. RN 1 stated that residents that have COPD shouldn't receive more than required amount of oxygen. RN 1 stated If a resident gets more than enough oxygen it would be toxic to body, and the breathing would be affected. During an interview on 8/21/2026 at 2:11 p.m. with the Director of Nursing (DON), the DON stated that the oxygen setting at four L/Min is not that of concern. The DON stated the oxygen is usually set up for residents at two to five L/Min on as needed basis. The DON stated Resident 3`s oxygen setting was reviewed, and a new physician order was obtained on 8/20/2026 to administer oxygen at 2-5 L/Min as needed. The DON stated that Resident 3 was assessed and no issues were identified. During a review of the facility's policy and procedure (PnP) titled, Oxygen Administration, last reviewed on 6/30/2026, the PnP indicated the purpose . to provide guidelines for safe oxygen administration. The PnP indicated that a Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following: Signs or symptoms of cyanosis (i.e., blue tone to the skin and mucous membranes); Signs or symptoms of hypoxia (i.e., rapid breathing, rapid pulse rate, restlessness, confusion); Signs or symptoms of oxygen toxicity (i.e., tracheal irritation, difficulty breathing, or slow, shallow rate of breathing); Vital signs; Lung sounds; Oxygen saturation. During a review of the facility's policy and procedure (PnP) titled Physician's Medication and Treatment Orders, last reviewed on 6/30/2026, the PnP indicated: Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state.

Based on observation, interview, and record review, the facility failed to ensure one of four emergency exit doors (Emergency Exit Door 1 - a specialized, outward-swinging door allowing for fast, unhindered evacuation from a building during a crisis) was not blocked. This failure had the potential to result in delays during emergency evacuation and provision of emergency care, negatively affecting residents' well-being. Findings: During a concurrent observation and interview on 8/4/2026 at 2:13 p.m. with Registered Nurse (RN) 1 in Station A, there was a swamp cooler (a machine that cools the air using water) placed in front of Emergency Exit Door 1, partially covering the emergency exit door. Observed swamp cooler cord plugged in to the power outlet located on top of Emergency Exit Door 1 with the cord crossing the length of the exit door. RN 1 stated the swamp cooler was placed in front of the emergency exit door, blocking the exit. RN 1 stated he (RN 1) would contact the maintenance department to move the swamp cooler. During an interview on 8/4/2026 at 2:29 p.m. with Maintenance Supervisor (MS) 1, MS 1 stated all facility staff are responsible for ensuring that the emergency exit doors are not blocked. MS 1 stated emergency exit doors are used for residents and facility staff to exit the facility during emergency situations. MS 1 stated blocked emergency exit door had the potential for residents and facility staff not being able to exit through the emergency exit door during emergency incidents, negatively affecting residents' safety. During an interview on 8/10/2026 at 12:35 p.m. with the Director of Nursing (DON), the DON stated emergency exit doors were used for evacuation during emergency situations. The DON stated failure to ensure emergency exit doors are not blocked could potentially lead to delay of provision of emergency services to residents negatively affecting residents' safety and well-being. During a review of the facility-provided policy and procedure (P&P) titled, Exits or Means of Egress, last reviewed on 4/27/2026, the P&P indicated, This facility has emergency exits for rapid evacuation. 5. All personnel shall keep exits clear at all times. Exit doors are never blocked, even briefly.

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of three sampled residents (Resident 2) by failing to:1. Ensure the residents respiratory rate (the number of breaths taken per minute) was counted and documented before administering Ativan (medication used to quickly calm the brain and nerves, primarily for severe anxiety, panic attacks, and insomnia).2. Ensure the physician order was followed to hold (temporarily stop) Ativan for a respiratory rate over 12 breathes per minute.These failures had the potential to result in medication errors and could potentially result in respiratory depression (a person is breathing too slowly or too shallowly).Findings:During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 4/15/2026, with diagnoses that included unspecified (unconfirmed) acute and chronic respiratory failure (a life-threatening medical emergency where a patient with an existing, long-term lung disease experiences a sudden, severe worsening of their breathing), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and generalized anxiety disorder (a chronic mental health condition characterized by excessive, uncontrollable worry about everyday issues like health, money, work, and family).During a review of Resident 2's Order Summary Report, dated 4/18/2026, the Order Summary Report indicated to administer Ativan oral tablet 0.5 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount), give 0.5 mg by mouth every six hours as needed for anxiety manifested by verbalization of nervousness for 14 days, Hold if respiratory rate is above 12.During a review of Resident 2's Medication Administration Record (MAR), dated 4/2026, the MAR indicated Resident 2 was administered Ativan on the following dates and times:1. 4/18/2026, at 6:20 p.m.2. 4/20/2026, at 8:44 a.m.3. 4/20/2026, at 4:33 p.m.4. 4/21/2026, at 12:30 a.m.During a review of Resident 2's Weights and Vital Summary, dated 4/18/2026, to 4/21/2026, the Weights and Vital Summary indicated the following documented respiratory rate before Ativan administration:1. 4/18/2026, at 12:28 a.m.- 18 breaths per minute2. 4/20/2026, at 3:39 a.m.-17 breaths per minute3. 4/20/2026, at 11:40 a.m.-18 breaths per minuteDuring a review of Resident 2's Minimum Data Set (MDS-a resident assessment tool), dated 4/21/2026, the MDS indicated Resident 2's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 2 had anxiety and depression disorder (a common, serious mood disorder that causes persistent feelings of sadness, hopelessness, and a loss of interest in activities you once enjoyed).During a concurrent interview and record review on 6/30/2026, at 10:45 a.m., with the Assistant Director of Nursing (ADON), Resident 2's Physician Order, dated 4/18/2026, and MAR, dated 4/2026, were reviewed. The ADON stated the Physician Order was to hold Ativan for a respiratory rate above 12 breaths per minute. The ADON stated Licensed Vocational Nurse 4 (LVN 4) received the physician order and she (LVN 4) should have clarified with the Physician since the Ativan is usually held if respiratory rate is below 12 breaths per minute not above 12 breaths per minute. The ADON stated because the order was incorrectly transcribed (written), nurses should have held the Ativan. The ADON stated nurses should have checked and documented the respiratory rate, and call the Physician for clarification before Ativan administration.During an interview on 7/1/2026, at 8:06 a.m., with LVN 5, LVN 5 stated Ativan order indicated to hold it if the respiratory rate was below 12. LVN 5 stated on 4/21/2026, at 12: 30 a.m., Resident 2 was agitated (a state of anxiety, worry, or restless excitement) and the respiratory rate was above 12 breaths per minute, so she (LVN 5) administered Ativan. LVN 5 stated she (LVN 5) did not notice the order to hold Ativan for respiratory rate over 12 breaths per minute. LVN 5 stated she (LVN 5) had checked Resident 2's respiratory rate and it was above 12 and she (LVN 5) might have forgotten to document the respiratory rate in Resident 2's medical record.During an interview on 7/1/2026, at 1:10 p.m., with LVN 4, LVN 4 stated if she (LVN 4) had wrongly transcribed the order, nurses who administered the Ativan should have called and clarified the order with the Physician before Ativan administration.During an interview on 7/1/2026, at 3:21 p.m., with the Director of Nursing (DON), the DON stated nurses should have clarified the order before Ativan administration. The DON stated based on the physician order, Ativan should have been held for a respiratory rate above 12 breathes per minute. The DON stated the respiratory rate should be checked and documented in Resident 2's medical record before Ativan administration.During a review of facility's policy and procedure (P&P), titled, Administering Medications, dated 4/27/2026, the P&P indicated, 4. Medications are administered in accordance with prescriber orders, including any required time frame. 11. The following information is checked/verified for each resident prior to administering medications: .b. Vital signs (clinical measurements used to assess the body's basic functions. The four standard vital signs monitored by healthcare providers include body temperature, pulse (heart) rate, respiration (breathing) rate, and blood pressure), if necessary.

Based on interview and record review, the facility failed to maintain accurate and complete medical record for one of three sampled residents (Resident 2) by failing to:1. Ensure Resident 2's medical records indicated the correct last name of Responsible Party 1 (RP 1).2. Ensure Registered Nurse 1 (RN 1) documented that RP 1 was notified of the purpose of the intravenous (IV-within the vein) hydration (the process of providing or maintaining the adequate fluid levels needed for the body).3. Ensure Licensed Vocational Nurse 6 (LVN 6) documented the accurate date of the Physician and RP 1 notification on the Change in Condition, dated 4/20/2026.These failures had the potential to cause confusion in care and the medical records containing inaccurate documentation.Findings:a. During a review of Resident 2's General Acute Care Hospital (GACH) Inpatient Registration Form, the Inpatient Registration Form indicated the person to notify was RP 1.During a review of Resident 2's Resident Administration Record, dated 4/14/2026, the Resident Administration Record indicated emergency contact was RP 1.During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 4/15/2026, with diagnoses that included unspecified (unconfirmed) acute and chronic respiratory failure (a life-threatening medical emergency where a patient with an existing, long-term lung disease experiences a sudden, severe worsening of their breathing), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and unspecified dementia (a progressive state of decline in mental abilities). The admission Record indicated RP 1's name but the last name was different.During a review of Resident 2's Informed Consents, dated 4/15/2026, the Informed Consents indicated RP 1's name but the last name was different.During a review of Resident 2's Consent to Treat, dated 4/16/2026, and 4/21/2026, the Consent to Treat indicated verbal consent obtained from RP 1 whose last name was different.During a review of Resident 2's Change in Condition (CIC) Evaluation, dated 4/16/2026, 4/20/2026, and 4/21/2026, indicated RP 1's last name was different.During a review of Resident 2's Interdisciplinary Team (IDT-group of healthcare professionals who collaborate to plan, deliver, and evaluate coordinated care for a resident) Conference Notes, dated 4/17/21026, the IDT Conference Notes indicated RP 1's first name but had a different last name.During a review of Resident 2's Hospital Transfer Form, dated 4/21/2026, the Hospital Transfer Form indicated RP 1's name but had a different last name.During a review of Resident 2's Minimum Data Set (MDS-a resident assessment tool), dated 4/21/2026, the MDS indicated Resident 2's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired.During an interview on 6/26/2026, at 8:48 a.m., with Family Member 1 (FM 1), FM 1 stated she (FM 1) had reviewed Resident 2's medical records and noticed the facility had notified and documented a different person not related to her (FM 1). FM 1 stated RP 1 had the Power of Attorney (POA-a legal document that authorizes a trusted person to make decisions or act on behalf of another person), and the facility had documented RP 1's name but with a different last name. FM 1 stated the admission Director (AD), recommended the facility and she (AD) just assumed his (RP 1) last name was the same as Resident 2.During an interview on 6/30/2026, at 10:32 a.m., with the admission Director (AD), the AD stated she (AD) was familiar with RP 1's last name and during admission she (AD) did fill up the contact list of Resident 2 documenting RP 1's last name. The AD stated she (AD) should have looked at the GACH records and called RP 1 to verify if the same last name as Resident 2 or not. The AD stated the wrong name documented in Resident 2's medical records indicated a different person. The AD stated the right person who is RP 1 will not be informed.During an interview on 6/30/2026, at 10:45 a.m., with the Assistant Director of Nursing (ADON), the ADON stated admission staff should accurately document names especially for residents and responsible party.During a concurrent interview and record review on 6/30/2026, at 10:53 a.m., with the AD, the GACH Inpatient Registration Form and the facility's Resident Administration Record, dated 4/14/2026 were reviewed. The GACH Inpatient Registration Form and the facility's Resident Administration Record indicated RP 1's name. The AD stated she (AD) added RP 1's first name and last name based on what she (AD) knows him (RP 1) for in the facility admission Record.During an interview on 7/1/2026, at 1:19 p.m., with RP 1, RP 1 stated his (RP 1) last name was different from Resident 2, and he (RP 1) was Resident 2's POA. RP 1 stated nobody from the facility had called and verified his (RP 1) full name. RP 1 stated nobody from the facility had called and notified him of any change in condition, any IDT, any care plans or any consents.During an interview on 7/1/2026, at 2:20 p.m., with the Assistant Director of Nursing (ADON), the ADON stated if the facility had requested a copy of RP 1's POA, it would have been uploaded in Resident 2's medical record. The ADON stated there were no POA uploaded in Resident 2's electronic medical record.During an interview on 7/1/2026, at 3:21 p.m., with the Director of Nursing (DON), the DON stated the admission Staff should have called and verified RP 1's last name before completing Resident 2's admission Record (Face Sheet). The DON stated it should match the exact name listed in the GACH record. The DON stated if the facility documented a different last name that could cause confusion and could be two different people. The DON stated Resident 2's medical record should be accurate since it is a legal paper, and it helps with communication between providers.b. During a review of Resident 2's Order Summary Report, dated 4/16/2026, the Order Summary Report indicated Lactated Ringers IV solution (a balanced fluid that contains a mixture of water and critical electrolytes the body needs to function), use 75 milliliter (ml-a metric unit of volume equal to one-thousandth of a liter) per hour, IV every shift for hydration for three days.During a review of Resident 2's Progress Notes, dated 4/16/2026, the Progress Notes indicated Minimum Data Set Nurse 2 (MDSN 2) obtained an order for Lactated Ringers 75 ml per hour for three days with 10 ml of infuvite multivitamin (a commercially prepared, multi-vitamin formulation administered intravenously) infused to one bag of IV fluids for hydration program. During an interview on 6/26/2026, at 8:48 a.m., FM 1, FM 1 stated they were not informed about the purpose of the IV. FM 1 stated she (FM 1) is a License Vocational Nurse (LVN) and knows Resident 2's laboratory results were normal.During a concurrent interview and record review on 6/26/2026, at 10:04 a.m., with RN 1, Resident 2's Progress Notes, dated 4/16/2026, were reviewed. RN 1 stated there was no documented evidence that RP 1 was informed of the purpose of the IV fluids. RN 1 stated IV insertion is an invasive procedure and RP 1 should have been notified.During an interview on 6/26/2026, at 10:26 a.m., with RN 1, RN 1 stated she (RN 1) had remembered that she (RN 1) had called RP 1 to notify him of the plan for IV fluids.During an interview on 6/30/2026, at 10:45 a.m., with the ADON, the ADON stated there was no documented evidence that RP 1 was notified of the purpose of IV fluids. The ADON stated the nurse should have notified RP 1 and documented in Resident 2's medical record that RP 1 was notified.During an interview on 7/1/2026, at 1:19 p.m. with RP 1, RP 1 stated he (RP 1) was not informed why there was an order for IV fluids. RP 1 stated Resident 2 eats and drinks, and just needs reminders and encouragement to drink.During an interview on 7/1/2026, at 1:34 p.m., with MDSN 2, MDSN 2 stated RN 1 initiated the IV insertion and had spoken to RP 1 at the bedside about the reason for IV fluids. MDSN 2 stated she (MDSN 2) did not hear RN 1 explain to RP 1 the reason for the IV fluids.During an interview on 7/1/2026, at 3:21 p.m., with the DON, the DON stated the nurses should document if they notify the family of any resident procedure and treatment.c. During a review of Resident 2's CIC, dated 4/20/2026, the CIC indicated Resident 2 had abnormal lung sounds, complained of chest pain and used her accessory muscle when breathing (occurs when the body uses muscles in the neck, chest, and abdomen to breathe because the primary muscle [the diaphragm] is struggling), with rales (clicking, bubbling, or rattling lung sounds heard during inhalation that indicates fluid accumulation, inflammation, or scarring in the small airways) right lung sound, diminished on the left lung, respiratory rate of 20 breathes per minute with oxygen saturation (O2 sat- a measurement of how much oxygen the blood is carrying as a percentage) of 93 percent (%-out of 100) and was on two liters of oxygen per minute. The CIC indicated the Physician was notified on 4/16/2026, (four days before the CIC happened) at 11:50 a.m. and RP 1 was notified on 4/16/2026, (four days before the CIC happen) at 12:10 p.m.During a concurrent interview and record review on 6/30/2026, at 10:45 a.m. with the ADON, Resident 2's CIC, dated 4/20/2026, was reviewed. The ADON stated LVN 6 documented the Physician and RP 1 was notified on 4/16/2026, four days before the CIC happen, when the CIC happened on 4/20/2026. The ADON stated the date was an inaccurately documented. The ADON stated it is important to document accurately the exact date and time of notification to avoid confusion in care.During an interview on 7/1/2026, at 3:21 p.m., with the DON, the DON stated the CIC on 4/20/2026, should be accurate. The DON stated when staff opens the CIC, the date and time of the Physician and RP notification from the last CIC automatically gets uploaded in the new CIC. The DON stated the nurses should have updated the new and current CIC with the correct date and time of when they called and notified the Physician and RP. The DON stated inaccurate documentation could result in confusion in care.During a review of facility's policy and procedure (P&P), titled Charting and Documentation, dated 4/27/2026, the P&P indicated, Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

Based on interview and record review, the facility failed to promptly (to do something quickly, without delay, or exactly at a scheduled time) notify one of three sampled residents (Resident 2) Responsible Party 1 (RP 1) of Resident 2's change in condition on 4/21/2026.This failure had violated RP 1's right to be informed and had the potential to increase RP 1's level of anxiety (an intense, persistent, and often overwhelming feeling of worry, dread, or unease). Findings:During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 4/15/2026, with diagnoses that included unspecified (unconfirmed) acute and chronic respiratory failure (a life-threatening medical emergency where a patient with an existing, long-term lung disease experiences a sudden, severe worsening of their breathing), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and unspecified dementia (a progressive state of decline in mental abilities).During a review of Resident 2's Change in Condition (CIC) Evaluation, dated 4/21/2026, the CIC on 4/20/2026, from 11 p.m., to 4/21/2026, at 1 a.m., indicated Resident 2 had noticeable crackles (when small airways and air sacs snap open as a person breathes in, signaling that air is passing through fluid, mucus, or narrowed, inflamed tissue) with no shortness of breath and on oxygen via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen). The CIC indicated at 4:08 a.m. Resident 2 was cyanotic (having blue or purplish skin or lips and fingernails because there is not enough oxygen in the blood) with cold clammy (skin that feels unusually cool to the touch and damp or sticky with sweat, often appearing pale) skin, visibly struggling to breath with oxygen saturation (O2 sat- a measurement of how much oxygen the blood is carrying as a percentage) at 66 percent (%) on two liters per minute via nasal cannula. The CIC indicated at 4:10 a.m., breathing treatment administered and at 4:12 a.m., 911 (emergency response system) called. The CIC indicated at 4:20 a.m. paramedics arrived and transferred Resident 2 to General Acute Care Hospital (GACH). The CIC indicated the physician was notified at 12 midnight, and RP 1 was notified at 6 a.m.During a review of Resident 2's Minimum Data Set (MDS-a resident assessment tool), dated 4/21/2026, the MDS indicated Resident 2's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired.During an interview on 6/26/2026, at 8:48 a.m., with Family Member 1 (FM 1), FM 1 stated RP 1 was notified of Resident 2's change in condition at 6 a.m., when Resident 2 was already in GACH.During a concurrent interview and record review on 6/30/2026, at 10:45 a.m., with the Assistant Director of Nursing (ADON), Resident 2's CIC, dated 4/21/2026, and Progress Notes, dated 4/20/2026, to 4/21/2026, were reviewed. The ADON stated Resident 2 had a CIC from, 4/20/2026, at 11 p.m., to 4/21/2026 at 1 a.m. The ADON stated paramedics picked up Resident 2 on 4/21/2026, at 4:20 a.m. and RP 1 was notified at 6 a.m. The ADON stated there were no documented attempts to call RP 1 from 1 a.m., when Resident 2 had a change in condition. The ADON stated it is important to notify RP 1 timely of Resident 2's change in condition to ensure RP 1 knew what was going on with Resident 2.During an interview on 7/1/2026, at 1:19 p.m., with RP 1, RP 1 stated on 4/21/2026, the facility called him (RP 1) after Resident 2 was already transferred to the GACH.During an interview on 7/1/2026, at 3:21 p.m., with the Director of Nursing (DON), the DON stated attempts should be made to call and inform the family before a resident is transferred out to GACH so the family will be informed of Resident 2's status.During a review of the facility's policy and procedure (P&P), titled, Change in a Resident's Condition or Status dated 4/27/2026, was reviewed. The P&P indicated, Our facility promptly (doing something quickly, without delay, or exactly at a specified time) notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (changes in level of care, billing/payments, resident rights).2. A significant change of condition is a major decline or improvement in the residents' status that:a. Will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions (is not self-limiting);b. Impacts more than one area of the resident's health status; .4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: .b. There is a significant change in the resident's physical, mental, or psychosocial status; .e. it is necessary to transfer the resident to a hospital/treatment center.

Based on interview, and record review, the facility failed to ensure an accurate assessment was conducted for one of three sampled residents (Resident 1). Resident 1 did not have an accurate assessment on 6/16/2026, when Resident 1 was using a single point cane (a standard, classic walking stick with one rubber tip at the bottom) instead of a walker (provides a wide, stable base of support so that the user can lean their weight on the device while moving forward, offering more stability than canes) and a wheelchair (chair with wheels).This failure had the potential to result in a delay in necessary care and treatment.Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 3/10/2026, with diagnoses that included cerebral infarction (brain tissue death caused by a lack of blood flow), essential hypertension (HTN-high blood pressure) and generalized muscle weakness.During a review of Resident 1's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 3/11/2026, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Rehabilitation-Screening Form, dated 4/21/2026, the Rehabilitation-Screening Form indicated Resident 1 was deemed safe after a Physical Therapy screening (a quick, proactive check-up used to identify potential movement issues, underlying weaknesses, or risks of future injury) to assess safety during ambulation using a single point cane. The Rehabilitation-Screening Form indicated the Restorative Nursing Assistance (RNA) orders were updated.During a review of Resident 1's Order Summary Report, dated 4/21/2026, the Order Summary Report indicated an order for RNA to perform active range of motion (AROM-how far a resident can move a joint like an elbow, knee, or shoulder using their own muscle power, without any outside help) exercises for bilateral lower extremity (legs) and ambulation with single point cane daily five times a week.During a review of Resident 1's Rehabilitation-Screening Form, dated 6/5/2026, the Rehabilitation-Screening Form indicated ambulation with single point cane daily.During a review of Resident 1's Interdisciplinary Team (IDT- the group of healthcare professionals who collaborate to create, manage, and update personalized care plan) Conference Notes, dated 6/16/2026, the IDT Conference Notes indicated ambulation with single point cane daily five times a week as tolerated.During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 6/16/2026, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 1 used a walker and a wheelchair as mobility devices. The MDS indicated Resident 1 was independent in walking 10 feet to 150 feet.During an interview on 6/26/2026, at 9:37 a.m., with RNA 1, RNA 1 stated Resident 1 is independent and ambulates with the use of single point cane. RNA 1 stated Resident 1 first used a quad cane and the therapist changed it to single point cane.During an interview on 6/26/2026, at 9:48 a.m. with the Rehabilitation Director (RD), the RD stated Resident 1 used a single point cane since 4/21/2026.During a concurrent interview and record review on 6/30/2026, at 9:28 a.m., with Minimum Data Set Nurse 1 (MDSN 1), Resident 1's MDS, dated [DATE], was reviewed. MDSN 1 stated the 6/16/2026, MDS assessment indicated Resident 1 used a walker and a wheelchair. MDSN 1 stated there was no documentation in the MDS, dated [DATE], regarding the use of a single point cane. MDSN 1 stated if Resident 1 used a single point cane, it should reflect in the MDS.During an interview on 6/30/2026, at 10:45 a.m., with the Assistant Director of Nursing (ADON), the ADON stated Resident 1 was highly functioning (manages daily living tasks independently). The ADON stated the MDS assessment on 6/16/2026, was not accurate. The ADON stated it is important to have an accurate MDS assessment to have an overall view of the status of the residents.During an interview on 7/1/2026, at 3:21 p.m., with the Director of Nursing (DON), the DON stated the MDS assessment should be accurate and if not accurate the right care will not be provided to Resident 1.During a review of the facility's policy and procedure (P&P) titled, MDS Assessment, dated 4/27/2026, was reviewed. The P&P indicated, The MDS coordinator is responsible for ensuring appropriate edits are made prior to transmitting MDS data and feedback and validation reports from each transmission are maintained for historical purposes and for tracking.During a review of facility's P&P, titled, Resident Assessment, dated 10/2023, and last reviewed on 4/27/2026, the P&P indicated, 12. Information in the MDS assessments will consistently reflect information in the progress notes, plans of care, and resident observations/interviews.

Based on interview, and record review, the facility failed to develop and implement a person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for two of three sampled residents (Residents 1 and 2) by failing to:1. Develop a care plan to address Resident 1's fabrication of stories (deliberately inventing or constructing false information, often with the intent to deceive, manipulate, or impress others) as per Change in Condition on 6/18/2026.2. Develop a care plan to address Resident 2's refusal of intravenous (IV- within a vein) IV insertion for hydration (giving the body the fluid and electrolytes it needs).These failures had the potential to result in delays in the delivery of necessary care and services.Findings:a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 3/10/2026, with diagnoses that included cerebral infarction (brain tissue death caused by a lack of blood flow), essential hypertension (HTN-high blood pressure) and unspecified depression.During a review of Resident 1's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 3/11/2026, 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 6/16/2026, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 1 used walkers and wheelchairs as mobility devices. The MDS indicated Resident 1 was independent in walking 10 feet to 150 feet.During a review of Resident 1's Change in Condition (CIC) Evaluation, dated 6/18/2026, the CIC indicated fabrication of stories.During a concurrent interview and record review on 6/30/2026, at 10:45 a.m., with the Assistant Director of Nursing (ADON), Resident 1's CIC dated 6/18/2026, and Care Plans were reviewed. The ADON stated there was no care plan developed for the fabrication of stories as per Resident 1's CIC on 6/18/2026. The ADON stated the care plan should have been developed. The ADON stated care plans are interventions provided to residents and provide communication between providers. The ADON stated that without a care plan, no appropriate intervention could be provided to Resident 1.During an interview on 7/1/2026, at 3:21 p.m., with the Director of Nursing (DON), the DON stated the care plan should have been developed for Resident 1's fabrication of stories to provide the right care and services. The DON stated if a care plan was not developed, the facility will not be able to meet Resident 1's needs.b. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 4/15/2026, with diagnoses that included unspecified (unconfirmed) acute and chronic respiratory failure (a life-threatening medical emergency where a patient with an existing, long-term lung disease experiences a sudden, severe worsening of their breathing), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and unspecified dementia (a progressive state of decline in mental abilities).During a review of Resident 2's Order Summary Report, dated 4/16/2026, the Order Summary Report indicated the following orders:1. Insert peripheral IV catheter (a short, flexible tube inserted into a vein [usually in the hand or arm] to administer fluids, medications, or blood) every 72 hours and as needed if signs and symptoms of complication are noted.2. Lactated Ringers IV solution (a balanced fluid that contains a mixture of water and critical electrolytes the body needs to function), use 75 milliliters (ml- a metric unit of volume equal to one-thousandth of a liter) per hour IV every shift for hydration for three days.During a review of Resident 2's Progress Notes, dated 4/17/2026, timed at 6:42 a.m., the Progress Notes indicated Registered Nurse 4 (RN 4) documented that Resident 2 refused the new peripheral IV insertion three times.During a review of Resident 2's Progress Notes, dated 4/17/2026, timed at 11:43 a.m., the Progress Notes indicated RN 5 documented that Resident 2 refused IV insertion three times.During a review of Resident 2's Progress Notes, dated 4/17/2026, timed at 4:12 p.m., the Progress Notes indicated RN 6 documented that Resident 2 refused IV insertion three times.During a review of Resident 2's Minimum Data Set (MDS-a resident assessment tool), dated 4/21/2026, the MDS indicated Resident 2's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 2 had peripheral IV access. During a concurrent interview and record review on 6/26/2026, at 10:04 a.m., with RN 1, Resident 2's Progress Notes, dated 4/17/2026, were reviewed. RN 1 stated on 4/17/2026, Resident 2 refused IV insertion.During a concurrent interview and record review on 6/30/2026, at 10:45 a.m., with the ADON, Resident 2's Care Plans were reviewed. The ADON stated there was no care plan developed for Resident 2's refusal of IV insertion. The ADON stated the care plan should have been developed for Resident 2's refusal of IV insertion.During an interview on 7/1/2026, at 3:21 p.m., with the DON, the DON stated the care plan should have been developed for Resident 2's refusal of IV to provide appropriate care and services to the resident. The DON stated that without a care plan, Resident 2's needs could not be provided.During a review of the facility's policy and procedure (P&P), titled, Comprehensive Person-Centered Care Plans, dated 4/27/2026, the P&P indicated, The comprehensive, person-centered care plan: a. Includes measurable objectives and timeframes; b. Describes the services that are to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being, including: (1) services that would otherwise be provided for the above but are not provided due to the resident exercising his or her rights, including the right to refuse treatment.

Based on interview and record review, the facility failed to ensure the residents received care consistent with professional standards of practice for one of three sampled residents (Resident 2) by failing to ensure Resident 2 had a diagnosis of dehydration (when the body uses or loses more fluid than it takes in) and was not drinking before providing intravenous (IV- within the vein) fluid hydration (giving the body the water it needs to function).This failure had the potential to place Resident 1 at risk for fluid overload (excess fluid). Findings:During a review of Resident 2's General Acute care Hospital (GACH) History and Physical (H&P), dated 3/31/2026, the H&P indicated the following:1. Blood Urea Nitrogen (BUN- test measures how much urea nitrogen is in your blood. BUN levels vary. High levels may indicate kidney damage) at normal range of 17 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) per/deciliter (dl- a metric unit of volume equal to one-tenth of a liter).2. Creatinine (a waste product created by your muscles as they move and break down) at normal range of 0.7 mg/dl.During a review of Resident 2's General Acute care Hospital (GACH) Progress Notes, dated 4/13/2026, the Progress Notes indicated the following:1. BUN at normal range of 9 mg/dl.2. Creatinine at low level (low level may indicate low muscle mass, malnutrition, or underlying health conditions like liver disease) of 0.4 mg/dl.During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 4/15/2026, with diagnoses that included unspecified (unconfirmed) acute and chronic respiratory failure (a life-threatening medical emergency where a patient with an existing, long-term lung disease experiences a sudden, severe worsening of their breathing), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and unspecified pulmonary hypertension (high blood pressure specifically in the arteries of the lungs).During a review of Resident 2's Progress Notes, dated 4/15/2026, the Progress Notes indicated the facility admitted Resident 2 on 4/15/2026, at 7:25 p.m.During a review of Resident 2's Intake and Output (I&O) Record, dated 4/15/2026, the I&O Record indicated Resident 2 had 240 milliliters (ml- a metric unit used to measure small amounts of liquid volume) of fluid intake on the night shift.During a review of Resident 2's Laboratory Results Report, dated 4/16/2026, the Laboratory Results Report indicated the following:1. BUN at normal range of 12 mg/dl.2. Creatinine low at 0.5 mg/dl.During a review of Resident 2's I&O Record, dated 4/16/2026, the I&O Record indicated Resident 2 had 1,630 ml of fluid intake.During a review of Resident 2's Order Summary Report, dated 4/16/2026, the Order Summary Report indicated to infuse Lactated Ringers IV solution (a balanced fluid that contains a mixture of water and critical electrolytes the body needs to function), at 75 ml per hour IV every shift for hydration for three days.During a review of Resident 2's I&O Record, dated 4/17/2026, the I&O Record indicated Resident 2 had 1,580 ml of fluid intake.During a review of Resident 2's I&O Record, dated 4/18/2026, the I&O Record indicated Resident 2 had 1,400 ml of fluid intake.During a review of Resident 2's Minimum Data Set (MDS-a resident assessment tool), dated 4/21/2026, the MDS indicated Resident 2's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 2 had peripheral IV access and had an average fluid intake of 501 ml per day or more.During an interview on 6/26/2026, at 8:48 a.m., with Family Member 1 (FM 1), FM 1 stated the facility gave Resident 2 IV fluids, even if she (Resident 2) did not need it, because she (Resident 2) drinks on her (Resident 2) own. FM 1 stated Resident 2 just needed encouragement to drink.During an interview on 6/26/2026, at 10:01 a.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 2 received IV fluids.During an interview on 6/26/2026, at 10:04 a.m., with Registered Nurse 1 (RN 1), RN 1 stated Resident 2 received Lactated Ringers IV for hydration on 4/16/2026 and 4/18/2026, RN 1 stated on 4/17/2026, Resident 2 refused IV insertion.During a concurrent interview and record review on 7/1/2026, at 1:34 p.m., with Minimum Data Set Nurse 2 (MDSN 2), Resident 2's GACH records and H&P, dated 3/31/2026, were reviewed. The H&P indicated normal BUN and creatinine. The GACH records and H&P did not indicate diagnosis of dehydration. MDSN 2 stated upon Resident 2's admission, she (MDSN 2) reviewed Resident 2's GACH records and noted Resident 2 had a diagnosis of dehydration and the laboratory results indicated elevated BUN and creatinine. MDSN 2 stated she (MDSN 2) called the Primary Medical Doctor (PMD) and recommended IV fluids for hydration. MDSN 2 stated when she (MDSN 2) obtained the order, the PMD had not seen Resident 2 at the facility yet. MDSN 2 stated looking into the GACH records, right now there were no documented dehydration diagnoses and BUN and creatinine were both within normal limits.During a concurrent interview and record review on 7/1/2026, at 3:21 p.m. with the Director of Nursing (DON), Resident 2's I&O, dated 4/15/2026, to 4/18/2026, were reviewed. The DON stated if laboratory results were normal and Resident 2 drinks, there is no need for IV hydration. The DON stated it is unnecessary to administer IV fluids when Resident 2 drinks and Resident 2's laboratory results were normal. The DON stated administering IV fluids could cause fluid overload.During a review of facility's policy and procedure (P&P), titled, Nutrition and Hydration to Maintain Skin Integrity, dated 4/2026, was reviewed. The P&P indicated, Hydration Assessment1. Assessment of hydration status involves monitoring the resident for clinical signs of fluid balance, including:a. Vital signs, .b. First morning urine color-pale yellow color generally indicates proper hydration.c. Body mass changes -monitoring and tracking daily morning body weight to measure fluid loss or gain.d. Urine specific gravity (USG-measures how concentrated or diluted your urine is compared to pure water)/Osmolality (a measure of how concentrated a fluid is) less than 1.020.e. Assessment of mucous membrane (the body's internal skin), skin turgor (skins elasticity), and thirst.f. Measuring total intake -total output to calculate fluid balance.Hydration Interventions:1. Encourage fluids for the resident at risk of fluid volume deficit. Oral intake is the preferred method for fluid administration. Administer IV fluids as ordered.2. Monitor and report symptoms of fluid loss including fatigue, thirst, decreased urine output, and dizziness or confusion.3. Monitor and report changes in clinical signs/symptoms of fluid volume imbalance including urine SG, vital signs, and body mass.Steps in the Procedure1. Explain and ask for residents' permission to conduct nutritional screening or hydration assessment.2. Complete nutritional screening or hydration assessment using nutrition screening tools, interview, observation, and record review.3. Review ancillary documentation including, but not limited to, food and fluid intake records, vital signs, weight and height records, laboratory results, and nursing notes.4. Document the results of the screening. Notify the provider of clinical indicators of malnutrition or dehydration.DocumentationRecord in the resident's medical record:1. The results of nutritional screening and assessment.2. Clinical signs or symptoms of fluid volume imbalance.3. Changes in the residents' clinical status.4. Problems or complaints reported by the residents related to intake of food or fluids.5. If the resident refuses nutrition or hydration, the reason(s) and explanation of risk, benefits, and alternatives.

Based on interview, and record review, the facility failed to ensure the resident received care consistent with professional standards of practice to prevent pressure ulcers (localized damage to the skin and/or underlying tissue usually over a bony prominence) for one of three sampled residents (Resident 2) by failing to administer pressure ulcer treatment on 4/16/2026.This failure had the potential to result in the development and worsening of pressure ulcers.Findings:During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 4/15/2026, with diagnoses that included unspecified (unconfirmed) acute and chronic respiratory failure (a life-threatening medical emergency where a patient with an existing, long-term lung disease experiences a sudden, severe worsening of their breathing), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and unspecified dementia (a progressive state of decline in mental abilities).During a review of Resident 2's Nursing-Comprehensive Skin Evaluation/Assessment (Skin Assessment), dated 4/15/2026, the Skin Assessment indicated a stage 2 pressure ulcer (partial-thickness loss of skin, presenting as a shallow open sore or wound) on the sacrococcyx (tailbone).During a review of Resident 2's Order Summary Report, dated 4/16/2026, the Order Summary Report indicated to clean sacral (tailbone) deep tissue injury (DTI-damage to underlying tissues, including muscles, bones, and subcutaneous layer) with normal saline (saline water), pat dry, apply zinc oxide (medication used to create a protective, breathable barrier, offering anti-inflammatory, soothing, and antibacterial properties) and leave open to air daily and as needed for 30 days.During a review of Resident 2's Treatment Administration Record (TAR- flowsheet that indicates treatment given to a resident), dated 4/16/2026, the TAR did not indicate treatment was provided to Resident 2's DTI.During a review of Resident 2's Minimum Data Set (MDS-a resident assessment tool), dated 4/21/2026, the MDS indicated Resident 2's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 2 required supervision from staff for toileting and transfer. The MDS further indicated Resident 2 had one unstageable (a severe wound where the true depth and tissue damage are hidden by dead tissue) pressure ulcer present upon admission.During a concurrent interview and record review on 6/30/2026, at 9:47 a.m., with Treatment Nurse 1 (TN 1), Resident 2's Physician Order, and TAR, dated 4/16/2026, were reviewed. TN 1 stated there was no documented wound treatment provided on 4/16/2026. TN 1 stated Resident 2 could have further skin integrity issues and worsening of Resident 2's wound.During an interview on 7/1/2026, at 3:21 p.m. with the Director of Nursing (DON), the DON stated treatment should be started right away after obtaining a physician order. The DON stated delay in treatment could potentially result in worsening pressure ulcers. During a review of the facility's policy and procedure (P&P) titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol, dated 4/27/2026, the P&P indicated, The physician will order pertinent wound treatments.During a review of facility's P&P, titled, Administering Medications, dated 4/27/2026, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed. Topical medications used in treatments are recorded on the residents treatment record (TAR).

Based on interview and record review, the facility failed to promptly notify Family Member (FM) 1, the resident's responsible party and legally recognized decisionmaker, regarding the change in condition (COC) on 6/4/2026 of one of three sampled residents (Resident 1), before Resident 1 was transferred to General Acute Care Hospital (GACH) 1. Resident 1 had a Do Not Resuscitate (DNR - a medical instruction that tell the healthcare team what kind of care a person wants or did not want at the end of the person's life) status. This deficient practice violated Resident 1's right designating FM 1 as the legally recognized decisionmaker and had the potential to increase FM 1's anxiety (an intense, persistent, and often overwhelming feeling of worry, dread, or unease).Findings: During a review of Resident 1's undated admission Record, the admission Record indicated the facility admitted the resident on 5/16/2023 with diagnoses including type 2 diabetes mellitus (a disease that occurs when the blood sugar level is too high), mild protein-calorie malnutrition (a serious condition that occurs when a body does not get enough protein and calories for energy to function properly), and age-related osteoporosis (a condition where bones become brittle, weak, and highly porous as a person gets older). The admission Record indicated FM 1 was Resident 1's responsible party and substitute decision maker. During a review of Resident 1's Physician orders for Life-Sustaining Treatment (POLST - a type of advance directive that helps communicate a person's wishes for medical treatment), dated 3/17/2026, the POLST indicated Resident 1 was a DNR. The POLST indicated FM 1 signed as Resident '1's legally recognized decisionmaker. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/24/2026, the MDS indicated Resident 1's cognitive skills (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) for daily decision making were severely impaired. The Health Condition Prognosis section indicated Resident 1 had a condition or chronic disease that may result in a life expectancy of less than six months. During a review of Resident 1's Change in Condition (COC) Evaluation, dated 6/4/2026, the COC Evaluation indicated Resident 1 had a COC for weakness, required more assistance during mealtime, and poor food intake with periods of refusing to eat. The COC Evaluation indicated on 6/4/2026 at 6 p.m., attending physician and FM 1 were notified. The COC did not indicate if the facility staff spoke to FM 1 or left a voicemail message. During a review of Resident 1's Progress Notes, dated 6/4/2026, the Progress Notes indicated on 6/4/2026 at 10:25 p.m., Registered Nurse (RN) 1 documented that Resident 1 left for GACH 1. The Progress Notes indicated a voicemail message was left for FM 1 and was waiting for FM 1 to call back. During a telephone interview on 6/17/2026 at 3:41 p.m. with RN 1, RN 1 stated the charge nurse (unable to remember the name of the charge nurse) informed her to create a COC for Resident 1 addressing the resident's weakness and poor food intake. RN 1 stated on 6/4/2026 at 7 p.m., the Social Service Director (SSD) called to inform her that he spoke to FM 1 and agreed to the transfer of Resident 1 to GACH 1. RN 1 stated she did not speak and confirmed with FM 1. During an interview on 6/17/2026 at 3:51 p.m. with the Social Services Director (SSD), the SSD stated he was on vacation and came back to work on 6/5/2026. The SSD stated on 6/5/2026, Social Services Assistant (SSA) 1 informed him that FM 1 was upset for taking Resident 1 to GACH 1 without their approval. The SSD stated he did not speak with FM 1 before 6/5/2026. During a concurrent interview and record review on 6/17/2026 at 12:05 p.m. with the Assistant Director of Nursing (ADON), Resident 1's POLST, dated 3/17/2026, and Resident 1's Progress Notes, dated 6/4/2026, were reviewed. The ADON stated Resident 1's POLST indicated Resident 1's code status was DNR. ADON stated the hospice agency staff and Resident 1's family should agree with the resident's transfer to GACH 1 before the resident was transferred. The ADON stated Resident 1 had a COC on 6/4/2026 and the resident's Progress Notes indicated the facility staff were waiting for FM 1 to return the call after Resident 1 was already transferred to GACH 1. The ADON stated there was no documented evidence that FM 1 responded and agreed to Resident 1's transfer to GACH 1. The ADON stated the process on implementing Resident 1's DNR order was not followed. The ADON acknowledged and stated the facility failed to ensure FM 1 was notified and agreed with the plan of care regarding Resident 1's transfer to GACH 1. During a concurrent interview and record review on 6/17/2026 at 2:20 p.m. with the Director of Nursing (DON), Resident 1's Progress Notes, dated 6/4/2026, and the facility's policy and procedures (PnP) titled, Resident Rights, were reviewed. The DON stated the facility's Quality Assurance Committee last reviewed the PnP on 4/27/2026. The DON stated Resident 1's Progress Notes did not indicate documented evidence that FM 1 agreed to Resident 1's transfer to GACH 1. The DON stated the PnP on Resident Rights indicated Federal and State laws guarantee certain basic rights to all residents. these rights include the resident's right to. appoint a legal representative of his or her choice. be informed of and participate in his or her care planning and treatment. The DON acknowledged and stated the facility failed to ensure resident rights was honored by ensuring FM 1 was notified and agreed with the plan of care regarding Resident 1's transfer to GACH 1.

Based on interview and record review, the facility failed to ensure necessary care was provided for one of three sampled residents (Resident 1), who was receiving Hospice services (a program designed to provide a caring environment for meeting the physical and emotional needs of the terminally ill) by failing to:Ensure Resident 1's Family Member (FM) 1 was informed and agreed with Resident 1's transfer to General Acute Care Hospital (GACH) 1.Ensure Resident 1's Hospice agency (HA) 1 was informed and agreed with Resident 1's transfer to GACH 1. These deficient practices resulted in failure to comply and coordinate with Resident 1's family and Hospice services.Findings: During a review of Resident 1's undated admission Record, the admission Record indicated the facility admitted the resident on 5/16/2023 with diagnoses including type 2 diabetes mellitus (a disease that occurs when the blood sugar level is too high), mild protein-calorie malnutrition (a serious condition that occurs when a body does not get enough protein and calories for energy to function properly), and age-related osteoporosis (a condition where bones become brittle, weak, and highly porous as a person gets older). The admission Record indicated FM 1 was Resident 1's responsible party and substitute decision maker. During a review of Resident 1's Certification of Terminal Illness, dated 5/13/2026, the Certification of Terminal Illness indicated the resident was terminally ill with a life expectancy of six months or less if the terminal illness runs its normal course. The Certification of Terminal Illness indicated the effective date of certification was 5/13/2026 to 8/10/2026. During a review of Resident 1's Hospice Election Statement, dated 5/13/2026, The Hospice Election Statement indicated the resident started receiving hospice services on 5/13/2026. During a review of Resident 1's History and Physical (H&P- a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 5/14/2026, the H&P indicated the resident did not have the capacity to understand and make decisions. The H&P indicated FM 1 was Resident 1's surrogate decisionmaker. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/24/2026, the MDS indicated Resident 1's cognitive skills (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) for daily decision making was severely impaired. The Health Condition Prognosis section indicated Resident 1 had a condition or chronic disease that may result in a life expectancy of less than six months. During a review of Resident 1's Change in Condition (COC) Evaluation, dated 6/4/2026, the COC Evaluation indicated Resident 1 had a COC for weakness, required more assistance during mealtime, and poor food intake with periods of refusing to eat. The COC Evaluation indicated on 6/4/2026 at 6 p.m., attending physician and FM 1 were notified. During a review of Resident 1's Progress Notes, dated 6/4/2026, the Progress Notes indicated on 6/4/2026 at 10:25 p.m., Registered Nurse (RN) 1 documented that Resident 1 left for GACH 1. The Progress Notes indicated a phone message was left for FM 1 and was waiting for FM 1 to call back. During a telephone interview on 6/17/2026 at 3:41 p.m. with RN 1, RN 1 stated the charge nurse (unable to remember the name of the charge nurse) informed her to create a COC for Resident 1 addressing the resident's weakness and poor food intake. RN 1 stated on 6/4/2026 at 7 p.m., the Social Service Director (SSD) called to inform her that he spoke to FM 1 and agreed to the transfer of Resident 1 to GACH 1. RN 1 stated she was informed (unable to state the name of the person who provided the information) Resident 1's transfer to GACH 1 was due to the hospice agencies scandal in California. RN 1 stated she did not speak with FM 1, hospice attending physician, and with HA 1. During an interview on 6/17/2026 at 3:51 p.m. with the Social Services Director (SSD), the SSD stated he was on vacation and came back to work on 6/5/2026. The SSD stated on 6/5/2026, Social Services Assistant (SSA) 1 informed him that FM 1 was upset for taking Resident 1 to GACH 1 without their approval. The SSD stated he spoke with the Director of Nursing (DON) and was informed that Resident 1 was transferred to GACH 1 on 6/4/2026 due to hospice agency issues. The SSD stated he spoke to FM 1 on 6/5/2026. The SSD stated Resident 1 was automatically disenrolled from hospice services due to the resident transfer to GACH 1. During a concurrent interview and record review on 6/17/2026 at 12:05 p.m. with Assistant Director of Nursing (ADON), Resident 1's Physician Orders, dated 5/13/2026, and Resident 1's Progress Notes, dated 6/4/2026, were reviewed. ADON stated Resident 1's Physician Order, dated 5/13/2026 at 8:14 p.m. indicated Resident 1 was admitted to HA 1 services. Resident 1's Physician Order, dated 5/13/2026 at 8:18 p.m. indicated to contact Resident 1's HA 1 for any COC and any change in medication or refill needs. ADON stated Resident 1's Physician Order, dated 5/13/2026 at 8:24 p.m. indicated not to transfer the resident to GACH without prior authorization from HA 1. ADON stated there was no documented evidence in Resident 1's Progress Notes that HA 1 was notified of the resident's COC. ADON stated there was no documented evidence that FM 1 responded and agreed to Resident 1's transfer to GACH 1. During a concurrent interview and record review on 6/17/2026 at 2:20 p.m. with the Director of Nursing (DON), Hospice and Nursing Facility Services Agreement, dated 5/13/2026 was reviewed. The DON stated Resident 1 had a COC on 6/4/2026 while under HA 1's care. The DON could not provide documented evidence that HA 1 was notified of Resident 1's COC and transfer to GACH 1. The DON could not provide documented evidence that FM 1 agreed with Resident 1's transfer to GACH 1 which was one hour away from the facility. The DON stated on 6/5/2026 at 4:05 a.m., 5 hours and 40 minutes after Resident 1 left the facility to GACH 1, the resident was readmitted to the facility and was automatically disenrolled from HA 1 services. The DON stated the Hospice and Nursing Facility Services Agreement indicated the nursing facility will: a notify Hospice when a significant change in a patient's physical, mantal, social, or emotional status occurs;clinical complications appear that suggest a need to alter the plan of care;a need to transfer a patient from the Skilled Nursing Facility (SNF). arises, so that the Hospice may make arrangements for, and remain responsible for any necessary continuous care or inpatient care necessary related to the terminal illness and related conditions.The DON acknowledged and stated the facility failed to ensure HA 1 and FM 1 were notified, per physician orders and hospice services contract, before Resident 1 was transferred to GACH 1. During a review of the facility's policy and procedures (PnP) titled, Hospice Program, last reviewed on 4/27/2026, the PnP indicated when a resident participates in the hospice program, a coordinated plan of care between the facility, hospice agency and resident/family will be developed and shall include directives for managing pain and other uncomfortable symptoms. The care plan be revised and updated as necessary to reflect the resident's current status. The PnP indicated all hospice services are provided under contractual arrangement. Complete details outlining the responsibilities of the facility and the hospice agency are contained in this agreement.

Based on observation, interview, and record review, the facility failed to provide a comfortable and safe temperature level for three of three sampled residents (Residents 1, 2, and 3) by failing to ensure the facility temperature was between 71 degrees Fahrenheit ( F, unit of measurement for temperature) to 81 F.This failure had the potential to cause serious medical problems and altered comfort level.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 6/10/2026, with diagnoses that included urinary tract infection (UTI - an infection in the bladder/urinary tract), unspecified (unconfirmed) multiple sclerosis (MS - a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord) and Guillain Barre Syndrome (GBS - a rare condition that causes sudden numbness and muscle weakness that can affect most of your body).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 6/16/2026, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired.During an interview on 6/12/2026 at 4:54 p.m. with Resident 1, Resident 1 stated she (Resident 1) was in room A, and the room was so hot. Resident 1 stated there were two other residents (Resident 2 and Resident 3) in room A.During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 4/1/2026, with diagnoses that included unspecified respiratory failure (a serious condition that makes it difficult to breathe on your own), unspecified hypothyroidism (a condition where the thyroid gland does not produce enough thyroid hormones to meet the body's needs) and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 2's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 4/3/2026, the H&P indicated Resident 2 did not have the capacity to understand and make decisions.During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decisions were intact.During a concurrent observation and interview on 6/13/2026 at 1:15 p.m. with Resident 2, inside Resident 2's room, observed a window fan noted on top of a chair to the right side of Resident 2's bed and a table fan on the left side. Resident 2 had an exposed shoulder and a white blanket covering her (Resident 2) chest area and lower legs. Resident 2 stated the room is very hot and is the reason why she (Resident 2) does not want any clothes on. Resident 2 stated it gets uncomfortable and she (Resident 2) sweats a lot when the room is hot.During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 4/7/2026, with diagnoses that included unspecified fracture (break in the bone) of upper end of left humerus (upper arm bone), DM and UTI.During a review of Resident 3's H&P, dated 4/8/2026, the H&P indicated Resident 3 had the capacity to understand and make decisions.During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's cognitive skills for daily decisions were intact.During a concurrent observation and interview on 6/13/2026 at 1:17 p.m. with Resident 3, inside Resident 3's room, observed a table fan on the right side of the bed clipped to the rolling table. Resident 3 stated the room is too hot and it has been reported, but nothing had been done. Resident 3 stated it gets uncomfortable if the room is hot.During a concurrent observation and interview on 6/13/2026 at 1:42 p.m. with Maintenance Staff (MS) 1, MS 1 used a thermometer scanner (a device that measures temperature using thermal radiation rather than physical contact by simply pointing the device and it instantly calculates the temperature within seconds) to check Resident 2 and Resident 3's room and the scanner showed 77 F. MS 1 stated the room was set between 72 F to 75 F. MS 1 stated the thermostat box that controls Room A was in room B. MS 1 asked Resident 2 and Resident 3 if the room was hot and both residents answered yes.During an observation on 6/13/2026, at 1:44 p.m., MS 1 went to check Room B's temperature, and the scanner read 79 F. MS 1 opened the thermostat box unit and the temperature was 83 F and temperature was set to 79 F. Observed MS 1 lower the temperature setting to 75 F.During an interview on 6/13/2026 at 1:47 p.m. with Registered Nurse (RN) 2, RN 2 stated if the room is hot, residents can sweat, get uncomfortable and can dehydrate (refers to either the body losing vital fluids like when sweating).During an observation on 6/13/2026 at 2:02 p.m. with MS 1, MS 1 checked all rooms in Station A and had temperature readings as follows:Room A - 82 [NAME] B - 78 [NAME] C - 80 [NAME] D - 82 [NAME] E - 82 [NAME] F- 78 [NAME] G -78.2 [NAME] H -80 [NAME] I - 77 FDuring an interview on 6/13/2026 at 2:32 p.m. with the Director of Nursing (DON), the DON stated the room temperatures should be between 71 F to 74 F unless there is a resident request. The DON stated if rooms are hot, residents can be uncomfortable.During a review of facility's policy and procedure (P&P) titled, Homelike Environment, dated 4/27/2026, the P&P indicated, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: .h. comfortable and safe temperatures;

Based on observation, interview, and record review, the facility failed to implement its infection control measures for one of three sampled residents (Resident 1) by failing to:1. Ensure Certified Nursing Assistant (CNA) 1, CNA 2 and CNA 3 wear a gown when providing incontinent (the loss of control over the bladder or bowels) care to Resident 1, who was on enhanced barrier precaution (EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO- a germ that is resistant to many antibiotics] in nursing homes).2. Ensure EBP signage was posted outside of Resident 1's room.These failures had the potential to spread and expose other residents, staff, and visitors to infection.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 6/10/2026, with diagnoses that included urinary tract infection (UTI- an infection in the bladder/urinary tract), unspecified (unconfirmed) multiple sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord) and Guillain Barre Syndrome (GBS-a rare condition that causes sudden numbness and muscle weakness that can affect most of your body).During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 6/16/2026, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired.During a review of Resident 1's Physician Order, dated 6/11/2026, the Physician Order indicated the following orders:1.Indwelling catheter (a hollow tube inserted into the bladder to drain or collect urine) for neuromuscular dysfunction of bladder (a person does not have bladder control because of brain, spinal cord, or nerve problems).2. EBP during high contact resident care activities (direct physical interaction with a resident for personal hygiene, medical needs, or mobility) secondary to indwelling urinary catheter every shift.During a review of Resident 1's Care Plan on EBP, dated 6/11/2026, the Care Plan indicated an intervention to utilize personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) like gown, gloves, face-shield as indicated during high-contact resident care activities (dressing, bathing/showering, transferring, hygiene, linen changes, brief changes, toileting assistance, device care, wound care).During an observation on 6/13/2026 at 3:33 p.m., inside Resident 1's room, observed Resident 1 in bed, indwelling catheter hanging on the left side of the bed, secured to Resident 1's left thigh.During an observation on 6/13/2026 at 3:36 p.m., at Resident 1's bedside, observed three CNAs (CNAs 1, 2 and 3) with no gown provide incontinent care and change Resident 1's incontinent brief.During a concurrent observation and interview on 6/13/2026 at 3:44 p.m. with Licensed Vocational Nurse (LVN) 1, inside Resident 1's room, LVN 1 confirmed and stated there was no signage posted on the door of what kind of isolation or precaution should be observed for Resident 1. LVN 1 stated Resident 1 had an indwelling catheter and three CNAs without a gown were inside Resident 1's room, changing Resident 1's incontinent brief. LVN 1 stated the three CNAs should wear a gown when changing Resident 1's incontinent brief.During an interview on 6/13/2026 at 3:46 p.m. with Registered Nurse (RN) 1, RN 1 stated staff should wear a gown when providing incontinent care for a resident who has an indwelling catheter. RN 1 stated there should be an EBP signage posted on the door to remind staff of what PPE to use. During an interview on 6/13/2026 at 3:50 p.m. with the Director of Nursing (DON), the DON stated residents with indwelling catheters should be on EBP. The DON stated staff who provide incontinent care and or indwelling catheter care should wear a gown for infection control.During a review of facility's policy and procedure (P&P) titled, Enhanced Barrier Precaution, dated 1/2026, and last reviewed on 4/27/2026, the P&P indicated, Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents.1. Enhanced barrier precautions (EBPs) refer to infection prevention and control interventions designed to reduce the transmission of multi-drug-resistant organisms (MDROs) during high contact resident care activities.2. Enhanced barrier precautions apply when: .b. A resident is NOT known to be infected or colonized with any MDRO, has a wound or indwelling medical devices, and does not have secretions or excretions that are unable to be covered or contained; .5. Indwelling medical devices include. urinary catheters.7. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply.a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room).8. Example of high-contact resident care activities requiring the use of gown and gloves for EBPs include: .c. providing hygiene or grooming;d. changing briefs or assisting with toileting; .g. changing linens; .i. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator).17. Signs are posted on the door or wall outside the residents' rooms which communicate the type of precautions and PPE required.

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for two of three sampled residents (Residents 1, and 2) by failing:1. To ensure Licensed Vocational Nurse 4 (LVN 4) follow physician order to hold (to temporarily pause or skip a dose as instructed by a healthcare professional) losartan (medication used to treat hypertension [HTN- high blood pressure]) for Resident 1's systolic blood pressure (sbp- the top or first number in a blood pressure reading. It measures the maximum pressure the blood exerts against the artery walls when the heart beats and pumps blood throughout the body) below 110 millimeters mercury (mmHg-standard unit of measurement for pressure) on 5/14/2026, at 9 a.m.2. To ensure LVN 3, LVN 5 and LVN 6 follow physician order to hold clonidine (medication used to treat HTN) and hydralazine (medication used to treat HTN) for Resident 2's sbp below 110 mmHg on 5/14/2026, at 6 a.m., 12 noon, 1 p.m., and on 5/16/2026, at 6 a.m.These failures had the potential to result in medication errors and could result in Resident 1 and 2's hypotension that could possibly cause fall and injury.Findings: a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 5/2/2026, with diagnoses that included essential HTN and cerebral infarction (occurs when a blocked or narrowed blood vessel cuts off the blood supply to part of the brain).During a review of Resident 1's Physician Order, dated 5/2/2026, the Physician Order indicated losartan potassium oral tablet 50 milligram (mg- metric unit of measurement, used for medication dosage and/or amount), give one tablet by mouth daily for HTN, hold if sbp below 110 mmHg.During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 5/8/2026, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired.During a review of Resident 1's Medication Administration Record (MAR- flowsheet that indicates medications given to a resident), dated 5/2026, the MAR indicated on 5/14/2026, at 9 a.m., LVN 4 administered losartan to Resident 1 who had a blood pressure of 101/68 mmHg.During a concurrent interview and record review on 6/8/2026, at 10:18 a.m., with the Assistant Director of Nursing (ADON), Resident 1's Physician Order, dated 5/2/2026, and MAR, dated 5/2026, were reviewed. The ADON stated on 5/14/2026, at 9 a.m., LVN 4 administered losartan to Resident 1 who had a blood pressure of 101/68 mmHg. The ADON stated the physician order was not followed. The ADON stated LVN 4 should read the physician order and held the losartan. The ADON stated Resident 1 could experience hypotension (low blood pressure).b. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 8/7/2024, with diagnoses that included unspecified (unconfirmed) nontraumatic subdural hemorrhage (bleeding in the space between the brain and skull without a history of head injury), and hypertensive chronic kidney disease (kidney damage and impaired function caused by long-term, unmanaged high blood pressure).During a review of Resident 2's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 8/13/2025, the H&P indicated Resident 2 had fluctuating capacity to understand and make decisions.During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decisions were intact.During a review of Resident 2's Order Recapitulation Report, dated 5/9/2026, the Order Recapitulation Report indicated the following orders:1. Clonidine hydrochloride tablet 0.2 mg, give one tablet by mouth two times a day for HTN, hold for sbp below 110 mmHg.2. Hydralazine hydrochloride oral tablet 50 mg, give one tablet by mouth every six hours for HTN, hold for sbp below 110 mmHg.During a review of Resident 2's MAR, dated 5/2026, the MAR indicated the following:1. LVN 3 administered clonidine on 5/14/2026, at 1 p.m. with blood pressure of 103/64 mmHg.2. LVN 5 administered hydralazine on 5/14/2026, at 6 a.m. with blood pressure of 94/60 mmHg.3. LVN 3 administered hydralazine on 5/14/2026, at 12 noon with blood pressure of 103/64 mmHg.4. LVN 6 administered hydralazine on 5/16/2026, at 6 a.m. with blood pressure of 109/89 mmHg.During a concurrent interview and record review on 6/5/2026, at 3:12 p.m., with the Director of Staff Development (DSD), Resident 2's Physician Order, dated 5/9/2026, and MAR, dated 5/2026, were reviewed. The DSD stated the physician ordered to hold the clonidine and hydralazine for sbp below 110 mmHg. The DSD stated LVN 3 should have held the clonidine on 5/14/2026, at 12 noon, since Resident 2's blood pressure was 103/64 mmHg. The DSD stated on 5/14/2026, at 1 p.m., LVN 3 should have held the hydralazine since Resident 2's blood pressure was still at 103/64 mmHg. The DSD stated LVN 5 should have held the hydralazine on 5/14/2026, at 6 a.m., since Resident 2's blood pressure was 94/60 mmHg. The DSD stated LVN 6 should have held the hydralazine on 5/16/2026, at 6 a.m., since Resident 2's blood pressure was 109/80 mmHg. The DSD stated Resident 2's could develop hypotension.During an interview on 6/5/2026, at 3:31 p.m. with the ADON, the ADON stated Resident 2 could develop orthostatic hypotension (a sudden drop in blood pressure that occurs when you stand up after sitting or lying down) because the LVNs administered the blood pressure medications below the parameter ordered by the physician.During an interview on 6/8/2026, at 10:56 a.m., with the Director of Nursing (DON), the DON stated Residents 1 and 2 could potentially experience hypotension. The DON stated LVNs 3, 4, 5 and 6 should check the blood pressure, compare result with the order and should have held the blood pressure medication as per physician order.During an interview on 6/8/2026, at 1:49 p.m., with LVN 3, LVN 3 stated she (LVN 3) did not have any documented evidence that she (LVN 3) had held the blood pressure medication. LVN 3 stated Resident 2's medical record indicated she (LVN 3) had administered clonidine and hydralazine on 5/14/2026. LVN 3 stated administration of blood pressure medication to a resident with low blood pressure can cause further drop of blood pressure causing hypotension.During an interview on 6/8/2026, at 1:54 p.m., with LVN 5, LVN 5 stated he (LVN 5) might have clicked administered accidentally. LVN 5 stated he (LVN 5) does not have documentary evidence that he (LVN 5) held the blood pressure medication on 5/16/2026, at 6 a.m. LVN 5 stated there were too many things to click in the electronic health record. LVN 5 stated he (LVN 5) honestly does not read everything. LVN 5 stated Resident 2's blood pressure can go down if medicated with blood pressure medication when Resident 2's blood pressure was already low at 94/60 mmHg and could result in fall and injury.During a review of facility's policy and procedure (P&P) titled, Administering Medications, dated 4/27/2026, was reviewed. The P&P indicated, Medications are administered in a safe and timely manner, and as prescribed.4. Medications are administered in accordance with prescriber orders, including any required time frame.11. The following information is checked/verified for each resident prior to administering medications: . b. Vital signs, if necessary.During a review of facility's P&P, titled, Adverse Consequences and Medication Errors, dated 4/27/2026, the P&P indicated, A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with provider's orders.

Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained dignity for one of the three sampled residents (Resident 4) by failing to ensure Resident 4 was provided with silverware (eating utensils such as forks, knives, and spoons) with breakfast tray. On 6/8/2026, Licensed Vocational Nurse (LVN) 1 provided disposable utensils to Resident 4.This failure had the potential to negatively affect Resident 4's self-esteem and self-worth.Findings: During a review of Resident 4's admission Record, the admission Record indicated the facility admitted Resident 4 on 2/27/2026, with diagnoses that included sacral (tailbone) stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone), mild protein-calorie malnutrition (a condition where the body receives inadequate protein and/or calories, leading to measurable but generally reversible physical changes) and adult failure to thrive (a syndrome characterized by unintended weight loss, decreased appetite, poor nutrition, and physical or mental decline).During a review of Resident 4's History and Physical (H&P - a medical examination that involves a doctor taking a resident's medical history, performing a physical exam, and documenting their findings), dated 3/2/2026, the H&P indicated Resident 4 did not have the capacity to understand and make decisions.During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool), dated 3/3/2026, the MDS indicated Resident 4's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired.During a review of Resident 4's Order Summary Report, dated 4/30/2026, the Order Summary Report indicated controlled carbohydrate (a meal plan that regulates the amount of carbohydrates resident eats to maintain stable blood sugar levels) regular textured diet (a normal, everyday diet requiring no restrictions or modifications).During an observation on 6/8/2026 at 8:57 a.m., outside of Resident 4's room, Certified Nursing Assistant (CNA) 2 delivered a food tray inside Resident 4's room. Observed the food tray had no utensils.During an observation on 6/8/2026 at 9:23 a.m. inside Resident 4's room, observed the breakfast tray unopened.During an interview on 6/8/2026 at 9:41 a.m. with LVN 1, LVN 1 stated Resident 4's breakfast tray had missing utensils. LVN 1 stated it could delay Resident 4's food intake.During an interview on 6/8/2026 at 9:46 a.m. with the Assistant Director of Nursing (ADON), the ADON stated kitchen staff should check for the completeness of the meal tray.During a concurrent observation and interview on 6/8/2026 at 9:48 a.m. with CNA 2, CNA 2 stated it was the kitchen's staff responsibility to ensure the residents had utensils. CNA 2 observed and stated Resident 4 was eating using a disposable spoon.During a concurrent interview and record review on 6/8/2026 at 10:05 a.m. with the Assistant Dietary Supervisor (ADS), Resident 4's Meal Ticket, was reviewed. The ADS stated the facility provides silverware to residents. The ADS stated if Resident 4 prefers disposable utensils it will be indicated in Resident 4's Meal Ticket under the Alerts. The ADS stated Resident 4's Meal Ticket did not indicate Resident 4's preference for disposable utensils. The ADS stated Resident 4 should have been provided with silverware for dignity purposes.During an interview on 6/8/2026 at 10:56 a.m. with the Director of Nursing (DON), the DON stated Resident 4 should have been provided with regular silverware unless it's Resident 4's preference. The DON stated providing disposable utensils could affect Resident 4's dignity.During a review of facility's policy and procedure (P&P) titled, Meal Service, dated 2023, and last reviewed on 4/27/2026, the P&P indicated, Trays will be delivered as completed to a designated area at a predetermined time for Nursing to pick up.8. Nursing personnel will serve the trays immediately upon checking the tray to be sure nothing is missing from the tray and the diets are correct.During a review of facility's P&P titled, Dignity, dated 4/27/2026, 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. Residents are treated with dignity and respect at all times.During a review of facility's P&P titled, Resident Rights, dated 4/27/2026, the P&P indicated, Employees shall treat all residents with kindness, respect, and dignity.1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; .

Based on interview and record review, the facility failed to promptly notify one of three sampled residents (Resident 3) Responsible Party (RP) 1 of Resident 3's change in condition on 6/1/2026, before Resident 3 was transferred to the General Acute Care Hospital (GACH).This failure had violated RP's 1's right to be informed and had the potential to increase RP 1's level of anxiety (an intense, persistent, and often overwhelming feeling of worry, dread, or unease).Findings: During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 12/27/2023, with diagnoses including unspecified (unconfirmed) Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), and unspecified schizophrenia (a mental illness that is characterized by disturbances in thought). The admission Record indicated RP 1 was Resident 3's responsible party.During a review of Resident 3's History and Physical (H&P - a medical examination that involves a doctor taking a resident's medical history, performing a physical exam, and documenting their findings), dated 12/5/2025, the H&P indicated Resident 3 did not have the capacity to understand and make decisions.During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 4/6/2026, the MDS indicated Resident 3's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired.During a review of Resident 3's Change in Condition Evaluation (CIC - a document used to record and report any significant changes in a resident's physical, mental, or psychosocial status), dated 6/1/2026, timed at 8:03 p.m., the CIC indicated Resident 3 had behavioral symptoms, nausea and vomiting. The CIC indicated Resident 3 had unmanageable behavior of disturbing other residents and had two episodes of coffee ground emesis (vomit that looks like dark brown or black coffee grounds). The CIC indicated the Physician was notified on 6/1/2026, at 8:15 p.m. and ordered to transfer Resident 3 to GACH. The CIC indicated RP 1 was notified on 6/1/2026, at 7 p.m. (one hour before the CIC and before the physician ordered the transfer to GACH).During a review of Resident 3's Progress Notes, dated 6/1/2026, timed at 9:00 p.m., the Progress Notes indicated transportation arrived to pick up Resident 3.During a review of Resident 3's Progress Notes, dated 6/1/2026, timed at 9:50 p.m., the Progress Notes indicated Resident 3's family arrived at the facility and RN 1 informed the family of Resident 3's significant changes.During an interview on 6/4/2026 at 3 p.m. with RP 1, RP 1 stated that on 6/1/2026, at 7:45 p.m., she (RP 1) received a call that Resident 3 had unmanageable behavior and that the Physician had ordered to transfer Resident 3 to GACH. RP 1 stated she (RP 1) was not informed that Resident 3 had vomited. RP 1 stated when she (RP 1) got to the facility, Resident 3 was not there, and RN 1 just notified her (RP 1) that Resident 3 had vomited coffee ground emesis. RP 1 stated nobody had contacted and informed her (RP 1) that Resident 3 had coffee ground emesis before the transfer.During an interview on 6/8/2026 at 1:12 p.m. with RN 1, RN 1 stated Resident 3 had a CIC of unmanageable behavior and she (RN 1) called the Physician who ordered to transfer Resident 3 to GACH. RN 1 stated transport was arranged at 11 p.m. pick up but transport arrived between 9 p.m. to 10 p.m. RN 1 stated before 9 p.m., Resident 3 had coffee ground emesis. RN 1 stated she (RN 1) had called RP 1 for the unmanageable behavior and was about to call RP 1 again for the coffee ground emesis, but transport arrived and picked up Resident 3. RN 1 stated she (RN 1) was not able to call RP 1 before the transfer because she (RN 1) got busy with another resident and did not have enough time to call RP 1. RN 1 stated she (RN 1) should have called RP 1 of Resident 3's coffee ground emesis before the transfer. RN 1 stated she (RN 1) should have called before the transfer to inform RP 1 of what's going on with Resident 3.During an interview on 6/8/2026 at 1:30 p.m. with the Assistant Director of Nursing (ADON), the ADON stated family should be notified of CIC for them to be informed.During a review of facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated 4/27/2026, the P&P indicated, Our facility promptly notifies the resident, his or her attending physician and the resident representative of the changes in the resident medical/mental condition and/or status.4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: . b. there is a significant change in the resident's physical, mental, or psychosocial status; .e. it is necessary to transfer the resident to a hospital/treatment center.

Based on interview and record review the facility failed to notify the resident's Responsible Party (RP - when signing admissions paperwork for a hospital, nursing home, or assisted living facility, the responsible party is the person designated to make medical or administrative decisions for the resident) of the transfer and the reasons for the move in writing for one of three sampled residents (Resident 3).This failure had the potential for incomplete information conveyed to residents or RP 1 and could have violated resident and RP 1's rights to appeal (the process in which cases are reviewed by a higher authority) transfer or discharge.Findings: During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 12/27/2023, with diagnoses that included unspecified (unconfirmed) Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), and unspecified schizophrenia (a mental illness that is characterized by disturbances in thought). The admission Record indicated RP 1 was Resident 3's responsible party.During a review of Resident 3's History and Physical (H&P - a medical examination that involves a doctor taking a resident's medical history, performing a physical exam, and documenting their findings), dated 12/5/2025, the H&P indicated Resident 3 did not have the capacity to understand and make decisions.During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 4/6/2026, the MDS indicated Resident 3's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 3 required maximum assistance from staff for eating, oral hygiene and personal hygiene.During a review of Resident 3's Change in Condition Evaluation (CIC - a document used to record and report any significant changes in a resident's physical, mental, or psychosocial status), dated 6/1/2026, at 8:03 p.m., the CIC indicated Resident 3 had unmanageable behavior of disturbing other residents and had two episodes of coffee ground emesis (vomit that looks like dark brown or black coffee grounds). The CIC indicated that the Physician was notified on 6/1/2026, at 8:15 p.m. and ordered to transfer Resident 3 to General Acute Care Hospital (GACH). The CIC indicated RP 1 was notified on 6/1/2026, at 7 p.m. (one hour before the CIC and before the physician order the transfer to GACH).During a review of Resident 3's Notice of Proposed Transfer/Discharge, dated 6/1/2026, timed at 8:36 p.m., the Notice of Proposed Transfer/Discharge indicated the transfer is necessary for the resident's welfare and the residents' needs cannot be met at the facility due to unmanageable behavior and two episodes of coffee ground emesis. The Notice of Proposed Transfer/Discharge indicated RP 1 signed the form as verified by Registered Nurse (RN) 1 and Licensed Vocational Nurse (LVN) 7.During a review of Resident 3's Progress Notes, dated 6/1/2026, timed at 9 p.m., the Progress Notes indicated the transportation arrived to pick up Resident 3.During a review of Resident 3's Skilled Nursing Facility (SNF) to Hospital Transfer Form (Transfer Form), dated 6/1/2026, the Transfer Form indicated the reason for transfer was behavioral symptoms. The Transfer Form indicated RP 1 was notified and aware of clinical symptoms. The Transfer Form did not indicate coffee ground emesis.During a review of Resident 3's Progress Notes, dated 6/1/2026, timed at 9:40 p.m., the Progress Notes indicated Resident 3 left the facility, family and physician informed.During a review of Resident 3's Progress Notes, dated 6/1/2026, timed at 9:50 p.m., the Progress Notes indicated Resident 3's family arrived at the facility, spoke with RN 1 and RN 1 informed and explained Resident 3's significant changes.During an interview on 6/2/2026 at 1:27 p.m. with RP 1, RP 1 stated on 6/1/2026, when she (RP 1) arrived at the facility, Resident 3 was already picked up by transportation to go to GACH. RP1 stated there was no form provided to her (RP 1) that Resident 3 will be transferred to GACH.During an interview on 6/4/2026 at 3 p.m. with RP 1, RP 1 stated on 6/1/2026, at 7:45 p.m., RP 1 received a call from LVN 7 informing her (RP 1) that Resident 3 will be transferred to GACH for unmanageable behavior, not about the coffee ground emesis.During an interview on 6/5/2026 at 2:55 p.m. with LVN 7, LVN 7 stated on 6/1/2026, she completed the Notice of Proposed Transfer and Discharge (Transfer Form). LVN 7 stated when she (LVN 7) completed the Transfer Form there was no signature from RP 1. LVN 7 stated she (LVN 7) had faxed (to send an exact electronic replica of a page, complete with text, images, and signatures from one machine to another over a telephone line or the internet) a copy to the Long Term Care Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities). LVN 7 stated she (LVN 7) called RP 1 before the transfer and RP 1 agreed. LVN 7 stated Resident 3 left the faciity on 6/1/2026, before 9 p.m.During an interview on 6/8/2026 at 1:12 p.m. with RN 1, RN 1 stated on 6/1/2026, Resident 3 was scheduled for 11 p.m. pick up to be transferred to GACH for behavioral management. RN 1 stated on 6/1/2026, she (RN 1) called and informed RP 1 that Resident 3 will be picked up at 11 p.m. to be transferred to GACH. RN 1 stated the transportation was already arranged. RN 1 stated RP 1 and family arrived at the facility, but Resident 3 was already transferred out since transportation arrived earlier than scheduled between 9 p.m. to 10 p.m. RN 1 stated she (RN 1) forgot to ask RP 1 to sign the Notice of Proposed Transfer/Discharge. RN 1 stated she (RN 1) wrote RP 1's name on the Notice of Proposed Transfer/Discharge since she (RN 1) had already called and notified RP 1 of the transfer due to behavior. RN 1 stated the signature in the Notice of Proposed Transfer/Discharge was not RP 1's signature. RN 1 stated she (RN 1) did not provide a copy of the Notice of Proposed Transfer/Discharge when RP 1 came at the facility on 6/1/2026.During an interview on 6/8/2026 at 1:30 p.m. with the Assistant Director of Nursing (ADON), the ADON stated the nurses are in charge of providing a copy of the Notice of Proposed Transfer/Discharge to resident or RP. The ADON stated if it's a planned transfer the Social Service or Case Manager will be in charge. The ADON stated the Notice of Proposed Transfer/Discharge should be provided to RP 1 so RP 1 will be aware of the transfer reason and knows where Resident 3 will be transferred to.During an interview on 6/9/2026 at 10:39 a.m. with the Director of Nursing (DON), the DON stated the facility only provides the Notice of Proposed Transfer/Discharge if the discharge or transfer is planned. The DON stated if residents were transferred due to a change in condition, the facility does not provide a copy of the Notice of Proposed Transfer/Discharge.During a review of facility's policy and procedure (P&P) titled, Transfer or Discharge Notices, dated 4/27/2026, the P&P indicated, Residents (or resident representatives) are notified of an impending transfer or discharge and the reasons for the move in writing and in a language and manner they understand.Notice of Transfer or Discharge (Anticipated)1. Under the following circumstances, the notice of transfer is given as soon as it is practicable but before the transfer or discharge: a. The health and/or safety of individuals in the facility would be endangered due to the clinical or behavioral status of the resident; b. The resident's health improves sufficiently to allow a more immediate transfer or discharge;c. An immediate transfer or discharge is required by the resident's urgent medical needs; or2. The residents and representatives are notified in writing of the following information:a. The specific reason for the transfer or discharge, including the basis.b. The effective date of the transfer or discharge;c. The specific location (such as the name of the new provider, description, and/or address if the location is a residence) to which the resident is being transferred or discharged ;d. The name, address, and telephone number of the Office of the State Long-term Care Ombudsman;e. The Notice of Facility Bed-Hold and policies;f. The name, address, email, and telephone number of the agency responsible for the protection and advocacy of residents with intellectual and developmental (or related) disabilities (as applies); andg. The name, address, email, and telephone number of the agency responsible for the protection and advocacy of residents with a mental disorder or related disabilities (as applies).3. A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the residents and representatives.4. When a resident is sent emergently to an acute care setting, this is considered a transfer, not discharge, because the resident's return is generally expected.5. Notice of Transfer is provided to the resident and representative as soon as practicable before the transfer and to the long-term care (LTC) ombudsman when practicable (in a monthly list of residents that includes all notice content requirements).

Based on observation, interview, and record review, the facility failed to ensure a resident received care consistent with professional standards of practice to prevent pressure ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence) for one of three sampled residents (Resident 4) by failing to ensure the low air loss mattress (LALM-a mattress designed to distribute the patient's body weight over a broad surface area to prevent skin breakdown and treat pressure ulcers) was set according to Resident 4's weight as per physician order and manufacturer's guidelines (the official recommendations and standards set by the company that built a product that outline the proper procedures for installation, operation, maintenance, and troubleshooting, ensuring the product functions safely, efficiently, and within its warranty limits).This failure had the potential for the worsening of Resident 4's pressure ulcers.Findings:During a review of Resident 4's admission Record, the admission Record indicated the facility admitted Resident 4 on 2/27/2026, with diagnoses that included sacral (tailbone) stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone), mild protein-calorie malnutrition (a condition where the body receives inadequate protein and/or calories, leading to measurable but generally reversible physical changes) and adult failure to thrive (a syndrome characterized by unintended weight loss, decreased appetite, poor nutrition, and physical or mental decline).During a review of Resident 4's Care Plan, dated 2/28/2026, for LALM for wound management, the Care Plan indicated an intervention to set at resident's weight.During a review of Resident 4's Order Summary Report, dated 3/1/2026, the Order Summary Report indicated LALM for wound management, set to residents' weight.During a review of Resident 4's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 3/2/2026, the H&P indicated Resident 4 did not have the capacity to understand and make decisions.During a review of Resident 4's Minimum Data Set (MDS-a resident assessment tool), dated 3/3/2026, the MDS indicated Resident 4's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 4's weight was 100 pounds (lbs-unit of weight and mass).During an observation on 6/8/2026, at 9:28 a.m., inside Resident 4's room, Resident 4 was on LALM and was set at 180 lbs. The low air loss machine had an arrow pointing close to 90 lbs.During a concurrent interview and record review on 6/8/2026, at 9:34 a.m., with the Assistant Director of Nursing (ADON), Resident 4's weight was reviewed. The ADON stated Resident 4's weight was 103 lbs on 6/2026.During a concurrent observation and interview on 6/8/2026, at 9:35 a.m., with the ADON, inside Resident 4's room. The ADON stated Resident 4's LALM was set at 180 lbs. and should be set close to 90 lbs. The ADON stated the LALM setting should be at Resident 4's weight level.During an interview on 6/8/2026, at 9:40 a.m., with the Treatment Nurse (TN), TN stated LALM setting should be based on resident's weight. The TN stated if the setting was above the resident's weight, the pressure was not circulating properly, and the LALM was not beneficial to Resident 4.During an interview on 6/8/202,6 at 10:48 am, with the ADON, the ADON stated LALM setting should be based on weight to prevent skin breakdown. The ADON stated if the setting is higher, the bed is firmer and defeats the purpose of the LALM.During an interview on 6/8/2026, at 10:56 a.m., with the Director of Nursing (DON), the DON stated LALM should be based on Resident 4's weight to prevent pressure ulcer and for Resident 4's comfort.During a review of the facility's LALM Manufacturers' Guidelines, dated 1/31/2024, the Manufacturer's Guidelines indicated, The system is a high quality and affordable mattress system suitable for treatment and prevention of pressure ulcers. This product is intended to help and reduce the incidence of pressure ulcers while optimizing patient comfort. Higher pressure output will support the heavier weight patient. According to the weight and height of the patient, adjust the pressure setting to the most comfortable level without bottoming out, then the pressure in mattress will slowly increase to the intended value after the air mattress is ready to use.

Based on observation, interview, and record review, the facility failed to ensure that resident's was free of unnecessary medication for one of three sampled residents (Resident 3) by failing to ensure Licensed Vocational Nurse (LVN) 8 and LVN 9 adequately monitor and document for the manifested behavior of restlessness for a resident who received antianxiety medications (medications used to treat symptoms of anxiety, such as excessive worry, panic attacks, fear, and physical tension).This failure had the potential to result in Resident 3 receiving unnecessary medications and not receiving the adequate care and treatment necessary for physical, mental and psychosocial well-being.Findings:During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 12/27/2023, with diagnoses that included unspecified (unconfirmed) Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), and unspecified schizophrenia (a mental illness that is characterized by disturbances in thought).During a review of Resident 3's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 12/5/2025, the H&P indicated Resident 3 did not have the capacity to understand and make decisions.During a review of Resident 3's Minimum Data Set (MDS-a resident assessment tool), dated 4/6/2026, the MDS indicated Resident 3's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 3 was on antianxiety medications.During a review of Resident 3's Physician Order, dated 5/3/2026, the Physician Order indicated Ativan (medication used to treat anxiety disorders) oral tablet 0.5 milligram (mg- metric unit of measurement, used for medication dosage and/or amount), give one tablet by mouth every six hours as needed for anxiety manifested by restlessness as evidenced by yelling and rocking back and forth aggressively for 14 days.During a review of Resident 3's Order Recapitulation Report, dated 5/3/2026, the Order Recapitulation Report indicated monitor behavior episode of antianxiety use manifested by restlessness as evidenced by yelling and rocking back and forth aggressivelyDuring a review of Resident 3's Medication Administration Record (MAR- flowsheet that indicates medications given to a resident), dated 5/2026, the MAR indicated Resident 3 had one behavioral episode of restlessness as evidenced by yelling and rocking back and forth aggressively on 5/4/2026, and 5/10/2026, from 3 p.m., to 11 p.m.During a review of Resident 3's MAR, dated 5/2026, the MAR indicated the following:1. Licensed Vocational Nurse 8 (LVN 8) administered Ativan on 5/5/2026, 5/6/2026, 5/10/2026, 5/11/2026, 5/12/2026, 5/13/2026, 5/14/2026 and 5/17/2026 between 8:03 a.m. to 8:39 a.m.2. LVN 9 administered Ativan on 5/9/2026, at 7:45 p.m.During an interview on 6/4/2026, at 3 p.m., with Responsible Party 1 (RP 1), RP 1 stated on 6/1/2026, at 7:45 p.m., she (RP 1) received a call that Resident 3 will be transferred to General Acute Care Hospital (GACH) for unmanageable behavior.During a concurrent interview and record review on 6/5/2026, at 3:31 p.m., with the Assistant Director of Nursing (ADON), Resident 3's Physician Order, dated 5/3/2026, and MAR, dated 5/2026, were reviewed. The ADON stated the physician ordered Ativan on 5/3/2026, for anxiety manifested by restlessness as evidenced by yelling. The ADON stated the monitoring for the behavior was documented in the MAR. The ADON stated the MAR indicated two episodes of restlessness, one on 5/4/2026, and one on 5/10/2026, at 3 p.m. to 11 p.m. The ADON stated the MAR did not indicate the behavior on 5/5/2026, 5/6/2026, 5/9/2026, 5/11/2026, 5/12/2026, 5/13/2026, 5/14/2026, and 5/17/2026. The ADON stated the Ativan was ordered to be administered as needed for Resident 3's behavior. The ADON stated the nurses should have documented the behavior in MAR to justify the need for Ativan. The ADON stated it was important to document number of episodes of behavior to inform the physician if the medication needs to be adjusted or not.During a concurrent interview and record review on 6/9/2026, at 9:29 a.m., with ADON, Resident 3's Progress Notes, dated 5/2026, were reviewed. The ADON stated the nurses should document reason why they administer the Ativan since it was ordered as needed. The ADON stated there were no documented episodes of behavior in Resident 3's Progress Notes. The DON stated the Ativan should be given as per physician order.During an interview on 6/9/2026, at 10:39 a.m., with the Director of Nursing (DON), the DON stated the nurses should document in Resident 3's medical record why they administered the Ativan. The DON stated the nurses should document number of Resident 3's behavioral episode of restlessness in the MAR or Progress notes. The DON stated Resident 3 had behavior, but nurses did not document that Resident 3 had behavior and still administered the Ativan. The DON stated since nurses did not document Resident 3's behavior, the nurses did not follow the physician order to medicate resident, only if Resident 3 had a behavior of restlessness.During a review of facility's policy and procedure (P&P) titled, Psychotropic (medication that affects the brain and alters the mood, thoughts, behavior, or perception) Medication Use, dated 4/27/2026, was reviewed. The P&P indicated, Residents do not receive psychotropic medications that are not clinically indicated and necessary to treat a specific condition documented in the medical record.2. Psychotropic medication management is an interdisciplinary process (when different fields or areas of expertise team up to tackle a problem) that involves the resident, family, and/or the representative and includes: a. determining adequate indications for use; .Adequate Indications for Psychotropic Medication Use1. Adequate indication for use refers to the identified, documented clinical rationale for administering medication that is based on: a. an assessment of the resident's condition and therapeutic goals; .3. The clinical rationale for the use of psychotropic medication, or a change from one type of psychotropic to another, is documented in the medical record.As Needed (PRN) Medication1. Psychotropic medications are not prescribed or administered on a PRN basis unless the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record.

Based on observation, interview, and record review, the facility failed to: A. Follow its policy and procedure titled, Infection Prevention and Control Program, last reviewed on 11/6/2025, for one of three sampled residents (Resident 1) by failing to: 1. Ensure that the third-party's (an external company or individual specializing in air and water safety to the facility) recommendations indicated in the Annual Analytical Validation Viable Legionella Bacteria Report (a document that confirms the effectiveness of a facility's Water Management Program [ongoing plan to control and minimize hazards in building water systems primarily to prevent growth of harmful bacteria such as Legionella bacteria {naturally found in [NAME], but becomes a health risk when they grow in man-made water systems and the contaminated water is aerosolized - tiny particles suspended in the air, leading to inhalation and causing lung illness}, ensure water safety by identifying risks, assess water systems and implement control measures] in controlling Legionella growth), dated 2/26/2024, 12/9/2024, 1/24/2025, 2/19/2025, and 3/17/2025 were reviewed and followed. These reports indicated that Legionella bacteria were found in the facility's water system since 2/26/2024; however, the facility failed to act on the findings and failed to implement the recommendations outlined in the report. 2. Ensure the facility's Water Management Program Water Safety Plan (a comprehensive risk assessment and risk management approach that encompasses all steps in a drinking-water supply chain to identify hazardous conditions and outline steps to minimize the health impact of waterborne pathogens [some bodies of water have microorganisms called pathogens that can cause residents to get sick]) was reviewed and followed when Legionella bacteria were detected (identify the presence or existence of) at the facility since 2/26/2024. 3. Ensure the Infection Preventionist Nurse (IP Nurse) carried out her (IP Nurse) duties and responsibilities by coordinating and overseeing the facility's Infection Prevention and Control Program (IPCP - refers to evidence-based practices and procedures that, when applied consistently in health care settings, can prevent or reduce the risk of transmission of microorganisms to residents and health workers) in relation to the Legionella bacteria detected at the facility since 2/26/2024. 4. Ensure the facility identified the areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria (caused by pathogenic microbes {microorganisms that can cause disease in humans) spread via contaminated water). 5. Ensure a communication process was in place for the previous Administrator (Administrator 2) to inform the current Administrator (Administrator 1) of the Legionella bacteria detected at the facility since 2/26/2024 when Administrator 1 took over and started working at the facility on 4/2025. B. Report to the California Department of Public Health (CDPH) that the facility's water system was positive for Legionella bacteria since 2/26/2024. These deficient practices resulted in Resident 1 having a Change in Condition (a major decline in a resident's health status) on 10/25/2025 at 7:37 a.m., including altered mental status (a change in mental function), fever (abnormally high body temperature), shortness of breath, and was found unresponsive (does not respond to activity, touch, sound, or other stimulation). The paramedics (individuals trained to provide emergency medical care to people who are injured or ill, typically in a setting outside of a hospital) arrived at the facility on 10/25/2025 at 7:45 a.m. and transferred Resident 1 to the General Acute Care Hospital (GACH) where Resident 1 underwent a Legionella pneumoniae sputum procedure (a diagnostic test in which a sample of sputum [thick, sticky substance from the lungs] is collected and analyze in a laboratory for the presence of Legionella bacteria) on 10/25/2025 at 10:46 a.m., which detected Legionella bacteria. Resident 1 subsequently died at the GACH on 10/31/2025 (specific time not indicated). Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted Resident 1 on 2/12/2025 and readmitted in the facility on 10/2/2025 with diagnoses including chronic obstructive pulmonary disease (COPD - a chronic lung disease that causes air to become trapped in the lungs, making it hard to breathe) and type two (2) diabetes mellitus (DM - a condition where the body does not use insulin [a hormone that regulates blood sugar by helping sugar from food move from the bloodstream into the body's cells for energy] properly to get energy from the food eaten). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 10/8/2025, the MDS indicated that Resident 1 was severely impaired (having significant limitations) in thought processes and required dependent assistance (resident requires total physical or mechanical help) from staff to complete activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). During a review of Resident 1's Change in Condition (CIC - major decline in a resident's health status that will not resolve without interventions) Form, dated 10/25/2025, the CIC indicated that Resident 1 was noted with altered mental status (change in mental function), fever, shortness of breath, and was unresponsive. The CIC further indicated that the paramedics arrived on 10/25/2025 at 7:45 a.m. and transferred Resident 1 to the GACH. During a review of Resident 1's Physician's Order, dated 10/25/2025, timed at 7:59 a.m., the Physician's Order indicated to transfer Resident 1 to GACH for further evaluation. During a review of Resident 1's Care Plan Report (a structured and individualized approach that helps clinicians provide effective care for the resident), dated 10/25/2025, the Care Plan Report indicated that Resident 1 was transferred to GACH for further evaluation due to abnormal vital signs (basic measurements of the body's essential functions), altered mental status, labored breathing (breathing feels difficult, requiring extra effort), desaturation (a drop in blood oxygen levels below normal) and lethargy (a condition marked by drowsiness and an unusual lack of energy and mental alertness). During a review of Resident 1's GACH record, dated 10/25/2025, the GACH record indicated the GACH Emergency Department (a medical unit for severe, life-threatening conditions and serious injuries needed immediate care) admitted Resident 1 on 10/25/2025 at 8:05 a.m. presenting with altered mental status and being found unresponsive. The GACH record indicated that on 10/25/2025 at 10:46 a.m., Resident 1 underwent a Legionella pneumoniae sputum procedure, which indicated that Legionella bacteria were detected. During an interview on 11/13/2025 at 11:04 a.m., with Maintenance Supervisor 1 (MS 1), in the facility's water room, MS 1 stated that the facility's most recent report titled, Annual Analytical Validation Viable Legionella Bacteria, which indicated that Legionella bacteria were present in the facility's water, was dated 3/2025. MS 1 stated he (MS 1) did not have a copy of the report in his (MS 1) office, but that a copy was kept by the IP Nurse. MS 1 stated that maintenance staff (depending on who was on duty each day) had been performing daily water flushing (the process of running water through the pipes in the water system) in room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], Nurse Station 1, Nurse Station 2, Bathtub 1, and Bathtub 2 since 1/2024, based on instructions from the previous Maintenance Supervisor 2 (MS 2). MS 1stated he (MS 1) did not change or rotate any rooms included in the water flushing routine. MS 1 stated there was no documented evidence that the facility implemented additional interventions (other than water flushing) to prevent Legionella bacteria growth, such as replacing the angle stop valves (small valves installed at the corner where a water line meets a fixture like under the sink, behind the toilet, or near the water heater), faucets, water supply hoses (used to connect faucets to the water pipes under the sink), or filters (devices that remove impurities by lowering contamination of water using a fine physical barrier). MS 1 further stated he (MS 1) did not have a copy of the facility's water flow diagram (a visual tool that shows all the water sources and system flow) and was therefore unable to determine where Legionella bacteria or other opportunistic pathogens (is an organism that normally does not harm its host but can cause disease especially when the host's resistance is low) could potentially grow. During an interview on 11/13/2025 at 11:31 a.m., with the IP Nurse, the IP Nurse stated that on 11/12/2025, Public Health Nurse 1 (PHN 1) e-mailed her (IP Nurse) indicating that the Los Angeles County Department of Public Health's Acute Communicable Disease Control Program (LACDPH-ACDC) had identified a presumptive healthcare-associated (when a resident had a continuous stay at the skilled nursing facility during the 14 days before onset of symptoms) Legionella disease case in the facility (Resident 1). During a concurrent interview and record review on 11/13/2025 at 2:02 p.m., with the IP Nurse, the recommended actions from the Annual Analytical Validation Viable Legionella Bacteria Reports dated 2/26/2024, 12/9/2024, 1/24/2025, 2/19/2025, and 3/17/2025, and the facility's Domestic Water Flushing Log since 1/2024, were reviewed. The IP stated that all the results indicated Legionella bacteria had been found in the facility's water since 2/26/2024. The IP stated that maintenance staff handled the interventions by performing daily flushing in room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], Nurse Station 1, Nurse Station 2, Bathtub 1, and Bathtub 2 and by conducting annual (every year) water testing for Legionella bacteria. During a concurrent interview and record review on 11/13/2025 at 2:31 p.m., with the Director of Nursing (DON), IP Nurse, and MS 1, the recommended actions from the Annual Analytical Validation Viable Legionella Bacteria Reports dated 2/26/2024, 12/9/2024, 1/24/2025, 2/19/2025, and 3/17/2025, the facility's Domestic Water Flushing Log since 1/2024, and the facility's Water Management Program Water Safety Plan, dated 2025 (specific month and day not indicated) were reviewed. The IP Nurse stated that the Water Management Program Water Safety Plan indicated to Isolate the system to minimize exposure of water to patients (residents) as directed by Infection Prevention. The Water Management Program Water Safety Plan indicated to Isolate means Disabling the water supply to the fixture until remediation (act of correcting an error or a fault) has been conducted. The IP Nurse further stated that the Water Management Program Water Safety Plan indicated to resample the water for Legionella bacteria within five to 10 days after corrective actions were implemented. The DON, IP Nurse, and MS 1 stated that the facility did not follow or act on the recommendations outlined in the Annual Analytical Validation Viable Legionella Bacteria Reports dated 2/26/2024, 12/9/2024, 1/24/2025, 2/19/2025, and 3/17/2025, or in the Water Management Program Water Safety Plan, dated 2025 and that there was no documented evidence indicating these actions were implemented. During an interview on 11/13/2025 at 3:13 p.m. with Administrator 1, Administrator 1 stated that he (Administrator 1) began working at the facility at the end of 4/2025. Administrator 1 stated that MS 1 was responsible for the facility's Water Management Program. Administrator 1 stated that the water testing company (third party) had been reporting the water test results to the previous administrator (Administrator 2), which was why he (Administrator 1) was not aware of the water test results. Administrator 1 further stated that he (Administrator 1) did not contact the water testing company to inform them that he (Administrator 1) was the new administrator of the facility because no issues had been reported to him (Administrator 1). During a concurrent observation and interview on 11/19/2025 at 10:55 a.m., the facility's water system in randomly selected residents rooms (room [ROOM NUMBER] and room [ROOM NUMBER]), shower tubs (Bathtubs 3, 4, 5, and 6), Station 1 utility faucet, Station 2 utility faucet, kitchen ice machine, and the beauty shops (Beauty Shop 1 and Beauty Shop 2), was observed with LACDPH-ACDC team (ACDC MD 2, ACDC MD 3, ACDC Team Member 1, ACDC Team Member 2, ACDC Team Member 3, and ACDC Team Member 4) together with the facility's DON, IP Nurse, and Nurse Consultant. ACDC MD 2 stated that the facility's water system had a lot of faucets (number of faucets not specified) that were not in use. During an interview with ACDC MD 2 on 11/19/2025 at 12:12 p.m., ACDC MD 2 stated that he (ACDC MD 2) was concerned that the facility's water system had a lot of dead leg (a section of potable {safe to drink} water pipe which contains water that has no flow or does not circulate). During an interview on 11/19/2025 at 3:14 p.m., with the IP Nurse, the IP Nurse stated that her (IP Nurse) responsibility as an IP Nurse regarding monitoring Legionella was to assist the administration and maintenance management with any potential or suspected exposure to Legionella bacteria. The IP nurse stated that she (IP Nurse) reviews the Annual Analytical Validation Viable Legionella Bacteria reports with the team, along with the accompanying recommendations. The IP Nurse stated that she (IP Nurse) did not carry out her role in managing Legionella, and that there was no documented evidence that the facility developed or implemented a plan to address facility-specific infection control needs and requirements identified in the facility assessment and infection control risk assessment. During an interview on 11/20/2025 at 11:13 a.m., with the IP Nurse, the IP Nurse stated that the facility should follow the water management recommendations until no Legionella bacteria were detected in the water. The IP Nurse stated that she (IP Nurse) was not aware that the facility's water tested positive for Legionella on 2/26/2024 and only became aware of the water test results conducted on 11/26/2024 (results and recommendations were reported by the third-party testing company to the facility on [DATE]) when Administrator 2 informed her (IP Nurse). The IP Nurse stated that she was not made aware of any water testing results after 12/9/2024. The IP Nurse stated that she (IP Nurse) did not maintain any logs indicating whether residents were being monitored for potential Legionella exposure. The IP Nurse stated that without monitoring residents and maintaining logs, the facility could not determine if residents were affected or potentially exposed to Legionella bacteria. The IP Nurse stated that monitoring residents was essential because they (residents) could develop worsening respiratory (refers to the lungs and breathing) issues, require hospitalization or die as a result of Legionella exposure. The IP Nurse stated that the facility failed to monitor residents for Legionella-related illness, failed to implement and follow the water management plan recommendations, and did not isolate residents with pneumonia (an infection in the lungs that inflames the air sacs, causing them to fill with fluid or pus [a thick, opaque (not transparent), usually yellowish-white, fluid matter that is formed as part of an inflammatory response typically associated with an infection]). The IP Nurse stated the facility did not report to CDPH that Legionella bacteria was detected at the facility's water system since 2/26/2024 to 3/17/2025. The IP Nurse stated the presence of Legionella bacteria in the facility's water system should be reported to CDPH within 24 hours due to unusual occurrence in the facility. During an interview on 11/20/2025 at 12:20 p.m., with the DON, the DON stated that the IP Nurse manages the monthly surveillance log for Legionella. The DON stated that the IP Nurse should notify the DON when the facility's water tests positive for Legionella bacteria. The DON stated that she (DON) was not aware that the 3/17/2025 water test was positive for Legionella. The DON stated that had she (DON) been aware, she (DON) would have ensured the facility implemented the recommended actions outlined in the Water Management Plan. The DON further stated that there was no documented evidence that the facility monitored the residents for Legionella exposure. The DON stated that the facility failed to ensure effective communication between incoming and outgoing administrators regarding the presence of Legionella bacteria in the water. The DON stated that this situation was preventable. The DON stated that monitoring and communication should have been the responsibility of the IP Nurse, but the IP Nurse did not carry out these duties, and proper communication did not occur. The DON stated the presence of Legionella bacteria in the facility's water system was an unusual occurrence and was not reported to CDPH. The DON stated the presence of Legionella bacteria in the facility's water system must be reported to CDPH within 24 to 48 hours as unusual occurrence according to facility's policy and procedure. During a review of the Infection Control Nurse - Job Description, undated, the job description indicated the primary purpose of the Infection Control Nurse is to plan, organize, develop, coordinate, and direct our infection control program and its activities in accordance with current federal, state, and local standards, guidelines, and regulations that govern such program, and as may be directed by the Administrator and the Infection Control Committee to ensure that an effective infection control program is maintained at all time. During a review of the facility's Domestic Water Flushing Log from 1/2024 to 3/31/2025, the log indicated that the facility performed water flushing in the following rooms:1. 1/1/2024 to 1/31/2024 - Rooms 1, 2, 3, and 4; Nurse Stations 1, and 2; Bathtubs 1 and 2. 2. 2/1/2024 to 2/28/2024 - Rooms 1, 2, 3, and 4; Nurse Stations 1, and 2; Bathtubs 1 and 2. 3. 11/1/2024 to 11/30/2024 - Rooms 1, 2, 3, and 4; Nurse Stations 1, and 2; Bathtubs 1 and 2. 4. 12/1/2024 to 12/31/2024 - Rooms 1, 2, 3, and 4; Nurse Stations 1, and 2; Bathtubs 1 and 2. 5. 1/1/2025 to 1/31/2025 - Rooms 1, 2, 3, and 4; Nurse Stations 1, and 2; Bathtubs 1 and 2. 6. 2/1/2025 to 2/28/2025 - Rooms 1, 2, 3, and 4; Nurse Stations 1, and 2; Bathtubs 1 and 2. 7. 3/1/2025 to 3/31/2025 - Rooms 1, 2, 3, and 4; Nurse Stations 1, and 2; Bathtubs 1 and 2. During a review of the facility's Annual Analytical Validation Viable Legionella Bacteria Reports dated 2/26/2024, 12/9/2024, 1/24/2025, 2/19/2025, and 3/17/2025 indicated the following results: 1. First water sample: Collected on 2/14/2024; result was reported to the facility on 2/26/2024. Result: For domestic water, one (1) sample showed the presence of Legionella bacteria (room [ROOM NUMBER]). 2. Second water sample: Collected on 11/26/2024; result was reported to the facility on [DATE].Result: For domestic water, two (2) water samples showed detectable Legionella bacteria (room [ROOM NUMBER] and room [ROOM NUMBER]). 3. Third water sample: Collected on 1/15/2025; result was reported to the facility on 1/24/2025. Result: For domestic water, three (3) water samples showed detectable Legionella bacteria (room [ROOM NUMBER], Bathtub 1, and room [ROOM NUMBER]). 4. Fourth water sample: Collected on 2/11/2025; result was reported to the facility on 2/19/2025. Result: For domestic water, three (3) water samples showed detectable Legionella bacteria (room [ROOM NUMBER], Bathtub 1, and room [ROOM NUMBER]). 5. Fifth and last water sample: Collected on 3/7/2025; result was reported to the facility on 3/17/2025. Result: For domestic water, two of three water samples showed detectable Legionella bacteria (Bathtub 1 and room [ROOM NUMBER]). Further review of the facility's Annual Analytical Validation Viable Legionella Bacteria Reports dated 2/26/2024, 12/9/2024, 1/24/2025, 2/19/2025, and 3/17/2025 indicated the following Recommended Actions for water samples reported on 2/26/2024, 12/9/2024, 1/24/2025, 2/19/2025, and 3/17/2025: - It is recommended that positive fixtures (general category of devices that are installed for the intentional supply and usage of water within a building) and adjacent taps be thoroughly flushed for five minutes a day for a period of five to seven days. It is important to verify the hot water temperature reaches the target temperature. It is also recommended that the affected showerheads and associated hose lines be replaced. - It is also recommended to either replace or descale (remove built-up or incrustation {formation of a hard, thick layer or crust of deposited material on the surfaces of pipes, pumps and other system components}) and disinfect the fixtures in the affected rooms per your Management Plan Standard Operating Procedures (SOP) in Section 4. - All positive locations should be re-tested following completion of corrective actions in order to re-establish acceptable control. If additional testing continues to show the presence of Legionella bacteria, alternate control measures should be considered, including the use of permanent secondary disinfection system or routine remediation procedures. - Continue to follow all the preventative actions as part of your Water Safety Plan, including routine testing of the water systems. Additional recommended action is advised for water sample report on 11/26/2025: - Since a majority of the samples were positive, it is recommended that a chlorination process (process of adding chlorine or chlorine compounds to water to kill harmful bacteria) be implemented in conjunction with flushing of the domestic water supply, as outlined in your Water Safety Program in Section 4.Additional recommended action is advised for water sample report on 1/24/2025: - It is recommended to sample from the angle stop at next visit to rule out detection in the line. - Localized treatments such as fixture disinfections, riser disinfections refers to the practice of using disinfectants within riser pipes, which are vertical sections of plumbing that carry water between floors in a building or from the ground into a storage tank or irrigation line, and drop-leg (synonymous with a dead leg or blind end, which is a section of piping with little or no water flow where water becomes stagnant) plumbing disinfections can be very effective if the source of the contamination is indeed local. Additional recommended action is advised for water sample report on 2/19/2025: - The samples with Legionella detections may be associated with low-use areas where stagnant conditions can occur. All affected fixtures should be temporarily isolated if directed by Infection Prevention. Examples of System Isolation may consist of 1) Disabling the water supply to the fixture until remediation has been conducted, 2) Isolating the room where the fixture is located from normal use, and 3) Installation of microbiological filters (physically remove harmful microorganisms such as bacteria and particles from water using fine pore membranes (like 0.1-10 micron {or micrometer - unit of measure, symbolized as um, refers to the use of highly precise filtration systems that measure and remove contaminants from water based on their extremely small size) to prevent exposure to Legionella. - Since a majority of the samples were positive, it is recommended that a chlorination process be implemented in conjunction with flushing of the domestic water supply, as outlined in your Water Safety Program in Section 4. Additional recommended action is advised for water sample report on 3/17/2025: - The samples with Legionella detections may be associated with low-use areas where stagnant conditions can occur. All affected fixtures should be temporarily isolated if directed by Infection Prevention. Examples of System Isolation may consist of 1) Disabling the water supply to the fixture until remediation has been conducted, 2) Isolating the room where the fixture is located from normal use, and 3) Installation of microbiological filters to prevent exposure to Legionella.- Since a majority of the samples were positive, it is recommended that a chlorination process be implemented in conjunction with flushing of the domestic water supply, as outlined in your Water Safety Program in Section 4. During a review of the facility-provided policy and procedure titled, Legionella Water Management Program, last reviewed on 11/6/2025, the policy indicated, Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella. Policy Interpretation and Implementation Section: 1. As part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team. 5. The water management program includes the following elements: .c. The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, including the following: (1) Storage tanks; (2) Water heaters; (3) Filters; (4) Aerators (process by which air is circulated through, mixed with or dissolved in a liquid or other substances that act as a fluid); (5) Showerheads and hoses; (6) Misters (a device, such as a bottle, with a nozzle for spraying a mist of water), atomizers (a device for emitting water as a fine spray), air washers (recirculating water systems to force air through a spray of water to remove impurities and humidity) and humidifiers (a device for keeping the atmosphere moist in a room); (7) Hot tubs; .(9) Medical devices such as continuous positive airway pressure (CPAP) machines (machines that uses mild air pressure to keep breathing airways open while you sleep), hydrotherapy equipment (assists in creating a safe water environment in which to exercise) . d. The identification of situations that can lead to Legionella growth, such as: (1) construction; (2) water main breaks; (7) water stagnation; and(8) inadequate disinfection. e. Specific measures used to control the introduction and/or spread or Legionella (e.g. [for example], temperature, disinfectants). f. The control limits or parameters that are acceptable and that are monitored. g. A system to monitor control limits and the effectiveness of control measures. h. Documentation of the program. 6. The water management program is reviewed at least once a year, or sooner if any of the following occur: a. The control limits are consistently not met.c. There are any disease cases associated with the water system. During a review of the facility-provided policy and procedure titled, Legionella Surveillance and Detection, last reviewed on 11/6/2025, the policy and procedure indicated, Our facility is committed to the prevention, detection and control of water-borne contaminants (any physical, chemical, biological (relating to living organisms), or radiological ( relating to or involving high-energy radiation) substances or matter in water, other than water molecules themselves, that can degrade water quality and pose risk to human health and environment), including Legionella. Legionnaire's disease is included as part of our infection surveillance activities. As part of the infection prevention and control program, all cases of pneumonia that are diagnosed in residents > [greater than] 48 hours after admission are investigated for possible Legionnaire's disease. Risk factors for developing Legionnaire's Disease include: c. Chronic lung disease, such as emphysema (progressive lung disease that causes shortness of breath) or COPD; . f. Underlying illness, such as diabetes, renal failure (kidney failure a condition which one or both kidneys no longer work on their own), or hepatic failure (liver is no longer to function adequately for body needs). Residents who have signs and symptoms of pneumonia may be placed on transmission-based (droplet [used to prevent transmission of infectious agents spread through respiratory]) precautions, although person-to person transmission is rare. During a review of the facility-provided policy and procedure titled, Infection Prevention and Control Program, last reviewed on 11/6/2025, the policy and procedure indicated, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections. The IPCP is developed to address the facility-specific infection control needs and requirements identified in the facility assessment and the infection control risk assessment. The IPCP provides a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents. Elements of the IPCP 1. Coordination and Oversight a. The IPCP is coordinated and overseen by an infection prevention specialist (infection preventionist). 2. Policies and Proceduresb. The infection prevention and control committee, medical director, director of nursing services, and other key clinical and administrative staff review the infection control policies at least annually. 3. Surveillance and reportingb. Surveillance tools are used for identifying the occurrence of infections, recording their number and frequency, .monitoring adherence to infection prevention and control practices, and detecting unusual pathogens with infection control implications. During a review of the facility-provided policy and procedure titled, Unusual Occurrence Reporting, last reviewed on 11/6/2025, the policy and procedure indicated, As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees or visitors. Unusual occurrences shall be reported via telephone to appropriate agencies as requires by current law and/or regulations such incident or as otherwise required by federal and state regulations. A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency (and other appropriate agencies as required by law) within forty-eight (48) hours of reporting the event or as required by federal and state regulations.

Based on interview and record review, the facility failed to ensure: A. That one of seven sampled residents (Resident 5), who had a history of multiple falls in the facility (6/24/2025, 6/25/2025, 7/19/2025, 7/20/2025, 7/26/2025, 7/27/2025, 8/3/2025, and 8/10/2025), was assessed as having moderately impaired cognitive function (a decline in a resident's mental abilities, impacting their ability to think, learn, remember, reason, and make decisions), and required moderate assistance (helper does more than half the effort) from staff for toilet transfers and mobility (movement), was free from accidents and was provided with supervision (refers to the ongoing monitoring and guidance provided by staff to ensure the safety and well-being of a resident) by failing to: A1. Initiate the facility's Falling Star Program (a resident safety initiative that uses a visual symbol, like a falling star, to identify residents at high risk for falls in healthcare settings) on 6/24/2025 when Resident 5 was identified as being at higher risk for falls following a fall incident on 6/24/2025. A fall risk assessment was completed for Resident 5 on 6/24/2025, however Resident 5 was not added to the facility's Falling Star Program until 7/21/2025 (nearly a month later). A2. Follow the facility's Falling Star Program procedures after Resident 5's falls on 6/24/2025 and 6/25/2025, which requires an Interdisciplinary Team (IDT - a group of professionals from different disciplines who work together to provide coordinated care for residents) Meeting to be held to determine whether Resident 5 should be placed on the Facility Star Program. A3. Implement close supervision interventions as indicated in the facility's Falling Star Program to provide close supervision for resident on the falling star program by increasing frequency of rounds (scheduled checks by healthcare staff to assess resident status, manage needs, and collaborate on care plans, often at the resident's bedside) to hourly. During hourly rounds, staff will ask or check . Potty - Evaluating . if they need to go to the bathroom. A4. Ensure Resident 5's wheelchair alarm (a safety device that alerts facility staff when a resident attempts to stand up or exit the wheelchair, used to prevent falls) was functioning, when on 8/13/2025 at 6 p.m. Resident 5 stood up from her wheelchair and entered Room A's bathroom without triggering her (Resident 5's) wheelchair alarm. These deficient practices resulted in a fall on 8/13/2025 at 6 p.m. when Resident 5 was left unsupervised in her wheelchair by Certified Nursing Assistant 4 (CNA 4) after being provided with a dinner meal tray. Resident 5 was then later found on the toilet in the bathroom of Room A with a posterior scalp (back portion of the scalp {hair-covered area of the head}) laceration (a deep cut or tear in the skin), posterior scalp hematoma (a collection of blood that has pooled outside of blood vessels {a tube through which the blood circulates in the body}, usually due to trauma or injury that damages a blood vessel) and bleeding. Resident 5's laceration measured two centimeters (cm - unit of measurement) in length, one cm in width, and 0.2 cm in depth and the hematoma on the posterior side of the scalp measured three cm in length and 3 cm in width. Licensed Vocational Nurse 6 (LVN 6) applied a dressing (a pad or cover applied to an injury or wound to protect it, promote healing and prevent infection) on Resident 5's laceration to control the bleeding. On 8/13/2025 at 6:30 p.m., Resident 5 was transferred to General Acute Care Hospital 1 (GACH 1) for further evaluation. B. Fall prevention interventions were implemented for one of four sampled residents (Resident 3) when Resident 3's Falling Star Program interventions to place a yellow star in front of Resident 3's door and footboard were not in place. This deficient practice had the potential to place Resident 3 at risk for falls. Findings: A. During a review of Resident 5's admission Record, the admission Record indicated the facility admitted Resident 5 on 6/21/2025 with diagnoses including dementia (a progressive state of decline in mental abilities), cerebral infarction (damage to the area of the brain caused by lack of blood flow), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and repeated falls. During a review of Resident 5's History and Physical (H&P - a comprehensive assessment of a resident's medical condition), dated 6/23/2025, the H&P indicated that Resident 5 had fluctuating capacity to understand and make decisions. During a review of Resident 5's Fall Risk Observation/Assessment form, dated 6/24/2025, after Resident 5 had a fall on 6/24/2025, the Fall Risk Observation/Assessment form indicated that Resident 5 had a fall risk score of 24 (a score ranging from 16 to 42 signifies a high risk for falls). During a review of Resident 5's Care Plan for fall, initiated on 6/24/2025, the Care Plan indicated that on 6/24/2025 Resident 5 had an unwitnessed fall (an instance where a person falls but no one was present to see the event occur) and was identified as being at risk for recurrent falls and injury. During a review of Resident 5's Minimum Data Set (MDS – a resident assessment tool), dated 6/27/2025, the MDS indicated Resident 5 had moderately impaired cognitive functioning. The MDS indicated Resident 5 required moderate assistance from staff for toilet transfers and mobility. The MDS indicated Resident 5 required maximal assistance (helper does more than half of the effort) from staff with toileting hygiene, showers, and lower body dressing. The MDS also indicated Resident 5 had a fall prior to admission to the facility. During a review of Resident 5's Physician's Order dated 7/21/2025, the Physician's Order indicated to increase staff supervision for safety. During a review of Resident 5's Physician's Order dated 7/23/2025, the Physician's Order indicated that a chair (wheelchair) alarm was to be used while Resident 5 was in a wheelchair for safety purposes. The Physician's Order further indicated for staff to monitor the functionality of the chair alarm every shift and at each opportunity the resident is observed to ensure continued safety. During a review of Resident 5's Care Plan for fall, initiated on 8/13/2025, the Care Plan indicated that on 8/13/2025 Resident 5 had an unwitnessed fall. The Care Plan interventions included anticipating and addressing the resident's needs, and the use of a chair alarm to ensure resident safety. During a review of Resident 5's Situational Background Assessment and Recommendation (SBAR – a communication tool used to provide concise, clear, and effective information regarding a resident's condition) Communication Form, dated 8/13/2025, timed at 6:32 p.m., the SBAR form indicated that on 8/13/2025 (time not indicated), CNA 4 reported that Resident 5 attempted to go to the bathroom unassisted and had an unwitnessed fall. The SBAR further indicated to transfer Resident 5 via 911 (a universally recognized and designated emergency telephone number in the United States used to request immediate assistance in an emergency) for further evaluation. During a review of Resident 5's Progress Note (written summary by a healthcare professional detailing a resident's condition, care, treatments, and response to interventions during a specific encounter), dated 8/13/2025, timed at 6:05 p.m., the Progress Note indicated that on 8/13/2025, at approximately 6:05 p.m., Registered Nurse (RN 2) was informed of an unwitnessed fall involving Resident 5. The Progress Note indicated that Resident 5 reported hitting her (Resident 5) head and had a visible laceration on the back of her (Resident 5) head. The Progress Note indicated a dressing was applied to Resident 5's head and the bleeding was controlled. The Progress Note further indicated that on 8/13/2025 at 6:30 p.m., Resident 5 was transferred to GACH 1 for further evaluation. During a review of Resident 5's Physician's Order dated 8/15/2025, the Physician's Order indicated to cleanse Resident 5's posterior scalp laceration with normal saline (NS – a salt and water solution), pat dry, apply xeroform (a moist yellow dressing that covers the wound and promote wound healing), cover with gauze (a thin, light, and loosely woven fabric used for wound dressings) and wrap with stretch gauze (a flexible, absorbent bandage used to secure dressings, provide compression, and offer support for wounds) every day or as needed for 21 days. During an interview on 8/19/2025 at 12:09 p.m., with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated that on 8/13/2025, at approximately 6 p.m., she (LVN 4) entered the bathroom in Room A and found Resident 5 sitting on the toilet without any assistance from facility staff. LVN 4 stated that there was no audible sound from Resident 5's wheelchair alarm at the time. LVN 4 further stated that Resident 5 had sustained a head injury and was subsequently transferred to GACH 1 on 8/13/2024 at 6:30 p.m. for further evaluation and treatment. During a concurrent interview and record review on 8/19/2025 at 1:18 p.m., with LVN 6, Resident 5's Comprehensive Skin Evaluation/Assessment form dated 8/13/2025 was reviewed. The form indicated that on 8/13/2025 (time not indicated) Resident 5 was observed with moderate sanguineous drainage (leakage of fresh blood from an open wound, characterized by a bright red color and a syrup like consistency) from a laceration located on the posterior scalp, measuring two cm in length, one cm in width, and 0.2 cm in depth. The form indicated Resident 5 had a purple-colored hematoma, on the posterior scalp measuring three cm in length and three cm in width. The form indicated that Resident 5's posterior scalp injury was cleansed, and treatment was provided in accordance with the Physician's Order. LVN 6 stated that on 8/13/2025, at approximately 6:30 p.m., she (LVN 6) was asked to assist with Resident 5's treatment. LVN 6 stated that upon entering Room A, LVN 6 observed Resident 5 sitting on the toilet. LVN 6 further stated that Resident 5 was repeatedly grabbing her head and had visible blood on her (Resident 5) hand. During a concurrent interview and record review on 8/19/2025 at 1:58 p.m. with the Assistant Director of Nursing (ADON), Resident 5's Care Plan for fall, initiated on 7/20/2025 was reviewed. The Care Plan indicated that Resident 5 was at risk for falls related to altered balance (difficulty keeping a stable and upright position) while standing and walking, decreased muscular coordination (ability of multiple muscle to work together accurately to produce a desired movement or action), history of multiple falls, and an unsteady gait (pattern of walking that lacks stability and coordination resulting in increased risk of falls). The Care Plan indicated that Resident 5 sustained falls on 7/19/2025, 7/20/2025, 8/3/2025, and 8/10/2025. The care plan interventions included Resident 5 was added to the facility's Falling Star Fall Prevention Program as of 7/21/2025 and to keep Resident 5 within supervised view as much as possible. The ADON stated that the purpose of the Falling Star Program was to alert and inform facility staff of residents identified as high risk for falls. The ADON further stated that the Falling Star Fall Prevention Program should have been initiated for Resident 5 on 6/24/2025, when Resident 5 was assessed and identified as being at high risk for falls. During an interview on 8/19/2025 at 3:58 p.m., with RN 2, RN 2 stated that on 8/13/2025, at approximately 6 p.m., she (RN 2) was informed by facility staff (unable to recall who) that Resident 5 had sustained a fall. RN 2 stated that upon entering Room A, she (RN 2) observed Resident 5 sitting on the toilet in the bathroom with a visible head injury. RN 2 stated that Resident 5 stated she (Resident 5) had hit her (Resident 5) head but could not recall where the fall occurred. RN 2 further stated that Resident 5's wheelchair alarm did not activate when Resident 5 got up from the wheelchair to go to the bathroom. RN 2 stated that the purpose of the wheelchair alarm is to alert staff when a resident attempts to stand, in order to prevent falls. RN 2 stated that facility staff failed to ensure the wheelchair alarm was functioning properly, as no alarm was triggered during the fall incident on 8/13/2025. RN 2 stated that this failure had the potential for Resident 5 to stand without staff assistance and sustain a fall resulting in injury or hemorrhage (a heavy, uncontrolled loss of blood, either externally from a wound or internally). During an interview on 8/20/2025 at 10:36 a.m., with the Director of Nursing (DON), the DON stated that the facility failed to conduct an IDT Meeting to review and update Resident 5's care plan and interventions following the falls that occurred on 6/24/2025 and 6/25/2025. The DON stated that the purpose of the IDT Meeting is to facilitate collaboration among team members to revise and develop an appropriate care plan in response to significant incidents such as multiple falls. The DON further stated that the failure to hold an IDT meeting after Resident 5's fall incidents had the potential to result in a care plan that was based on incomplete or inaccurate information placing Resident 5 at continued risk for harm. The DON stated that the facility's Falling Star Program serves as a communication tool to enhance staff awareness of residents identified as being at risk for falls. The DON stated that the goal of the Falling Star Program is to implement close supervision interventions including increased monitoring such as hourly rounding, particularly for residents placed in the Red Star category, indicating resident had two or more falls within a one-month period. The DON further stated that the Falling Star Program should have been initiated for Resident 5 on 6/24/2025, following completion of a fall risk assessment that identified Resident 5 as being at high risk for falls. The DON stated Resident 5 sustained multiple falls on 6/24/2025, 6/25/2025, 7/19/2025, 7/20/2025, 7/26/2025, 7/27/2025, 8/3/2025, and 8/10/2025. During a follow-up interview on 8/20/2025 at 12:14 p.m., with the DON, the DON stated that the facility staff (did not specify) did not inform her of the specific details regarding Resident 5's fall on 8/13/2025 at 6 p.m. The DON stated Resident 5 returned to the facility from GACH 1 the same night, 8/13/2025, Resident 5 was transferred. The DON further stated that facility staff failed to verify the functionality of Resident 5's wheelchair alarm while Resident 5 was seated in the wheelchair. The DON stated that Resident 5 was added to the facility's Falling Star Program on 7/21/2025 as part of the fall prevention interventions (nearly one month after Resident 5's initial fall on 6/24/2025). The DON stated there was no documented evidence that facility staff provided Resident 5 with supervision and hourly monitoring on 8/13/2025, as indicated in the facility's Falling Star Program. During an interview on 8/20/2025 at 4:50 p.m., with CNA 4, CNA 4 stated that on 8/13/2025, during dinner service (unable to recall specific time), she (CNA 4) provided a meal tray to Resident 5, who was seated in her (Resident 5) wheelchair next to her (Resident 5) bed in Room A. CNA 4 stated that after she (CNA 4) provided the meal tray to Resident 1, she (CNA 4) proceeded to distribute meal trays to other residents. CNA 4 stated approximately 20 minutes after she (CNA 4) last observed Resident 5 in Room A, CNA 4 was called by LVN 4 to assist in Room A. CNA 4 further stated that upon entering Room A, CNA 4 observed Resident 5 seated on the toilet in the bathroom. CNA 4 stated that Resident 5's wheelchair was positioned outside the bathroom door. CNA 4 stated that she (CNA 4) did not hear Resident 5's wheelchair alarm activate when Resident 5 stood up, indicating that the alarm did not function as intended. During an interview on 8/21/2025 at 12 p.m., with LVN 4, LVN 4 stated that Resident 5's injury on 8/13/2025, which included a posterior scalp laceration and hematoma could have been prevented if Resident 5's wheelchair alarm had been functioning properly. LVN 4 stated had the alarm sounded, a staff member could have responded promptly, assisted Resident 5, and potentially prevented the fall and resulting injury. During an interview on 8/21/2025 at 1:10 p.m., with the DON, the DON stated that facility staff (did not specify) were under the impression that Resident 5 had sustained an unwitnessed fall. The DON further stated that it was possible Resident 5 may have struck her (Resident 5) head on the metal grab bars attached to the toilet. The DON stated that if Resident 5's wheelchair alarm was functioning properly, Resident 5's wheelchair alarm should have been heard from Hallway A and Nursing Station 1 when Resident 5 stood up from the wheelchair. The DON stated Resident 5's injury could have been prevented if facility staff had ensured that the wheelchair alarm was both operational and appropriately positioned. The DON stated that the facility does not have a policy and procedure (P&P) in place for the use and monitoring of chair alarms. During a review of the current facility-provided P&P titled, Falls and Fall Risk, Managing, last reviewed on 4/24/2025, the P&P indicated, Based on previous evaluations and current data, that staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. During a review of the facility-provided P&P titled, Falling Star Program, last reviewed on 4/24/2025, the P&P indicated, Our ultimate goals are: To arm our caregivers with the tools, proactive strategies and interventions, needed to be more vigilant with all residents and especially with those who are at high risk. Residents that qualify to be in the Falling Star Program are: Residents scoring high risk based on most recent Fall Risk Assessment. We adopted a red star to symbolize the following residents: Current, new admissions . with fall incidents of two or more in a month. IDT will be held to discuss residents to be placed on the Falling Star program. In addition, staff will use the following proactive strategies to resident under the Falling Star Program and reflected on resident's care plan: 1. Close supervision for resident on the falling star program by increasing frequency of rounds to hourly. 2. During hourly rounds staff will ask or check . Potty – Evaluating them . if they need to go to the bathroom. B. During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 8/14/2025 with diagnoses including metabolic encephalopathy (any condition that damages or impairs the brain, leading to changes in brain function or structure), muscle weakness (generalized), and rhabdomyolysis (a condition where muscle tissue breaks down, releasing harmful substances from within the muscle cells into the bloodstream, which can cause kidney damage and other serious problems). During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's cognitive functioning for daily decision making was independent (decisions consistent and reasonable). The MDS indicated Resident 3 required substantial assistance (helper does more than half the effort) with toileting, showering, upper and lower body dressing, putting on and taking off footwear, and with personal hygiene and required supervision or touch assistance (helper provides verbal cues, and touching and or steadying and or contact guard assistance) with eating and oral hygiene. During a review of Resident 3's Fall Risk Observation/Assessment form, dated 8/14/2025, at 9:24 p.m., the Fall Risk Observation/Assessment indicated Resident 3 had a fall risk score of 20 (a score of 16 to 42 is a high risk for fall). During a review of Resident 3's SBAR Communication Form, dated 8/14/2025, the SBAR Communication Form indicated at 11:40 p.m., Resident 3 had a fall and was found on the floor at the bedside, sitting up. During a review of Resident 3's Fall Risk Observation/Assessment, dated 8/14/2025, at 11:40 p.m., the Fall Risk Observation/Assessment indicated Resident 3 had a fall risk score of 22. During a review of Resident 3's Care Plan for risk for falls, initiated on 8/14/2025, the Care Plan indicated Resident 3 is at risk for falls with and without injury related to altered balance while standing or walking, and unsteady gait. The Care Plan interventions included Falling Star Program: yellow star and keep within supervised view as much as possible. During a review of Resident 3's Care Plan for falls, initiated 8/15/2025, the Care Plan indicated Resident 3 had an unwitnessed fall and is at risk for injury and recurring falls. The Care Plan interventions included Falling Star Program: yellow star and anticipate and meet needs. During a review of Resident 3's IDT Note, dated 8/15/2025 at 1:34 p.m., the IDT Note indicated an IDT meeting was conducted to discuss Resident 3's enrollment in the falling star program following recent fall. The IDT indicated: - A fall risk assessment was performed on Resident 3 on 8/14/2025 and identified Resident 3 as high-risk status. - Resident 3 meets the criteria for a yellow star designation under the falling star program. - A yellow star has been placed on Resident 3's door and footboard per protocol. During a concurrent observation, record review, and interview on 8/19/2025 at 12:08 p.m. inside Resident 3's room, with the ADON, Resident 3's Fall Risk Observation/Assessment and Resident 3's Care Plans for falls were reviewed. The ADON stated the Falling Star Program identifies residents with any falls in the last 30 days with a yellow star. The ADON stated residents that are identified as a high risk for falls get a star on the outside of the door by their names and at the end of their foot board. The ADON reviewed Resident 3's Fall Risk Observation/ Assessment, dated 8/14/2025, and stated Resident 3 had a fall risk score of 20. The ADON stated Resident 3's Fall Risk Observation/Assessment, dated 8/14/2025, indicated Resident 3 had another fall and Resident 3's score went up to 22. The ADON stated Resident 3 is at high risk for falls. The ADON reviewed Resident 3's Care Plan for unwitnessed fall and stated the interventions indicate for Resident 3 to be on the falling star program. The ADON observed Resident 3's door and footboard and stated Resident 3 does not have a star on the resident's door and footboard. The ADON stated residents on the falling star program should have a star on their door and footboard. The ADON stated Resident 3 should have a star on his footboard and by the door to ensure facility staff sees who the residents at risk for falls are. The ADON stated the falling star program should have been implemented after Resident 3's fall on 8/14/2025. The ADON stated if the facility is not implementing interventions like the falling star program, the staff will not be able to identify the fall risk residents, and staff will not be able to be vigilant with checking on the residents. During an interview on 8/19/2025 at 4:06 p.m. with the DON, the DON stated Resident 3 was a fall risk and had a fall on 8/14/2025. The DON stated the falling star program makes the staff aware of high fall risk residents by identifying residents with a yellow star outside the residents' door and footboard. The DON stated the purposes of the stars at the footboard and outside the door are to provide staff with awareness, minimize falls, allow staff to identify immediately who is a fall risk, and provide a form of communication. The DON stated she is aware Resident 3 did not have yellow star outside door or footboard. The DON stated not implementing the falling star program can be a potential contributing factor for resident falls. During a review of the facility's P&P titled, Falling Star Program, last reviewed on 4/24/2025, the P&P indicated: 1. To standardize our screening identification and falls prevention strategies in order to reduce both the number and severity of falls in our facility. 2. To successfully raise awareness about Falls Prevention throughout our facility. 3. To arm our caregivers with the tools, proactive strategies and interventions, needed to be more vigilant with all residents and especially with those who are at high risk. Protocol: 2. We adopted a Yellow Star to symbolize the following residents: - who are new admit/readmit residents who score High Risk or with a history of fall/s within the last 30 days. - current residents who had fallen with no major injury in the last 30 days. - any resident who scored High Risk on Fall Risk Assessment. To alert all members of our Health Care Team: - A Yellow Star is placed at the door by the name of these residents. This star will follow with residents as room changes occur. - A Yellow Star is placed on the footboard of these residents.

Based on interview and record review, the facility failed to notify the physician of a change of condition (COC - a major decline in a resident ' s status) for one of nine sampled residents (Resident 1) when on 3/12/2025 at approximately 5 p.m., Resident 1 had a low blood pressure (BP - measurement of the pressure or force of blood inside your arteries [the elastic, muscular tubes or blood vessels responsible for carrying the blood away from the heart and distributing it to several other organs and tissues]) reading of 86/57 millimeters of mercury (mmHg - unit of measurement used to measure BP and is abnormal if less than 90/60 mmHg or greater than 139/89 mmHg) and increased heart rate (HR - the number of heartbeats per unit of time) of 111 beats per minute (bpm - considered abnormal if less than 60 bpm or greater than 100 bpm). As a result, Resident 1 experienced severe respiratory distress (a life-threatening condition characterized by difficult breathing, rapid breathing, and low oxygen levels, often requiring immediate medical intervention) was transferred to a General Acute Care Hospital (GACH) on 3/13/2025 at 12:37 a.m., and pronounced dead on 3/13/2025 at 4:27 p.m. On 3/26/2025 at 5:31 p.m., while onsite at the facility, the State Survey Agency (SSA) called 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) in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility ' s failure to notify the physician regarding Resident 1 ' s COC on 3/12/2025 at approximately 5 p.m. On 3/28/2025 at 10:06 a.m., the ADM and DON provided an acceptable IJ Removal Plan (a detailed plan to address the IJ findings) for the facility ' s failure to notify the physician regarding Resident 1 ' s COC on 3/12/2025 at approximately 5 p.m. On 3/28/2025 at 7:28 p.m., while onsite at the facility, the SSA verified that the IJ situation was no longer present and confirmed the facility ' s full implementation of the IJ Removal Plan through observations, interviews, and record reviews, the SSA removed the IJ situation for the facility ' s failure to notify the physician regarding Resident 1 ' s COC on 3/12/2025 at approximately 5 p.m., in the presence of the ADM, DON, and Assistant Director of Nursing (ADON). The acceptable IJ Removal Plan included the following summarized actions: 1. On 3/26/2025 and 3/27/2025, the nursing staff, including Certified Nursing Assistants (CNAs), Licensed Vocational Nurses (LVNs), and Registered Nurses (RNs), obtained vital signs for 262 in-house residents to identify abnormal (out of range) vital signs (measurements of the body ' s most basic functions), including BP, HR or pulse rate (PR), respiratory rate (RR - refers to the number of breaths a person takes per minute), and body temperature (refers to the measurement of the heat generated by the human body). The facility defined parameters for abnormal vital signs are as follows: HR or PR is considered abnormal if less than 60 or greater than 100 beats per minute; RR is abnormal if less than 12 or greater than 25 breaths per minute; temperature is abnormal if less than 97.8 Fahrenheit ( F - unit of measurement) or greater than 99.0 F; systolic BP (the upper number in the BP reading) is abnormal if less than 90 mmHg or greater than 139 mmHg; and diastolic BP (the lower number in the BP reading) is abnormal if less than 60 mmHg or greater than 89 mmHg. 2. On 3/26/2025, the LVNs and RNs reviewed the current in-house residents who were actively being monitored for COCs between 3/23/2025 to 3/26/2025. Out of 262 in-house residents, 45 residents were identified as having recent COCs. For these 45 residents with COCs, the physicians were promptly notified, and appropriate orders were obtained and implemented to address the identified changes. 3. On 3/26/2025, following the completion of the vital signs audit, the facility identified 23 out of the 45 residents with recent COCs were directly related to abnormal vital signs. For these 23 residents, COC evaluations were promptly completed, primary care physicians were notified by LVNs and RNs, and appropriate medical orders were obtained and implemented. 4. On 3/26/2025, the facility implemented a structured communication protocol (is a set of guidelines and procedures ensuring clear, consistent, and effective communication among staff, residents, and families, promoting resident safety, dignity, and positive results) for reporting findings of abnormal vital signs among CNAs, LVNs, RNs, and ultimately to the attending physician. This protocol was reviewed and approved by the Quality Assurance Committee (QAC - is a group that regularly reviews care quality, identifies issues, and develops plans to address deficiencies, ensuring residents receive safe and effective care) and serves as a standardized guideline for nursing staff to ensure timely and accurate escalation (an increase in the intensity or seriousness) of clinical concerns (health-related issues or problems that require medical attention): i. CNAs are to report abnormal vital signs to the charge nurse immediately. ii. Once abnormal vital signs are rechecked and verified by the charge nurse, the charge nurse will escalate to the RN Supervisor for further evaluation. iii. A COC evaluation using the eInteract tool (a tool used in healthcare that helps care teams prevent unnecessary hospitalization s and improve resident outcomes to alert staff to changes in a resident ' s condition) will be initiated when abnormal vital signs are identified as part of a resident's COC. This applies to residents with underlying clinical concerns, including but not limited to the following: a history of hypertension (high BP), hypotension (low BP), recent infection, cardiac (heart) conditions, respiratory compromise (a situation where a person ' s breathing is at risk of becoming severely impaired), or any other medical condition that may predispose (to make more likely or render susceptible) the resident to instability. iv. A paper log titled, Abnormal Vital Sign Log will be maintained by each charge nurse to document communication between nursing staff and, ultimately, with the physician regarding abnormal vital signs. v. Family members / responsible party will be notified by the LVNs or RNs of any change of condition unless the resident has indicated otherwise. The nurse must document all attempts made in the resident's medical record and the outcome of the family notification. vi. Vital signs will be monitored every shift for a minimum of 72 hours for residents identified with a COC, or longer if clinically indicated. 5. On 3/27/2025, the ADM and DON initiated a root cause analysis (a systematic approach to identify the underlying reasons for a problem or failure, rather than just addressing its immediate symptoms, to prevent recurrence) on the facility ' s failure to ensure any resident having abnormal vital signs was provided with necessary care and services, including notification of the physician, to address a COC. The facility identified the root causes included licensed nurses have a lack of supervision to ensure they (licensed nurses) follow protocols, that proactive audits (conducting internal reviews before potential problems arise to prevent future issues) or quality checks to identify gaps in care were not addressed timely, and adequate training during the hiring orientation process was provided to staff. 6. On 3/26/2025, the DON provided one-on-one in-service training (is a personalized, focused training method where a healthcare professional learns a specific skill or procedure from a more experienced colleague in a one-to-one setting) to LVN 1. The planned training focused on providing care and services to residents, with the focus on the critical importance of documenting identified COCs, and notifying the primary physician when a change in a resident's condition is identified. Abnormal vital signs are communicated between CNAs, LVNs, RNs, and ultimately to the attending physician. Residents with COCs are monitored, and interventions are provided to address the COCs. 7. On 3/26/2025, LVN 1 was suspended and is currently still on suspension. 8. On 3/27/2025, the DON implemented staff training focusing on providing care and services to residents, with focus on critical importance of documenting identified COCs, and notifying the primary physician when a change in a resident's condition is identified. Abnormal vital signs are communicated between CNAs, LVNs, RNs, and ultimately to the attending physician. Residents with COCs are monitored, and interventions are provided to address the COCs. 9. On 3/26/2025, the DON initiated competency skills checks (are assessments that ensure healthcare professionals possess the necessary knowledge, skills, and abilities to perform their roles safely and effectively, often using checklists and other methods to evaluate performance) for LVNs and RNs to ensure that the licensed staff are proficient (competent or skilled) in evaluating COCs and accurately/timely reporting abnormal vital signs. The skills check included core competencies such as recognizing COCs, identifying abnormal vital signs, taking immediate action, notifying physicians promptly, and ensuring follow-up and continuous monitoring of COCs. Each nursing staff member was evaluated using a structured scoring tool, with opportunities for return demonstrations (a teaching technique where a student, after being shown a skill or procedure, demonstrates their understanding by performing it themselves, allowing the instructor to assess their learning) as needed to confirm competency. 10. On 3/26/2025, the DON, in collaboration with the Director of Staff Development (DSD), initiated in-service trainings for nursing staff, including CNAs, LVNs, and RNs, with a focus on recognizing COCs. The training emphasized timely reporting and appropriate interventions (including physician notification), ongoing monitoring of residents identified with a COC, and accurate documentation of abnormal vital signs. For staff who were unable to attend the scheduled in-service trainings, in-service trainings will be provided prior to the start of their next scheduled shift and will not be allowed to report to the assigned unit until training is completed. Nursing staff on leave or on vacation will receive competency-based education upon return to work. 11. The DON/designee will review newly identified COCs daily, from Monday through Friday. During weekends, holidays, and after-hours when the DON is not available, the RN Supervisor on duty will assume the responsibility of reviewing COCs. This process will continue for the next three months to ensure that physicians are promptly notified, appropriate orders are obtained, and interventions are implemented in a timely manner to address the identified changes. Issues identified will be addressed immediately by the DON/designee/RN supervisor. If gaps in practice or knowledge are identified, the DON will initiate targeted in-service training to reinforce expectations and ensure staff competency in managing COCs. 12. Medical Records Director 1/designee will audit ongoing COCs daily (Monday to Friday) to ensure residents are monitored every shift for at least 72 hours or more if necessary. 13. Unit Managers will review Abnormal Vital Sign Logs daily (Monday to Friday) and RN Supervisors on weekends/holidays for the next 3 months to ensure communication of abnormal vital signs between nursing staff and ultimately to the physician. A COC/elnteract electronic medical record is initiated, and the physician/provider is notified immediately as applicable. 14. During annual competency skills evaluation, LVNs and RNs will be evaluated on core competencies addressing residents with COCs. As part of the new hire orientation process, newly-hire RNs and LVNs will undergo training on addressing COC communication protocol among nursing staff on abnormal vital signs, initiating COC/elnteract record for abnormal vital signs and COCs, and reporting abnormal vital signs to RN supervisor and, ultimately, to the physician. 15. LVNs and RNs will undergo at least yearly in-service/training on addressing COCs, communication protocol among nursing staff on abnormal vital signs, initiating COC/elnteract record for abnormal vital signs and COCs, and reporting abnormal vital signs to RN supervisor and, ultimately, to the physician. 16. CNAs will undergo yearly in-service/training on obtaining vital signs, reporting abnormal vital signs immediately to the charge nurse and utilization of the Abnormal Vital Sign log. 17. The DON, ADON, and DSD will re-inservice all nursing staff, which include CNAs, LVNs, and RNs, monthly for the next three months on key areas such as recognizing and responding to COCs, timely and accurate reporting of abnormal vital signs, appropriate clinical interventions, and adherence to the structured communication protocol for escalating clinical concerns to the RN Supervisor and the attending physician. Licensed nurses will undergo competency-based skills checks to evaluate their proficiency in initiating COC / elnteract electronic medical record, notifying physicians promptly, and ensuring follow-up and monitoring. Staff will be assessed using a structured scoring tool, with return demonstrations conducted as needed to confirm understanding. Participants will also be required to complete a five-question post-test (an assessment or test administered after a training) to assess comprehension (understanding) of the material. Any staff unable to attend the scheduled sessions will receive the re-inservice and competency validation (to confirm) prior to the start of their next scheduled shift to ensure complete participation and sustained compliance. Cross Reference F600 and F684. Findings: During a review of Resident 1 ' s Admission Record, the Admission Record indicated the facility admitted Resident 1 on 3/4/2025 with diagnoses including unspecified hypothyroidism (unidentified cause for thyroid gland to not produce thyroid hormone, causing weakness), essential hypertension (persistent elevated blood pressure), and occlusion and stenosis of left carotid artery (complete blockage and narrowing of carotid artery, a major blood vessel supplying the brain). During a review of Resident 1 ' s Minimum Data Set (MDS - a resident assessment tool), dated 3/12/2025, the MDS indicated Resident 1 was severely impaired with thought process and required substantial assistance from staff to complete activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). During a review of Resident 1 ' s record titled, eInteract Change of Condition Evaluation, dated 3/12/2025 at 11:40 p.m., the evaluation indicated Resident 1 had a change of condition of Abnormal vital signs and altered mental status (a change in a resident ' s mental state, including changes in awareness, alertness, and mental function). The evaluation indicated on 3/12/2025 at 5 p.m., Resident 1 ' s BP on a sitting position taken on Resident 1 ' s right arm was 86/57 mmHg and HR of 111 beats per minute. The evaluation indicated there were no other BP and HR assessments collected for Resident 1 after 5 p.m. on 3/12/2025. During a review of the physician ' s Progress Notes for Resident 1, dated 3/13/2025 at 1:06 a.m., the physician ' s Progress Notes indicated Resident 1 ' s physician (MD 1) called RN 1 after multiple times before RN 1 answered. The physician Progress Notes indicated MD 1 instructed RN 1 to check and examine Resident 1, then to call back MD 1. The physician ' s Progress Notes indicated RN 1 called back and told MD 1 Resident 1 ' s BP was 86/57 mmHg and HR was 111 bpm (these vital signs were the same readings taken on 3/12/2025 at approximately 5 p.m.). The physician ' s Progress Notes indicated RN 1 told MD 1 that it was unclear if Resident 1 was responsive (able to respond or reply) or not, so MD 1 ordered Resident 1 to be transferred to the GACH. During a review of Resident 1 ' s Physician ' s Orders, dated 3/13/2025 at 6:48 a.m., the Physician ' s Orders indicated Resident 1 was sent out to the GACH for abnormal vital signs and for altered level of consciousness (a change in mental status not normal from baseline). During an interview on 3/25/2025 at 3:54 p.m. with CNA 1, CNA 1 stated she was working on 3/12/2025 during the 3 p.m. to 11 p.m. shift and was assigned to Resident 1. CNA 1 stated she checked Resident 1 ' s vital signs approximately four to five times using both arms, and the BP readings were consistently low. CNA 1 stated she informed LVN 1, who was assigned to Resident 1 about Resident 1 ' s low BP and increased HR. CNA 1 stated LVN 1 told her (CNA 1) that she (LVN 1) will recheck Resident 1 ' s vital signs. CNA 1 stated, to be honest, I don ' t know if she (LVN 1) checked since I went to my other residents During an interview on 3/26/2025 at 7:05 a.m., with RN 1, RN 1 stated on 3/12/2025, he arrived at the facility at approximately 11:35 p.m., for the 11 p.m. to 7 a.m. shift. RN 1 stated he received a call from Resident 1 ' s primary physician asking if RN 1 was the supervisor on duty, and for a report on Resident 1 ' s condition. RN 1 stated, upon observing Resident 1, I was stunned, like he (Resident 1) was dying or towards the end of life RN 1 stated the previous shift staff failed to act to save Resident 1. RN 1 stated the previous shift staff should have notified the RN on duty, or called a code blue (an emergency code typically indicating a resident experiencing a life-threatening medical emergency that requires immediate medical attention) for Resident 1. RN 1 stated, When I saw the resident (Resident 1), to me, it looked like he (Resident 1) was gone. RN 1 stated the previous shift staff failed to notify Resident 1 ' s physician about the decreased blood pressure, and failed to call emergency services sooner for Resident 1. During a concurrent interview and record review on 3/26/2025 at 7:47 a.m., with LVN 2, Resident 1 ' s COC, dated 3/12/2025 documented at 11:40 p.m., and progress notes were reviewed. LVN 2 stated she worked on 3/12/2025 for the 11 p.m. to 7 a.m. shift, and was assigned to Resident 1. LVN 2 stated she did not recall if Resident 1 was receiving any oxygen. LVN 2 stated LVNs were to notify the RN on duty first for any residents with a COC. LVN 2 stated, from what I saw, he (Resident 1) was in code blue status because of his shallow breathing. LVN 2 stated Resident 1 ' s COC, dated 3/12/2025 documented at 11:40 p.m., indicated Resident 1 ' s last assessed BP of 86/57 mmHg and HR of 111 beats/minute recorded at 5 p.m. LVN 2 stated, for his (Resident 1 ' s) blood pressure, it was very low. When the emergency personnel (paramedics - health professionals certified to perform advanced life support procedures) came, she (LVN 1) mentioned it was taken around 6 p.m. 7 hours from the last collected vital signs. Per progress notes, the LVN (LVN 1) failed to notify the RN as there were no RN notification, no doctor (physician) notification, no code blue announced, and no interventions done on records (Resident 1 ' s medical records). The LVN (LVN 1) stated to the emergency personnel that was the resident ' s (Resident 1 ' s) baseline. From what I saw, that was not the resident ' s (Resident 1) baseline. During an interview on 3/26/2025 at 2:16 p.m. with LVN 1, LVN 1 stated she was informed of Resident 1 ' s change in vital signs on 3/12/2025, at approximately at 5 p.m. LVN 1 stated she did not discuss Resident 1 ' s COC with the on duty RN (RN2), and did not notify Resident 1 ' s physician. LVN 1 stated she did not call emergency services for Resident 1 and the incoming night shift (11 pm. to 7 a.m.) staff (LVN 2) notified the emergency services for Resident 1 ' s COC. During a phone interview on 3/26/2025 at 4:20 p.m. with MD 1, MD 1 stated on 3/12/2025 approximately after 11:30 p.m., she called the facility to get an update on Resident 1. MD 1 stated no facility staff notified her (MD 1) earlier in the day. MD 1 stated she was concerned about Resident 1 ' s kidney function, so MD 1 called the facility for an update on Resident 1. MD 1 stated staff knew on 3/12/2025 at 5 p.m., Resident 1 ' s BP was 86/57 mmHg and HR of 111 beats per minute. MD 1 stated doctors (in general) should be made aware of this. MD 1 stated she spoke to an RN (RN 1) who told her The patient does not look good. MD 1 stated, I would expect the nurses in general, when the BP is that low, the RN should evaluate the resident (Resident 1). MD 1 stated she was not informed of Resident 1 ' s COC on 3/12/2025 at 5 p.m. and the facility should have informed her (MD 1). During an interview on 3/28/2025 at 10:15 a.m. with Unit Manager 1 (LVN), Unit Manager 1 stated Resident 1 had no nursing progress notes from the 3 p.m. to 11 p.m., shift, no documented interventions and no physician notifications. Unit Manager 1 stated, The vital signs provide an internal baseline or anything happening for the residents, like blood pressures dropping or an increase in temperature could be related to possible infection, so vital signs help notify us (nursing staff) an indication of how the resident is doing, or to identify if any changes need to be addressed. There was about six hours and 40 minutes from when the MD was informed of the resident ' s (Resident 1 ' s) condition. Unit Manager 1 stated, For this case, after finding the vital signs at 5 p.m., the LVN (LVN 1) failed to reassess the resident ' s (Resident 1 ' s) vital signs, failed to notify the RN to assess the resident, and failure to notify the doctor of the COC. He (Resident 1) had a care plan for hypertension initiated on 3/4/2025, on his admitted . The interventions by licensed nurses (LVNs and RNs) are to observe for signs and symptoms of abnormal blood pressure and complications related to hypertension, and notify the physician as needed. In this scenario, the LVN (LVN 1) failed to implement this (Resident 1) care plan ' s intervention. During a concurrent interview and record review with MD 1 on 3/28/2025 at 11:30 a.m., Resident 1 ' s eInteract Change of Condition Evaluation, dated 3/12/2025 at 11:40 p.m., was reviewed. MD 1 stated she called the facility on 3/12/2025 approximately 11:30 p.m. MD 1 stated she did not realize the vital signs provided to her (MD 1) over the phone were Resident 1 ' s BP of 86/57 mmHg and HR of 111 bpm were the same collected vital signs from 5 p.m., earlier in the day (3/12/2025). MD 1 stated, I ' m talking to them on the phone, so I didn ' t know they (RN 1) used the same vital signs from 5 p.m. I thought it was a recent set of vital signs. During a concurrent interview and record review with the DON on 3/28/2025 at 5:50 p.m., Resident 1 ' s paramedics ' report, dated 3/13/2025 at 12:19 a.m., and the facility ' s undated policy and procedure titled, Change in a Resident ' s Condition or Status, were reviewed. The DON stated on 3/12/2025, staff knowing the changes in vital signs for Resident 1 at 5 p.m., to the time the physician called the facility at approximately 11:40 p.m., was almost seven hours of no interventions. The DON stated the paramedics ' report indicated the paramedics were contacted on 3/13/2025 at 12:19 a.m., arrived at the facility by 12:28 a.m., at bedside with Resident 1 at 12:30 a.m., and left the facility with Resident 1 by 12:37 a.m. The DON stated the report described Resident 1 as having decreased breath sounds and the vital signs collected by the paramedics on 3/13/2025 at 12:30 a.m. were a BP of 74/50 mmHg, HR of 56 beats per RR of 4 breaths per minute, and oxygen saturation (percentage of oxygen to the blood measuring how well the lungs deliver oxygen to the body) of 74 percent (% - per one hundred). The DON stated the paramedics described Resident 1 as lying in bed with the current concern of respiratory failure (occurs when the lungs are unable to adequately perform their primary function: taking in oxygen and removing carbon dioxide [a colorless, odorless gas formed when people breathe out] from the blood). The DON stated the report indicated Resident 1 was found in severe respiratory distress and had a nasal cannula (a small plastic tube which fits into nostrils to provide supplemental oxygen) and staff were standing by with no interventions to Resident 1 ' s RR. The DON stated the report indicated Resident 1 was assisted by the paramedics with a bag valve mask (a handheld device used to deliver breaths to someone who cannot breathe on their own) and transported on advanced life support (ALS - a set of life-saving protocols and skills to provide urgent care during critical conditions) to the nearest GACH 1. The DON stated, This resident passed away on 3/13/2025. The facility ' s policy and procedure titled Change in a Resident ' s Condition or Status was also reviewed with the DON. The DON was asked to clarify what Promptly meant as indicated in the policy. The DON stated, For the notification of promptly, whatever the change of condition was from the resident ' s baseline, licensed staff (LVNs & RNs) need to assess and inform the attending physician. There is no time indicated, but for emergent needs, like for this case, the doctor should have been notified from the initial identification of the 5 p.m. decreased blood pressure of Resident 1. During a review of Resident 1 ' s GACH records titled, Discharge Summary, the GACH records indicated Resident 1 passed away on 3/13/2025 at 4:27 p.m., and the preliminary cause of Resident 1 ' s death was septic shock (a life-threatening condition that happens when the BP drops to a dangerously low level after an infection). The Discharge Summary also indicated additional pertinent diagnoses of acute respiratory failure with hypoxia (when the lungs fail to provide oxygen to the body ' s tissues, leading to low oxygen levels in the blood) and anoxic brain damage (brain injury caused by lack of oxygen to the brain). During a review of the current facility-provided undated policy and procedure titled, Change in Resident ' s Condition or Status, the policy and procedure indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident ' s medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). The policy also indicated: 1. The nurse will notify the resident ' s attending physician or physician on call when there has been a (an): d. significant change in the resident ' s physical/emotional/mental condition; g. need to transfer the resident to a hospital/treatment center; 2. A Significant change of condition is a major decline or improvement in the resident ' s status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not Self-limiting); b. impacts more than one area of the resident ' s health status; c. requires interdisciplinary review and/or revision of the care plan

Based on interview and record review, the facility failed to ensure one of nine sampled residents (Resident 1) was free from neglect (the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress) when Resident 1 had a change of condition (COC - a major decline in a resident ' s status) on 3/12/2025 at approximately 5 p.m. when Resident 1 had a low blood pressure (BP - measurement of the pressure or force of blood inside your arteries [the elastic, muscular tubes or blood vessels responsible for carrying the blood away from the heart and distributing it to several other organs and tissues]) reading of 86/57 millimeters of mercury (mmHg - unit of measurement used to measure BP and is abnormal if less than 90/60 mmHg or greater than 139/89 mmHg) and increased heart rate (HR - the number of heartbeats per unit of time) of 111 beats per minute (bpm - considered abnormal if less than 60 bpm or greater than 100 bpm). As a result, Resident 1 experienced severe respiratory distress (a life-threatening condition characterized by difficult breathing, rapid breathing, and low oxygen levels, often requiring immediate medical intervention) was transferred to a General Acute Care Hospital (GACH) on 3/13/2025 at 12:37 a.m., and pronounced dead on 3/13/2025 at 4:27 p.m. On 3/26/2025 at 5:31 p.m., while onsite at the facility, the State Survey Agency (SSA) called 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) in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility ' s neglect by failing to provide the necessary care and services when Resident 1 had a COC on 3/12/2025 at approximately 5 p.m. On 3/28/2025 at 10:06 a.m., the ADM and DON provided an acceptable IJ Removal Plan (a detailed plan to address the IJ findings) for the facility ' s neglect by failing to provide the necessary care and services when Resident 1 had a COC on 3/12/2025 at approximately 5 p.m. On 3/28/2025 at 7:28 p.m., while onsite at the facility, the SSA verified that the IJ situation was no longer present and confirmed the facility ' s full implementation of the IJ Removal Plan through observations, interviews, and record reviews, the SSA removed the IJ situation for the facility ' s neglect by failing to provide the necessary care and services when Resident 1 had a COC on 3/12/2025 at approximately 5 p.m., in the presence of the ADM, DON, and Assistant Director of Nursing (ADON). The acceptable IJ Removal Plan included the following summarized actions: 1. On 3/26/2025 and 3/27/2025, the nursing staff, including Certified Nursing Assistants (CNAs), Licensed Vocational Nurses (LVNs), and Registered Nurses (RNs), obtained vital signs for 262 in-house residents to identify abnormal (out of range) vital signs (measurements of the body ' s most basic functions), including BP, HR, pulse rate (PR), respiratory rate (RR - refers to the number of breaths a person takes per minute), and body temperature (refers to the measurement of the heat generated by the human body). The facility defined parameters for abnormal vital signs are as follows: HR or PR is considered abnormal if less than 60 or greater than 100 beats per minute; RR is abnormal if less than 12 or greater than 25 breaths per minute; temperature is abnormal if less than 97.8 Fahrenheit ( F - unit of measurement) or greater than 99.0 F; systolic BP (the upper number in the BP reading) is abnormal if less than 90 mmHg or greater than 139 mmHg; and diastolic BP (the lower number in the BP reading) is abnormal if less than 60 mmHg or greater than 89 mmHg. 2. On 3/26/2025, the LVNs and RNs reviewed the current in-house residents who were actively being monitored for COCs between 3/23/2025 to 3/26/2025. Out of 262 in-house residents, 45 residents were identified as having recent COCs. For these 45 residents with COCs, the physicians were promptly notified, and appropriate orders were obtained and implemented to address the identified changes. 3. On 3/26/2025, following the completion of the vital signs audit, the facility identified 23 out of the 45 residents with recent COCs were directly related to abnormal vital signs. For these 23 residents, COC evaluations were promptly completed, primary care physicians were notified by LVNs and RNs, and appropriate medical orders were obtained and implemented. 4. On 3/26/2025, the facility implemented a structured communication protocol (is a set of guidelines and procedures ensuring clear, consistent, and effective communication among staff, residents, and families, promoting resident safety, dignity, and positive results) for reporting findings of abnormal vital signs among CNAs, LVNs, RNs, and ultimately to the attending physician. This protocol was reviewed and approved by the Quality Assurance Committee (QAC - is a group that regularly reviews care quality, identifies issues, and develops plans to address deficiencies, ensuring residents receive safe and effective care) and serves as a standardized guideline for nursing staff to ensure timely and accurate escalation (an increase in the intensity or seriousness) of clinical concerns (health-related issues or problems that require medical attention): i. CNAs are to report abnormal vital signs to the charge nurse immediately. ii. Once abnormal vital signs are rechecked and verified by the charge nurse, the charge nurse will escalate to the RN Supervisor for further evaluation. iii. A COC evaluation using the eInteract tool (a tool used in healthcare that helps care teams prevent unnecessary hospitalization s and improve resident outcomes to alert staff to changes in a resident ' s condition) will be initiated when abnormal vital signs are identified as part of a resident's COC. This applies to residents with underlying clinical concerns, including but not limited to the following: a history of hypertension (high BP), hypotension (low BP), recent infection, cardiac (heart) conditions, respiratory compromise (a situation where a person ' s breathing is at risk of becoming severely impaired), or any other medical condition that may predispose (to make more likely or render susceptible) the resident to instability. iv. A paper log titled, Abnormal Vital Sign Log will be maintained by each charge nurse to document communication between nursing staff and, ultimately, with the physician regarding abnormal vital signs. v. Family members / responsible party will be notified by the LVNs or RNs of any change of condition unless the resident has indicated otherwise. The nurse must document all attempts made in the resident's medical record and the outcome of the family notification. vi. Vital signs will be monitored every shift for a minimum of 72 hours for residents identified with a COC, or longer if clinically indicated. 5. On 3/27/2025, the ADM and DON initiated a root cause analysis (a systematic approach to identify the underlying reasons for a problem or failure, rather than just addressing its immediate symptoms, to prevent recurrence) on the facility ' s failure to ensure any resident having abnormal vital signs was provided with necessary care and services, including notification of the physician, to address a COC. The facility identified the root causes included licensed nurses have a lack of supervision to ensure they (licensed nurses) follow protocols, that proactive audits (conducting internal reviews before potential problems arise to prevent future issues) or quality checks to identify gaps in care were not addressed timely, and adequate training during the hiring orientation process was provided to staff. 6. On 3/26/2025, the DON provided one-on-one in-service training (is a personalized, focused training method where a healthcare professional learns a specific skill or procedure from a more experienced colleague in a one-to-one setting) to LVN 1. The planned training focused on providing care and services to residents, with the focus on the critical importance of documenting identified COCs, and notifying the primary physician when a change in a resident's condition is identified. Abnormal vital signs are communicated between CNAs, LVNs, RNs, and ultimately to the attending physician. Residents with COCs are monitored, and interventions are provided to address the COCs. 7. On 3/26/2025, LVN 1 was suspended and is currently still on suspension. 8. On 3/27/2025, the DON implemented staff training focusing on providing care and services to residents, with focus on critical importance of documenting identified COCs, and notifying the primary physician when a change in a resident's condition is identified. Abnormal vital signs are communicated between CNAs, LVNs, RNs, and ultimately to the attending physician. Residents with COCs are monitored, and interventions are provided to address the COCs. 9. On 3/26/2025, the DON initiated competency skills checks (are assessments that ensure healthcare professionals possess the necessary knowledge, skills, and abilities to perform their roles safely and effectively, often using checklists and other methods to evaluate performance) for LVNs and RNs to ensure that the licensed staff are proficient (competent or skilled) in evaluating COCs and accurately/timely reporting abnormal vital signs. The skills check included core competencies such as recognizing COCs, identifying abnormal vital signs, taking immediate action, notifying physicians promptly, and ensuring follow-up and continuous monitoring of COCs. Each nursing staff member was evaluated using a structured scoring tool, with opportunities for return demonstrations (a teaching technique where a student, after being shown a skill or procedure, demonstrates their understanding by performing it themselves, allowing the instructor to assess their learning) as needed to confirm competency. 10. On 3/26/2025, the DON, in collaboration with the Director of Staff Development (DSD), initiated in-service trainings for nursing staff, including CNAs, LVNs, and RNs, with a focus on recognizing COCs. The training emphasized timely reporting and appropriate interventions (including physician notification), ongoing monitoring of residents identified with a COC, and accurate documentation of abnormal vital signs. For staff who were unable to attend the scheduled in-service trainings, in-service trainings will be provided prior to the start of their next scheduled shift and will not be allowed to report to the assigned unit until training is completed. Nursing staff on leave or on vacation will receive competency-based education upon return to work. 11. The DON/designee will review newly identified COCs daily, from Monday through Friday. During weekends, holidays, and after-hours when the DON is not available, the RN Supervisor on duty will assume the responsibility of reviewing COCs. This process will continue for the next three months to ensure that physicians are promptly notified, appropriate orders are obtained, and interventions are implemented in a timely manner to address the identified changes. Issues identified will be addressed immediately by the DON/designee/RN supervisor. If gaps in practice or knowledge are identified, the DON will initiate targeted in-service training to reinforce expectations and ensure staff competency in managing COCs. 12. Medical Records Director 1/designee will audit ongoing COCs daily (Monday to Friday) to ensure residents are monitored every shift for at least 72 hours or more if necessary. 13. Unit Managers will review Abnormal Vital Sign Logs daily (Monday to Friday) and RN Supervisors on weekends/holidays for the next 3 months to ensure communication of abnormal vital signs between nursing staff and ultimately to the physician. A COC/elnteract electronic medical record is initiated, and the physician/provider is notified immediately as applicable. 14. During annual competency skills evaluation, LVNs and RNs will be evaluated on core competencies addressing residents with COCs. As part of the new hire orientation process, newly-hire RNs and LVNs will undergo training on addressing COC communication protocol among nursing staff on abnormal vital signs, initiating COC/elnteract record for abnormal vital signs and COCs, and reporting abnormal vital signs to RN supervisor and, ultimately, to the physician. 15. LVNs and RNs will undergo at least yearly in-service/training on addressing COCs, communication protocol among nursing staff on abnormal vital signs, initiating COC/elnteract record for abnormal vital signs and COCs, and reporting abnormal vital signs to RN supervisor and, ultimately, to the physician. 16. CNAs will undergo yearly in-service/training on obtaining vital signs, reporting abnormal vital signs immediately to the charge nurse and utilization of the Abnormal Vital Sign log. 17. The DON, ADON, and DSD will re-inservice all nursing staff, which include CNAs, LVNs, and RNs, monthly for the next three months on key areas such as recognizing and responding to COCs, timely and accurate reporting of abnormal vital signs, appropriate clinical interventions, and adherence to the structured communication protocol for escalating clinical concerns to the RN Supervisor and the attending physician. Licensed nurses will undergo competency-based skills checks to evaluate their proficiency in initiating COC / elnteract electronic medical record, notifying physicians promptly, and ensuring follow-up and monitoring. Staff will be assessed using a structured scoring tool, with return demonstrations conducted as needed to confirm understanding. Participants will also be required to complete a five-question post-test (an assessment or test administered after a training) to assess comprehension (understanding) of the material. Any staff unable to attend the scheduled sessions will receive the re-inservice and competency validation (to confirm) prior to the start of their next scheduled shift to ensure complete participation and sustained compliance. Cross Reference F600 and F684. Findings: During a review of Resident 1 ' s Admission Record, the Admission Record indicated the facility admitted Resident 1 on 3/4/2025 with diagnoses including unspecified hypothyroidism (unidentified cause for thyroid gland to not produce thyroid hormone, causing weakness), essential hypertension (persistent elevated blood pressure), and occlusion and stenosis of left carotid artery (complete blockage and narrowing of carotid artery, a major blood vessel supplying the brain). During a review of Resident 1 ' s Minimum Data Set (MDS - a resident assessment tool), dated 3/12/2025, the MDS indicated Resident 1 was severely impaired with thought process and required substantial assistance from staff to complete activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). During a review of Resident 1 ' s record titled, eInteract Change of Condition Evaluation, dated 3/12/2025 at 11:40 p.m., the evaluation indicated Resident 1 had a change of condition of Abnormal vital signs and altered mental status (a change in a resident ' s mental state, including changes in awareness, alertness, and mental function). The evaluation indicated on 3/12/2025 at 5 p.m., Resident 1 ' s BP on a sitting position taken on Resident 1 ' s right arm was 86/57 mmHg and HR of 111 beats per minute. The evaluation indicated there were no other BP and HR assessments collected for Resident 1 after 5 p.m. on 3/12/2025. During a review of the physician ' s Progress Notes for Resident 1, dated 3/13/2025 at 1:06 a.m., the physician ' s Progress Notes indicated Resident 1 ' s physician (MD 1) called RN 1 after multiple times before RN 1 answered. The physician Progress Notes indicated MD 1 instructed RN 1 to check and examine Resident 1, then to call back MD 1. The physician ' s Progress Notes indicated RN 1 called back and told MD 1 Resident 1 ' s BP was 86/57 mmHg and HR was 111 bpm (these vital signs were the same readings taken on 3/12/2025 at approximately 5 p.m.). The physician ' s Progress Notes indicated RN 1 told MD 1 that it was unclear if Resident 1 was responsive (able to respond or reply) or not, so MD 1 ordered Resident 1 to be transferred to the GACH. During a review of Resident 1 ' s Physician ' s Orders, dated 3/13/2025 at 6:48 a.m., the Physician ' s Orders indicated Resident 1 was sent out to the GACH for abnormal vital signs and for altered level of consciousness (a change in mental status not normal from baseline). During an interview on 3/25/2025 at 3:54 p.m. with CNA 1, CNA 1 stated she was working on 3/12/2025 during the 3 p.m. to 11 p.m. shift and was assigned to Resident 1. CNA 1 stated she checked Resident 1 ' s vital signs approximately four to five times using both arms, and the BP readings were consistently low. CNA 1 stated she informed LVN 1, who was assigned to Resident 1 about Resident 1 ' s low BP and increased HR. CNA 1 stated LVN 1 told her (CNA 1) that she (LVN 1) will recheck Resident 1 ' s vital signs. CNA 1 stated, to be honest, I don ' t know if she (LVN 1) checked since I went to my other residents During an interview on 3/26/2025 at 7:05 a.m., with RN 1, RN 1 stated on 3/12/2025, he arrived at the facility at approximately 11:35 p.m., for the 11 p.m. to 7 a.m. shift. RN 1 stated he received a call from Resident 1 ' s primary physician asking if RN 1 was the supervisor on duty, and for a report on Resident 1 ' s condition. RN 1 stated, upon observing Resident 1, I was stunned, like he (Resident 1) was dying or towards the end of life RN 1 stated the previous shift staff failed to act to save Resident 1. RN 1 stated the previous shift staff should have notified the RN on duty, or called a code blue (an emergency code typically indicating a resident experiencing a life-threatening medical emergency that requires immediate medical attention) for Resident 1. RN 1 stated, When I saw the resident (Resident 1), to me, it looked like he (Resident 1) was gone. RN 1 stated the previous shift staff failed to notify Resident 1 ' s physician about the decreased blood pressure, and failed to call emergency services sooner for Resident 1. RN 1 stated, This was . negligence because the vital signs were known since 5 p.m. and the documents show the doctor was not notified until 11:40 p.m., that ' s almost 7 hours. During a concurrent interview and record review on 3/26/2025 at 7:47 a.m., with LVN 2, Resident 1 ' s COC, dated 3/12/2025 documented at 11:40 p.m., and progress notes were reviewed. LVN 2 stated she worked on 3/12/2025 for the 11 p.m. to 7 a.m. shift, and was assigned to Resident 1. LVN 2 stated she did not recall if Resident 1 was receiving any oxygen. LVN 2 stated LVNs were to notify the RN on duty first for any residents with a COC. LVN 2 stated, from what I saw, he (Resident 1) was in code blue status because of his shallow breathing. LVN 2 stated Resident 1 ' s COC, dated 3/12/2025 documented at 11:40 p.m., indicated Resident 1 ' s last assessed BP of 86/57 mmHg and HR of 111 beats/minute recorded at 5 p.m. LVN 2 stated, for his (Resident 1 ' s) blood pressure, it was very low. When the emergency personnel (paramedics - health professionals certified to perform advanced life support procedures) came, she (LVN 1) mentioned it was taken around 6 p.m. 7 hours from the last collected vital signs. Per progress notes, the LVN (LVN 1) failed to notify the RN as there were no RN notification, no doctor (physician) notification, no code blue announced, and no interventions done on records (Resident 1 ' s medical records). The LVN (LVN 1) stated to the emergency personnel that was the resident ' s (Resident 1 ' s) baseline. From what I saw, that was not the resident ' s (Resident 1) baseline. LVN 2 stated an example for neglect would be if a resident needed care and no care was provided for many hours. LVN 2 stated, The LVN (LVN 1) failed to notify the RN on duty, failed to notify the doctor of the change of condition, failed to call a code blue, and failed to (immediately) call (the) emergency first responders (paramedics). LVN 2 further stated, It was about seven hours from when LVN (LVN 1) knew of the COC, so I feel this was neglect. During an interview on 3/26/2025 at 2:16 p.m. with LVN 1, LVN 1 stated she was informed of Resident 1 ' s change in vital signs on 3/12/2025, at approximately at 5 p.m. LVN 1 stated she did not discuss Resident 1 ' s COC with the on duty RN (RN2), and did not notify Resident 1 ' s physician. LVN 1 stated she did not call emergency services for Resident 1 and the incoming night shift (11 pm. to 7 a.m.) staff (LVN 2) notified the emergency services for Resident 1 ' s COC. During a phone interview on 3/26/2025 at 4:20 p.m. with MD 1, MD 1 stated on 3/12/2025 approximately after 11:30 p.m., she called the facility to get an update on Resident 1. MD 1 stated no facility staff notified her (MD 1) earlier in the day. MD 1 stated she was concerned about Resident 1 ' s kidney function, so MD 1 called the facility for an update on Resident 1. MD 1 stated staff knew on 3/12/2025 at 5 p.m., Resident 1 ' s BP was 86/57 mmHg and HR of 111 beats per minute. MD 1 stated doctors (in general) should be made aware of this. MD 1 stated she spoke to an RN (RN 1) who told her The patient does not look good. MD 1 stated, I would expect the nurses in general, when the BP is that low, the RN should evaluate the resident (Resident 1). MD 1 stated she was not informed of Resident 1 ' s COC on 3/12/2025 at 5 p.m. and the facility should have informed her (MD 1). During an interview on 3/28/2025 at 10:15 a.m. with Unit Manager 1 (LVN), Unit Manager 1 stated Resident 1 had no nursing progress notes from the 3 p.m. to 11 p.m., shift, no documented interventions and no physician notifications. Unit Manager 1 stated, The vital signs provide an internal baseline or anything happening for the residents, like blood pressures dropping or an increase in temperature could be related to possible infection, so vital signs help notify us (nursing staff) an indication of how the resident is doing, or to identify if any changes need to be addressed. There was about six hours and 40 minutes from when the MD was informed of the resident ' s (Resident 1 ' s) condition. Unit Manager 1 stated, For this case, after finding the vital signs at 5 p.m., the LVN (LVN 1) failed to reassess the resident ' s (Resident 1 ' s) vital signs, failed to notify the RN to assess the resident, and failure to notify the doctor of the COC. He (Resident 1) had a care plan for hypertension initiated on 3/4/2025, on his admitted . The interventions by licensed nurses (LVNs and RNs) are to observe for signs and symptoms of abnormal blood pressure and complications related to hypertension, and notify the physician as needed. In this scenario, the LVN (LVN 1) failed to implement this (Resident 1) care plan ' s intervention. During a concurrent interview and record review with MD 1 on 3/28/2025 at 11:30 a.m., Resident 1 ' s eInteract Change of Condition Evaluation, dated 3/12/2025 at 11:40 p.m., was reviewed. MD 1 stated she called the facility on 3/12/2025 approximately 11:30 p.m. MD 1 stated she did not realize the vital signs provided to her (MD 1) over the phone were Resident 1 ' s BP of 86/57 mmHg and HR of 111 bpm were the same collected vital signs from 5 p.m., earlier in the day (3/12/2025). MD 1 stated, I ' m talking to them on the phone, so I didn ' t know they (RN 1) used the same vital signs from 5 p.m. I thought it was a recent set of vital signs. During a concurrent interview and record review with the DON on 3/28/2025 at 5:50 p.m., Resident 1 ' s paramedics ' report, dated 3/13/2025 at 12:19 a.m., and the facility ' s undated policy and procedure titled, Change in a Resident ' s Condition or Status, were reviewed. The DON stated on 3/12/2025, staff knowing the changes in vital signs for Resident 1 at 5 p.m., to the time the physician called the facility at approximately 11:40 p.m., was almost seven hours of no interventions. The DON stated the paramedics ' report indicated the paramedics were contacted on 3/13/2025 at 12:19 a.m., arrived at the facility by 12:28 a.m., at bedside with Resident 1 at 12:30 a.m., and left the facility with Resident 1 by 12:37 a.m. The DON stated the report described Resident 1 as having decreased breath sounds and the vital signs collected by the paramedics on 3/13/2025 at 12:30 a.m. were a BP of 74/50 mmHg, HR of 56 beats per minute, RR of 4 breaths per minute, and oxygen saturation (percentage of oxygen to the blood measuring how well the lungs deliver oxygen to the body) of 74 percent (% - per one hundred). The DON stated the paramedics described Resident 1 as lying in bed with the current concern of respiratory failure (occurs when the lungs are unable to adequately perform their primary function: taking in oxygen and removing carbon dioxide [a colorless, odorless gas formed when people breathe out] from the blood). The DON stated the report indicated Resident 1 was found in severe respiratory distress and had a nasal cannula (a small plastic tube which fits into nostrils to provide supplemental oxygen) and staff were standing by with no interventions to Resident 1 ' s decreased RR. The DON stated the report indicated Resident 1 was assisted by the paramedics with a bag valve mask (a handheld device used to deliver breaths to someone who cannot breathe on their own) and transported on advanced life support (ALS - a set of life-saving protocols and skills to provide urgent care during critical conditions) to the nearest GACH 1. The DON stated, This resident passed away on 3/13/2025. The facility ' s policy and procedure titled Change in a Resident ' s Condition or Status was also reviewed with the DON. The DON was asked to clarify what Promptly meant as indicated in the policy. The DON stated, For the notification of promptly, whatever the change of condition was from the resident ' s baseline, licensed staff (LVNs & RNs) need to assess and inform the attending physician. There is no time indicated, but for emergent needs, like for this case, the doctor should have been notified from the initial identification of the 5 p.m. decreased blood pressure of Resident 1. During a review of Resident 1 ' s GACH records titled, Discharge Summary, the GACH records indicated Resident 1 passed away on 3/13/2025 at 4:27 p.m., and the preliminary cause of Resident 1 ' s death was septic shock (a life-threatening condition that happens when the BP drops to a dangerously low level after an infection). The Discharge Summary also indicated additional pertinent diagnoses of acute respiratory failure with hypoxia (when the lungs fail to provide oxygen to the body ' s tissues, leading to low oxygen levels in the blood) and anoxic brain damage (brain injury caused by lack of oxygen to the brain). During a review of the current facility-provided undated policy and procedure titled, Identifying Types of Abuse, the policy and procedure indicated, Neglect/Deprivation of Goods and Services by Staff .: 1. Neglect is the failure of the facility, its employees or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. 2. Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident requires but the facility fails to provide them and this has resulted in (or may result in) physical harm, pain, mental anguish, or emotional distress. 3. Neglect includes cases where the facility ' s indifference to or disregard for resident care, comfort, or safety results in (or could have resulted in) physical harm, pain, mental anguish, or emotional distress. 4. Neglect may be a pattern of failures or may be the result of one or more failures involving one resident and one staff person. During a review of the current facility-provided undated policy and procedure titled, Recognizing Signs and Symptoms of Abuse/Neglect, the policy and procedure indicated, All types of resident . neglect . are strictly prohibited. The policy indicated, Neglect is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, and mental illness. During a review of the current facility-provided undated policy and procedure titled, Resident Rights, the policy and procedure indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident ' s right to: c. be free from . neglect During a review of the current facility-provided undated policy and procedure titled, Change in Resident ' s Condition or Status, the policy and procedure indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident ' s medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). The policy also indicated: 1. The nurse will notify the resident ' s attending physician or physician on call when there has been a (an): d. significant change in the resident ' s physical/emotional/mental condition; g. need to transfer the resident to a hospital/treatment center; 2. A Significant change of condition is a major decline or improvement in the resident ' s status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not Self-limiting); b. impacts more than one area of the resident ' s health status; c. requires interdisciplinary review and/or revision of the care plan

Based on interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one of nine sampled residents (Resident 1), who had a change of condition (COC - a major decline in a resident ' s status) on 3/12/2025 at approximately 5 p.m., when Resident 1 had a low blood pressure (BP - measurement of the pressure or force of blood inside your arteries [the elastic, muscular tubes or blood vessels responsible for carrying the blood away from the heart and distributing it to several other organs and tissues]) reading of 86/57 millimeters of mercury (mmHg - unit of measurement used to measure BP and is abnormal if less than 90/60 mmHg or greater than 139/89 mmHg) and increased heart rate (HR - the number of heartbeats per unit of time) of 111 beats per minute (bpm - considered abnormal if less than 60 bpm or greater than 100 bpm). The facility failed to address Resident 1 ' s COC (low BP of 86/57 mmHg and high HR of 111 bpm) by: 1. Failing to ensure Licensed Vocation Nurse (LVN) 1 rechecked and monitored Resident 1 ' s vital signs (measurements of the body ' s most basic functions including but not limited to BP and HR) after getting a report from Certified Nursing Assistant (CNA) 1 regarding Resident 1 ' s COC. 2. Failing to ensure LVN 1 reported Resident 1 ' s COC to Registered Nurse (RN) 2 who was the RN on duty during the 3 p.m. to 11 p.m. shift. As a result, on 3/13/2025 at 12:30 a.m., the paramedics (health professionals certified to perform advanced life support procedures) found Resident 1 in severe respiratory distress (a life-threatening condition characterized by difficult breathing, rapid breathing, and low oxygen levels, often requiring immediate medical intervention) and transferred Resident 1 to the nearest General Acute Care Hospital (GACH) on 3/13/2025 at 12:37 a.m. for emergency (a serious, unexpected, and often dangerous situation requiring immediate action) needs. On 3/13/2025 at 4:27 p.m., Resident 1 was pronounced dead at the GACH with the preliminary cause of death of septic shock (a life-threatening condition that happens when the BP drops to a dangerously low level after an infection). On 3/26/2025 at 5:31 p.m., while onsite at the facility, the State Survey Agency (SSA) called 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) in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility ' s failure to provide treatment and care in accordance with professional standards of practice when Resident 1 had a low BP of 86/57 mmHg and low HR of 111 bpm on 3/12/2025 at approximately 5 p.m. On 3/28/2025 at 10:06 a.m., the ADM and DON provided an acceptable IJ Removal Plan (a detailed plan to address the IJ findings) for the facility ' s failure to provide treatment and care in accordance with professional standards of practice when Resident 1 had a COC on 3/12/2025 at approximately 5 p.m. On 3/28/2025 at 7:28 p.m., while onsite at the facility, the SSA verified that the IJ situation was no longer present and confirmed the facility ' s full implementation of the IJ Removal Plan through observations, interviews, and record reviews, the SSA removed the IJ situation for the facility ' s failure to provide treatment and care in accordance with professional standards of practice when the IJ situation was no longer present in the presence of the ADM, DON, and Assistant Director of Nursing (ADON). The acceptable IJ Removal Plan included the following summarized actions: 1. On 3/26/2025 and 3/27/2025, the nursing staff, including CNAs, LVNs, and RNs, obtained vital signs for 262 in-house residents to identify abnormal (out of range) vital signs including BP, HR, pulse rate (PR), respiratory rate (RR - refers to the number of breaths a person takes per minute), and body temperature (refers to the measurement of the heat generated by the human body). The facility defined parameters for abnormal vital signs are as follows: HR or PR is considered abnormal if less than 60 or greater than 100 bpm; RR is abnormal if less than 12 or greater than 25 breaths per minute; temperature is abnormal if less than 97.8 Fahrenheit ( F - unit of measurement) or greater than 99.0 F; systolic BP is abnormal if less than 90 mmHg or greater than 139 mmHg; and diastolic BP is abnormal if less than 60 mmHg or greater than 89 mmHg. 2. On 3/26/2025, the LVNs and RNs reviewed the current in-house residents who were actively being monitored for COCs between 3/23/2025 to 3/26/2025. Out of 262 in-house residents, 45 residents were identified as having recent COCs. For these 45 residents with COCs, the physicians were promptly notified, and appropriate orders were obtained and implemented to address the identified changes. 3. On 3/26/2025, following the completion of the vital signs audit, the facility identified 23 out of the 45 residents with recent COCs were directly related to abnormal vital signs. For these 23 residents, COC evaluations were promptly completed, primary care physicians were notified by LVNs and RNs, and appropriate medical orders were obtained and implemented. 4. On 3/26/2025, the facility implemented a structured communication protocol (is a set of guidelines and procedures ensuring clear, consistent, and effective communication among staff, residents, and families, promoting resident safety, dignity, and positive results) for reporting findings of abnormal vital signs among CNAs, LVNs, RNs, and ultimately to the attending physician. This protocol was reviewed and approved by the Quality Assurance Committee (QAC - is a group that regularly reviews care quality, identifies issues, and develops plans to address deficiencies, ensuring residents receive safe and effective care) and serves as a standardized guideline for nursing staff to ensure timely and accurate escalation (an increase in the intensity or seriousness) of clinical concerns (health-related issues or problems that require medical attention): i. CNAs are to report abnormal vital signs to the charge nurse immediately. ii. Once abnormal vital signs are rechecked and verified by the charge nurse, the charge nurse will escalate to the RN Supervisor for further evaluation. iii. A COC evaluation using the eInteract tool (a tool used in healthcare that helps care teams prevent unnecessary hospitalization s and improve resident outcomes to alert staff to changes in a resident ' s condition) will be initiated when abnormal vital signs are identified as part of a resident's COC. This applies to residents with underlying clinical concerns, including but not limited to the following: a history of hypertension (high BP), hypotension (low BP), recent infection, cardiac (heart) conditions, respiratory compromise (a situation where a person ' s breathing is at risk of becoming severely impaired), or any other medical condition that may predispose (to make more likely or render susceptible) the resident to instability. iv. A paper log titled, Abnormal Vital Sign Log will be maintained by each charge nurse to document communication between nursing staff and, ultimately, with the physician regarding abnormal vital signs. v. Vital signs will be monitored every shift for a minimum of 72 hours for residents identified with a COC, or longer if clinically indicated. 5. On 3/27/2025, the ADM and DON initiated a root cause analysis (a systematic approach to identify the underlying reasons for a problem or failure, rather than just addressing its immediate symptoms, to prevent recurrence) on the facility ' s failure to ensure any resident having abnormal vital signs was provided with necessary care and services, including notification of the physician, to address a COC. The facility identified the root causes included licensed nurses have a lack of supervision to ensure they (licensed nurses) follow protocols, that proactive audits (conducting internal reviews before potential problems arise to prevent future issues) or quality checks to identify gaps in care were not addressed timely, and adequate training during the hiring orientation process was provided to staff. 6. On 3/26/2025, the DON provided one-on-one in-service training (a personalized, focused training method where a healthcare professional learns a specific skill or procedure from a more experienced colleague in a one-to-one setting) to LVN 1. The planned training focused on providing care and services to residents, with the focus on the critical importance of documenting identified COCs, and notifying the primary physician when a change in a resident's condition is identified. Abnormal vital signs are communicated between CNAs, LVNs, RNs, and ultimately to the attending physician. Residents with COCs are monitored, and interventions are provided to address the COCs. 7. On 3/26/2025, LVN 1 was suspended and is currently still on suspension. 8. On 3/27/2025, the DON implemented staff training focusing on providing care and services to residents, with focus on critical importance of documenting identified COCs, and notifying the primary physician when a change in a resident's condition is identified. Abnormal vital signs are communicated between CNAs, LVNs, RNs, and ultimately to the attending physician. Residents with COCs are monitored, and interventions are provided to address the COCs. 9. On 3/26/2025, the DON initiated competency skills checks (are assessments that ensure healthcare professionals possess the necessary knowledge, skills, and abilities to perform their roles safely and effectively, often using checklists and other methods to evaluate performance) for LVNs and RNs to ensure that the licensed staff are proficient (competent or skilled) in evaluating COCs and accurately/timely reporting abnormal vital signs. The skills check included core competencies such as recognizing COCs, identifying abnormal vital signs, taking immediate action, notifying physicians promptly, and ensuring follow-up and continuous monitoring of COCs. Each nursing staff member was evaluated using a structured scoring tool, with opportunities for return demonstrations (a teaching technique where a student, after being shown a skill or procedure, demonstrates their understanding by performing it themselves, allowing the instructor to assess their learning) as needed to confirm competency. 10. On 3/26/2025, the DON, in collaboration with the Director of Staff Development (DSD), initiated in-service trainings for nursing staff, including CNAs, LVNs, and RNs, with a focus on recognizing COCs. The training emphasized timely reporting and appropriate interventions (including physician notification), ongoing monitoring of residents identified with a COC, and accurate documentation of abnormal vital signs. For staff who were unable to attend the scheduled in-service trainings, in-service trainings will be provided prior to the start of their next scheduled shift and will not be allowed to report to the assigned unit until training is completed. Nursing staff on leave or on vacation will receive competency-based education upon return to work. 11. The DON/designee will review newly identified COCs daily, from Monday through Friday. During weekends, holidays, and after-hours when the DON is not available, the RN Supervisor on duty will assume the responsibility of reviewing COCs. This process will continue for the next three months to ensure that physicians are promptly notified, appropriate orders are obtained, and interventions are implemented in a timely manner to address the identified changes. Issues identified will be addressed immediately by the DON/designee/RN supervisor. If gaps in practice or knowledge are identified, the DON will initiate targeted in-service training to reinforce expectations and ensure staff competency in managing COCs. 12. Medical Records Director 1/designee will audit ongoing COCs daily (Monday to Friday) to ensure residents are monitored every shift for at least 72 hours or more if necessary. 13. Unit Managers will review Abnormal Vital Sign Logs daily (Monday to Friday) and RN Supervisors on weekends/holidays for the next 3 months to ensure communication of abnormal vital signs between nursing staff and ultimately to the physician. A COC/elnteract electronic medical record is initiated, and the physician/provider is notified immediately as applicable. 14. During annual competency skills evaluation, LVNs and RNs will be evaluated on core competencies addressing residents with COCs. As part of the new hire orientation process, newly-hire RNs and LVNs will undergo training on addressing COC communication protocol among nursing staff on abnormal vital signs, initiating COC/elnteract record for abnormal vital signs and COCs, and reporting abnormal vital signs to RN supervisor and, ultimately, to the physician. 15. LVNs and RNs will undergo at least yearly in-service/training on addressing COCs, communication protocol among nursing staff on abnormal vital signs, initiating COC/elnteract record for abnormal vital signs and COCs, and reporting abnormal vital signs to RN supervisor and, ultimately, to the physician. 16. CNAs will undergo yearly in-service/training on obtaining vital signs, reporting abnormal vital signs immediately to the charge nurse and utilization of the Abnormal Vital Sign log. 17. The DON, ADON, and DSD will re-inservice all nursing staff, which include CNAs, LVNs, and RNs, monthly for the next three months on key areas such as recognizing and responding to COCs, timely and accurate reporting of abnormal vital signs, appropriate clinical interventions, and adherence to the structured communication protocol for escalating clinical concerns to the RN Supervisor and the attending physician. Licensed nurses will undergo competency-based skills checks to evaluate their proficiency in initiating COC / elnteract electronic medical record, notifying physicians promptly, and ensuring follow-up and monitoring. Staff will be assessed using a structured scoring tool, with return demonstrations conducted as needed to confirm understanding. Participants will also be required to complete a five-question post-test (an assessment or test administered after a training) to assess comprehension (understanding) of the material. Any staff unable to attend the scheduled sessions will receive the re-inservice and competency validation (to confirm) prior to the start of their next scheduled shift to ensure complete participation and sustained compliance. Cross Reference F580 and F600. Findings: During a review of Resident 1 ' s Admission Record, undated, the Admission Record indicated the facility admitted Resident 1 on 3/4/2025 with diagnoses including unspecified hypothyroidism (unidentified cause for thyroid gland [a large ductless gland in the neck] to not produce thyroid hormone [hormone regulating growth and development], causing weakness), essential hypertension (persistent elevated blood pressure), and occlusion and stenosis of left carotid artery (complete blockage and narrowing of carotid artery, a major blood vessel supplying the brain). During a review of Resident 1 ' s Minimum Data Set (MDS - a resident assessment tool), dated 3/12/2025, the MDS indicated Resident 1 was severely impaired with thought process and required substantial assistance from staff to complete activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). During a review of Resident 1 ' s record titled, eInteract Change of Condition Evaluation, dated 3/12/2025 at 11:40 p.m., the evaluation indicated Resident 1 had a change of condition of Abnormal vital signs and altered mental status (a change in a resident ' s mental state, including changes in awareness, alertness, and mental function). The evaluation indicated on 3/12/2025 at 5 p.m., Resident 1 ' s BP on a sitting position taken on Resident 1 ' s right arm was 86/57 mmHg and HR of 111 bpm. The evaluation indicated there were no other BP and HR assessments collected for Resident 1 after 5 p.m. on 3/12/2025. During a review of the physician ' s Progress Notes (PN) for Resident 1, dated 3/13/2025 at 1:06 a.m., the PN indicated Resident 1 ' s Medical Doctor (MD) 1 called RN 1 after multiple times before RN 1 answered. The PN indicated MD 1 instructed RN 1 to check and examine Resident 1, then call back MD 1. The PN indicated RN 1 called back and told MD 1, Resident 1 ' s BP was 86/57 mmHg and HR was 111 bpm (these vital signs were the same readings taken on 3/12/2025 at approximately 5 p.m.). The PN indicated RN 1 told MD 1 that it was unclear if Resident 1 was responsive (able to respond or reply) or not, so MD 1 ordered Resident 1 to be transferred to a GACH. During a review of Resident 1 ' s Physician ' s Orders (PO), dated 3/13/2025 at 6:48 a.m., the PO indicated Resident 1 was sent out to the GACH for abnormal vital signs and for altered level of consciousness (a change in mental status not normal from baseline). During an interview on 3/25/2025 at 3:54 p.m. with CNA 1, CNA 1 stated she was working on 3/12/2025 during the 3 p.m. to 11 p.m. shift and was assigned to care for Resident 1. CNA 1 stated she checked Resident 1 ' s vital signs approximately four to five times on Resident 1 ' s both arms, and the BP readings were consistently low (did not state the other low BP readings). CNA 1 stated she informed LVN 1, who was assigned to Resident 1 about Resident 1 ' s vital sign readings of low BP and increased HR. CNA 1 stated LVN 1 told her (CNA 1) that she (LVN 1) will recheck Resident 1 ' s vital signs. CNA 1 stated, To be honest, I don ' t know if she (LVN 1) checked since I went to my other residents During an interview on 3/26/2025 at 7:05 a.m. with RN 1, RN 1 stated RN 1 was working on 3/12/2025 and arrived at the facility at approximately 11:35 p.m. for the 11 p.m. to 7 a.m. shift. RN 1 stated RN 1 received a call from MD 1 (on 3/12/2025 at approximately 11:40 p.m.). RN 1 stated he was being asked by MD 1 if RN 1 was the supervisor on duty, and to provide a report on Resident 1 ' s condition. RN 1 stated, upon observing Resident 1, I was stunned, like he (Resident 1) was dying or towards the end of life RN 1 stated the previous shift staff failed to act to save the resident (Resident 1). RN 1 stated the previous shift staff (LVN 1) should have notified the RN on duty (RN 2), or by calling a code blue. RN 1 stated, When I saw the resident (Resident 1), to me, it looked like he (Resident 1) was gone. RN 1 stated the previous shift staff failed to notify Resident 1 ' s physician about the decreased blood pressure, and that staff also failed to call emergency services (the paramedics) sooner for Resident 1. During a concurrent interview and record review on 3/26/2025 at 7:47 a.m. with LVN 2, Resident 1 ' s eInteract Change of Condition Evaluation, dated 3/12/2025 at 11:40 p.m., was reviewed. LVN 2 stated she worked on 3/12/2025 for the 11 p.m. to 7 a.m. shift and was assigned to care for Resident 1. LVN 2 stated she cannot recall if Resident 1 was receiving any oxygen. LVN 2 stated LVNs are to notify the RN on duty first for any residents with a COC. LVN 2 stated (on 3/12/25 at approximately after 11 p.m.) From what I saw, he (Resident 1) was in code blue (an emergency code typically indicating a resident experiencing a life-threatening medical emergency that requires immediate medical attention) status because of his shallow breathing. LVN 2 stated Resident 1 ' s COC, dated 3/12/2025 documented at 11:40 p.m., indicated Resident 1 ' s last assessed BP of 86/57 mmHg and HR of 111 bpm recorded at 5 p.m. LVN 2 stated, For his (Resident 1 ' s) blood pressure, it was very low. LVN 2 stated when the emergency personnel (paramedics) came to the facility (on 3/13/2025 at 12:28 a.m.), she (LVN 1) mentioned it (BP and HR) was taken around 6 p.m. LVN 2 stated the paramedics arrived after midnight (3/13/25, after 12 a.m.). LVN 2 stated that would be 7 hours from the last collected vital signs. LVN 2 stated per the nursing progress notes, LVN 1 failed to notify RN 2 regarding Resident 1 ' s COC. LVN 2 stated there were no RN notification, no doctor (physician) notification, no code blue announced, and no interventions done on records (Resident 1 ' s medical records). LVN 2 stated, The LVN (LVN 1) stated to the emergency personnel that it (the BP of 86/57 mmHg and HR of 111 bpm) was the resident ' s (Resident 1 ' s) baseline. From what I saw, that was not the resident ' s (Resident 1) baseline. LVN 2 stated, The LVN (LVN 1) failed to notify the RN on duty (RN 2) During an interview on 3/26/2025 at 2:16 p.m. with LVN 1, LVN 1 stated she was informed of Resident 1 ' s change in vital signs approximately at 5 p.m. on 3/12/2025. LVN 1 stated she did not discuss Resident 1 ' s COC with the on-duty RN (RN 2), and she (LVN 1) did not inform Resident 1 ' s physician of Resident 1 ' s low vital signs. LVN 1 stated she did not call emergency services for Resident 1 and that it was the incoming night shift (11 pm. to 7 a.m.) staff (LVN 2) that notified emergency services for Resident 1 ' s COC. During a phone interview on 3/26/2025 at 4:20 p.m. with MD 1, MD 1 stated MD 1 called the facility to get an update on Resident 1 on 3/12/2025 approximately after 11:30 p.m. MD 1 stated that no facility staff had reached out to MD 1 earlier in the day. MD 1 stated MD 1 was concerned about Resident 1 ' s kidney function, so MD 1 called the facility for an update on Resident 1. MD 1 stated staff knew of Resident 1 ' s vital signs recorded on 3/12/2025 at 5 p.m. were a BP of 86/57 mmHg and a HR of 111 bpm, but staff did not make MD 1 aware of Resident 1 ' s condition timely. MD 1 stated (on 3/12/25, at approximately 11:30 pm) MD 1 spoke to an RN (RN 1) who told MD 1 The patient does not look good. MD 1 stated, MD 1 expected the nurses in general, evaluate Resident 1 when Resident 1 ' s BP was that low (86/57 mmHg). During an interview on 3/28/2025 at 10:15 a.m. with Unit Manager 1 (LVN), Unit Manager 1 indicated Resident 1 had no nursing progress notes from the 3 p.m. to 11 p.m. shift, no documented interventions. Unit Manager 1 stated the vital signs provide an internal baseline or anything happening for the residents, like blood pressures dropping or an increase in temperature could be related to possible infection, so vital signs help notify nursing staff an indication of how the resident is doing, or to identify if any changes need to be addressed. Unit Manager stated there was about six hours and 40 minutes from when MD 1 was informed of the Resident 1 ' s condition. Unit Manager 1 stated, For this case, after finding the vital signs at 5 p.m., the LVN (LVN 1) failed to reassess the resident ' s (Resident 1 ' s) vital signs, failed to notify the RN to assess the resident, and failure to notify the doctor of the COC. Unit Manager 1 stated Resident 1 had a care plan for hypertension initiated on 3/4/2025, upon admitted . Unit Manager 1 stated the interventions by licensed nurses (LVNs and RNs) are to observe for signs and symptoms of abnormal blood pressure and complications related to hypertension, and notify physician as needed. Unit Manager 1 stated, In this scenario, the LVN (LVN 1) failed to implement this (Resident 1) care plan ' s intervention. During a concurrent interview and record review on 3/28/2025 at 11:30 a.m., Resident 1 ' s eInteract Change of Condition Evaluation, dated 3/12/2025 at 11:40 p.m., was reviewed with MD 1. MD 1 stated MD 1 called the facility on 3/12/2025 at approximately after 11:30 p.m. MD 1 stated MD 1 did not realize the vital signs provided to MD 1 over the phone were Resident 1 ' s BP of 86/57 mmHg and HR of 111 bpm per minute were the same collected vital signs from 5 p.m. earlier in the day (3/12/2025). MD 1 stated, I ' m talking to them on the phone, so I didn ' t know they (RN 1) used the same vital signs from 5 p.m. I thought it was a recent set of vital signs. During a concurrent interview and record review on 3/28/2025 at 5:50 p.m., Resident 1 ' s paramedics ' report, dated 3/13/2025 at 12:19 a.m., and the facility ' s policy titled, Change in a Resident ' s Condition or Status, were reviewed with the DON. The DON stated on 3/12/2025, for Resident 1, from staff knowing the changes in vital signs for Resident 1 at 5 p.m., to the time the physician called the facility at approximately 11:40 p.m., that was almost seven hours of no interventions. The DON stated the paramedics ' report indicated that the paramedics were contacted on 3/13/2025 at 12:19 a.m., arrived at the facility by 12:28 a.m., at bedside with the Resident 1 at 12:30 a.m., and left the facility with Resident 1 by 12:37 a.m. The DON stated the report described Resident 1 as having decreased breath sounds and the vital signs collected by the paramedics on 3/13/2025 at 12:30 a.m. were a BP of 74/50 mmHg, HR of 56 beats per minute, RR of 4 breaths per minute, and oxygen saturation (percentage of oxygen to the blood measuring how well the lungs deliver oxygen to the body) of 74 percent (% - per one hundred, typically ranges from 95% to 100%). The DON stated the paramedics described Resident 1 as lying in bed with the current concern of respiratory failure (occurs when the lungs are unable to adequately perform their primary function: taking in oxygen and removing carbon dioxide [a colorless, odorless gas formed when people breathe out] from the blood). The DON stated the report indicated Resident 1 was found in severe respiratory distress and had a nasal cannula (a small plastic tube which fits into nostrils to provide supplemental oxygen) and staff were standing by with no interventions to Resident 1 ' s decreased RR. The DON stated the report indicated Resident 1 was assisted by the paramedics with a bag valve mask (a handheld device used to deliver breaths to someone who cannot breathe on their own) and transported on advanced life support (ALS - a set of life-saving protocols and skills to provide urgent care during critical conditions) to the nearest GACH 1. The DON stated, This resident passed away on 3/13/2025. During further record review of the policy titled Change in a Resident ' s Condition or Status with the DON, the DON was asked to clarify what Promptly meant as stated in the policy. The DON stated, For the policy titled Change in a Resident ' s Condition or Status, there is no date on this policy. For the notification of promptly, whatever the change of condition was from the resident ' s baseline, licensed staff (LVNs & RNs) need to assess and inform the attending physician. During a review of Resident 1 ' s GACH records titled, Discharge Summary, reviewed on 3/28/2025, the GACH records indicated Resident 1 passed away on 3/13/2025 at 4:27 p.m. The preliminary cause of Resident 1 ' s death was septic shock. The Discharge Summary also indicated additional pertinent diagnoses of acute respiratory failure with hypoxia (when the lungs fail to provide oxygen to the body ' s tissues, leading to low oxygen levels in the blood) and anoxic brain damage (brain injury caused by lack of oxygen to the brain). During a review of the current facility-provided undated policy and procedure titled, Change in Resident ' s Condition or Status, the policy and procedure indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident ' s medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). The policy also indicated: 1. The nurse will notify the resident ' s attending physician or physician on call when there has been a (an): d. significant change in the resident ' s physical/emotional/mental condition; g. need to transfer the resident to a hospital/treatment center; 2. A Significant change of condition is a major decline or improvement in the resident ' s status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not Self-limiting); b. impacts more than one area of the resident ' s health status; c. requires interdisciplinary review and/or revision of the care plan

Based on interview and record review, the facility failed to protect a resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of four sampled residents (Resident 1) when on 1/29/2025 at 10:55 a.m., Student Nurse 1 (SN 1) and Student Nurse 2 (SN 2) witnessed Certified Nurse Assistant 1 (CNA 1) hit Resident 1 in the back of the head three times with an open hand (did not indicate which hand). This deficient practice resulted in Resident 1 being subjected to physical abuse by CNA 1 while under the care of the facility. Resident 1 stated he (Resident 1) felt humiliated (ashamed), sad, and complained of pain to the back of the head. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated the facility admitted Resident 1 on 11/16/2023, with diagnoses that included hemiplegia (paralysis [inability to move] that affects only one side of the body) and hemiparesis (muscle weakness that affects one side of the body) following a cerebral infarction (a condition where blood flow to the brain is interrupted causing brain tissue to die) affecting right dominant side, difficulty walking, heart failure (when the heart does not pump blood as well as it should), and history of falling. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/5/2024, the MDS indicated Resident 1 had moderate impairment of cognition (ability to think and make decisions). The MDS indicated Resident 1 required moderate assistance with activities of daily living (ADL - routine tasks and or activities such as bathing, dressing, and toileting a person performs daily to care for themselves). During a review of Resident 1's document titled, Interact Change in Condition (COC - when there is a sudden change in a resident's health condition or behavior) Evaluation, dated 1/29/2025, the COC indicated that on 1/29/2025 at 10:55 a.m., SN 1 and SN 2 reported seeing CNA 1 in Resident 1's room, hitting the top of Resident 1's head three times. The COC further indicated that CNA 1 was immediately removed and a head-to-toe assessment (a comprehensive medical examination where a healthcare professional checks a resident's entire body from the top of their head to the tips of their toes, systematically evaluating each body system to assess their overall health and identify any potential problems) on Resident 1 was completed with no skin issues noted. The COC indicated that Resident 1 was interviewed and reported in Spanish that CNA 1 hit him (Resident 1) in the head three times. During a review of Resident 1's Plan of Care, dated 1/29/2025, the Plan of Care indicated Resident 1 had an incident of alleged abuse. The Plan of Care indicated a goal that Resident 1 will be free from abuse in the facility by encouraging to verbalize feelings and provide psychosocial (relating to the interrelation of social factors and individual thought and behavior) support. During a review of CNA 1's Employee Counseling and or Disciplinary Notice, dated 1/29/2025, the notice indicated CNA 1 was witnessed hitting Resident 1 on his (Resident 1) head. During a review of Resident 1's Psychiatric Evaluation follow up note, dated 2/3/2025, the Psychiatric Evaluation follow up note indicated that Resident 1 was seen for a follow-up visit after reporting an incident (abuse) to staff. The note indicated Resident 1 alleges that a nurse (referring to CNA 1) tapped Resident 1 on the back of Resident 1's head. During an interview with Resident 1 on 2/7/2025 at 9 a.m., Resident 1 stated that CNA 1 hit him (Resident 1) three times on the back of his head. Resident 1 stated he (Resident 1) had asked the staff (referring to CNA 1) for assistance. Resident 1 stated that CNA 1 did not want to help Resident 1, so CNA1 started hitting Resident 1. Resident 1 stated he (Resident 1) felt sad, ashamed, and had some pain to the back of the head because CNA 1 hit him (Resident 1) very hard. Resident 1 stated he (Resident 1) could not defend himself (referring to Resident 1) because he (Resident 1) was sick and felt very bad. During a review of SN 2's written statement, dated 1/29/2025, the written statement indicated that SN 2 witnessed CNA 1 hit Resident 1 on the head (did not indicated which part) three times. The written statement indicated Resident 1, and CNA 1 were previously arguing in the bathroom. The written statement indicated when CNA 1 hit Resident 1, Resident 1 yelled in Spanish (a type of language), The CNA (CNA 1) hit me, she hit me. SN 2's written statement indicated that CNA 1 verbalized hitting Resident 1 by stating I hit him (Resident 1). During an interview on 2/7/2025 at 10 a.m. with SN 1, SN 1 stated on 1/29/2025, she (SN 1) observed CNA 1 slapped the back of Resident 1's head. SN 1 stated CNA 1 had her palm (inner part of hand) open (did not indicate which palm) and slapped Resident 1 in the head three times very hard. SN 1 stated Resident 1 was yelling out that a CNA (referring to CNA 1) hit him. During an interview with the Clinical Instructor (CI) on 2/7/2025 at 11 a.m., the CI stated, on 1/29/2025, SN 1 and SN 2 came to her and reported witnessing CNA 1 hitting Resident 1 in the head. The CI stated they (SN 1, SN 2, and CI) went to report the incident (abuse) to the Director of Nurses (DON). During an interview on 2/7/2025 at 3:30 p.m. with the DON, the DON stated the incident that occurred on 1/29/2025 with Resident 1 and CNA 1 was considered abuse. The DON stated the facility does not allow any type of abuse to occur because there is zero tolerance (a strict policy that prohibits violence, bullying, and other harmful behaviors in the workplace) for abuse. The DON stated CNA 1 was removed from the facility staffing schedule. During a review of the current facility-provided policy and procedure (P & P) titled, Abuse, Neglect, Exploitation (the act of taking advantage of someone or something for personal gain) and Misappropriation (unauthorized, improper, or unlawful use) Prevention Program, dated 2021, the P & P indicated residents have the right to be free from abuse. This includes . physical abuse.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had risk for fractures (break of bones), was provided with an environment free of accident hazards and was gently assisted by Certified Nursing Assistant 1 (CNA 1) to use the toilet as indicated in the plan of care and facility's policies. As a result, on 4/1/2021 at 7:30 p.m., Resident 1 sustained a left femur (thighbone) fracture and required transfer to General Acute Care Hospital 1 (GACH 1) where she underwent surgery to repair the fracture on 4/2/2021. Findings: A review of Resident 1's Admission Record indicated the facility originally admitted the resident on 8/28/2019 with a readmitted dated 11/7/2019. Resident 1's diagnoses included type 2 diabetes mellitus (a long-term chronic condition in which there is an impairment in the way the body regulates and uses sugar [glucose] as a fuel), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), age-related [CONDITION(S)] (a condition that makes the bones thin and brittle posing a greater risk for sudden and unexpected bone fractures), unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning) with behavioral disturbance (such as agitation, restlessness, and aggressiveness). A review of Resident 1's Care Plan developed on 8/28/ for the resident's risk of injuries, deformities, fractures, and pain related to [CONDITION(S)], included in the interventions maintaining a safe and hazard free environment, handling gently the resident during care especially when moving, turning, and repositioning. A review of Resident 1's History and Physical exam dated 2/8/2020 by the attending physician indicated the resident did not have capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 1/30/2021 indicated the resident had memory problems, was able to make self-understood and understands others. Resident 1 needed extensive assistance with two-person physical assist with transfers, one-person physical assist with dressing, toilet use, and personal hygiene. Resident 1's balance was unsteady for surface-to-surface transfer (transfer between bed and chair). Resident 1 used a wheelchair as a mobility device. A review of Resident 1's Situation, Background, Assessment, Recommendations (SBAR - a tool that provides a framework for communication between members of the health care team about a patient's condition) form, dated 4/1/2021 timed at 7:32 p.m., by Licensed Vocational Nurse 1 (LVN 1), indicated the resident was sitting in the wheelchair and stated the left leg was in a lot of pain with visible swelling to the left thigh. LVN 1 notified the physician who ordered STAT (immediately) X-rays ([CONDITION(S)] called electromagnetic waves which create pictures of the inside of the body) of the left leg/hip. A review of Resident 1's Radiology Results Report dated 4/1/2021 and timed at 8:42 p.m., indicated the resident had a fracture of left femur. A review of the Physician's Order for Resident 1, dated 4/1/2021 timed at 11:13 p.m., indicated to send the resident to GACH 1 due to the left femur fracture. A review of GACH 1 Operative Report for Resident 1, dated 4/2/2021, indicated Resident 1 underwent a left femur fracture retrograde nailing (left thighbone shaft fracture fixation). A record review of the facility's Final Investigation Summary indicated a day after Resident 1's injury, on 4/2/2021 at 10:45 a.m., Family Member 1 (FM 1) reported the resident said a staff wheeled her against the wall and that was the reason she sustained the injury. On 4/9/2021 at 10:01 a.m., during a telephone, LVN 1 stated that on 4/1/2021 at 7:30 p.m., she heard Resident 1 screaming from the room. LVN 1 entered Resident 1's room and saw CNA 1 wheeling the resident from the restroom to the bed and Resident 1 was screaming in pain on the left leg. LVN 1 checked it and noticed the knee was swollen. LVN 1 asked Resident 1 what happened but the resident did not answer but kept saying she was in pain. LVN 1 asked CNA 1 what happened, and CNA 1 stated nothing had happened but Resident 1 started screaming in pain. On 5/7/2021 at 5:17 p.m., during a telephone interview, CNA 1 stated that on 4/1/2021 Resident 1 complained of pain on the left leg from the beginning of the shift (3 p.m.) and at 7:30 p.m., she had just taken her to the restroom when Resident 1 started screaming in pain. CNA 1 stated there was no fall and the resident did not hit or bumped into a wall or a door. CNA 1 stated she had not notified LVN 1 the resident was complaining of left leg pain since the beginning of her shift. On 5/20/2021 at 10:12 a.m., during an interview, the Director of Nursing (DON) stated the incident was investigated and concluded Resident 1 could have bumped onto the wall accidently and CNA 1 did not realize it. The DON stated Resident 1 had the pre-exiting condition of [CONDITION(S)] and was susceptible to sustaining fracture. A review of the facility's policy and procedure titled, Activity of Daily Living (ADL), Supporting revised 3/2018, indicated that 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). A review of the facility's policy and procedure titled, Safety and Supervision of Residents revised 7/2017 indicated that the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.

Based on observation, interview, and record review, the facility failed to prevent the development of multiple pressure ulcers (the most severe form of the wound, as it has spread to the underlying bone or muscle) with infection that progressed to Stage IV pressure ulcers for one of five sampled residents (Resident 1) by failing to: 1. Ensure Resident 1 who was assessed at a risk to develop pressure ulcers was provided with care and services that included weekly skin assessment, turning and repositioning every two hours and/or as often as necessary as indicated in the plan of care; 2. Ensure Resident 1 skin condition was assess accurately daily by treatment nurses and certified nursing assistant when providing care and treatment to identify new skin breakdown promptly. 3. Ensure dietitian review Resident 1 pressure ulcers monthly and documents for worsening wounds. 4. Ensure Resident 1 was provided and consumed the nourishment needed to prevent the development of pressure ulcers and to promote wound healing, evaluate food consumption, and plan accordingly to assure the resident would not be malnourished; 5. Inform the physician and family member (FM) about the development of worsening wounds and poor meal intake to evaluate the need for alternative nourishment as appropriate when the resident was unable to consume and refused foods and fluids served in order to meet the resident's caloric, protein and fluid needs. Resident 1 developed MASD (moisture associated skin disorder) that progressed to Stage IV on the right and left buttocks, and Stage IV on the left heel. Resident 1 was transferred to the general acute care hospital (GACH), on (MONTH) 29, (YEAR), with [DIAGNOSES REDACTED]. Resident 1 was then admitted into hospice services (supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than cure) from GACH and subsequently died several days later in another skilled nursing facility. Findings: On (MONTH) 12, (YEAR), at 12:45 p.m., an unannounced complaint visit was conducted at the facility regarding a quality of care concern. According the admission record Resident 1 was admitted to the facility on (MONTH) 31, 2013, with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a comprehensive assessment and care-screening tool), dated (MONTH) 13, (YEAR), indicated Resident 1's cognitive skills for daily decision-making were severely impaired, and required extensive assistance from staff with activities of daily living. The MDS indicated the resident did not have any pressure ulcers but had a [MEDICAL CONDITION]. A review of the Weights and Vitals Summary record indicated the following weight changes: - On (MONTH) 2, (YEAR), Resident 1 weighed 184 lbs. - On (MONTH) 8, (YEAR), Resident 1 weighed 179 lbs. - On (MONTH) 5, (YEAR), Resident 1 weighed 176 lbs. - On (MONTH) 19, (YEAR), Resident 1 weighed 170 lbs. (Significant weight loss of over 7.5% in than less three months). A total of 14-pounds weight loss in less than three months. A review of Resident 1's Nutritional Assessment Screening dated (MONTH) 3, (YEAR) indicated Resident 1 was on Pureed diet, CCHO (carbohydrate controlled diet), decubitus (pressure ulcer), and thin liquids and had dietary supplements of Glucerna 1 can twice daily and snacks three times daily. The record indicated Resident 1 required cueing, supervision, assistance with eating, and was not in a feeding program. The Dietician recommended increased nutritional needs due to wounds, monitor food intake, weights, and laboratory tests. A review of Resident 1's [MEDICATION NAME] level test result dated (MONTH) 7, (YEAR), indicated the level was 3.8 g/dL (gram per deciliter-reference range 3.5 to 5.2 gram/dL). ([MEDICATION NAME] is a blood test to detect whether a person is getting proper nutrition, specifically protein, it also a test to identify malnutrition). There was no documented evidence of any further dietician recommendations for weight loss of 14 lbs. on (MONTH) 19, (YEAR). There was no documented evidence of further laboratory tests to monitor [MEDICATION NAME] levels. A review of Resident 1's meal consumption recorded on the Documentation Survey Report from the Certified Nurse Assistants from (MONTH) 1, (YEAR), until (MONTH) 29, (YEAR), indicated Resident 1 had consumed less than 50 percent of his meal. For example: 1. During the month of (MONTH) (YEAR), the resident's food consumption was less than 50 percent 8 times for breakfast, 8 times for lunch and 6 times during dinner. 2. During the month of (MONTH) (YEAR), the resident's food consumption was not recorded. 3. During the month of (MONTH) (YEAR), the resident's food consumption was less than 50 percent 18 times for breakfast, 16 times for lunch and 13 times during dinner. A review of Resident 1's care plan dated (MONTH) 19, (YEAR) for skin integrity, high risk for further skin breakdown, skin tears or bruises, hematoma (clotted blood), [MEDICAL CONDITION] ([MEDICAL CONDITION], narrowing and hardening of the blood vessels that supply the legs and feet, that causes decrease blood flow), diabetic ulcers (any breakdown in the skin on the foot of a diabetic person), and pressure ulcer related to history of skin breakdown, incontinence (no control of bowel and bladder), cognitive impairment, poor safety awareness, and diabetes (high blood sugar). The intervention included to apply lotion daily, apply moisture skin barrier, encourage and assist to consume ,[DATE]% of diet, and special attention to fragile skin, sensitive skin areas when providing care. A review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR), Communication Form and Progress Note, dated (MONTH) 18, (YEAR), indicated Resident 1 had a change of condition. The record indicated, MASD to coccyx (tailbone) extended to left and right buttock length of 7.5 centimeters (cm) x 9 cm (width) x 0.2 cm (depth). A review of Resident A's Skin Re-Assessment, dated (MONTH) 18, (YEAR), indicated upon assessment Resident 1 was noted with MASD on coccyx extending to left to right buttock, no odor noted, and with small amount of serous drainage. A review of Resident A's care plan dated (MONTH) 18, (YEAR) for impaired skin integrity related to MASD in the coccyx extended to the left and right buttocks, indicated to monitor for signs and symptoms of infection, redness, drainage, and increased temperatures. A review of Resident A's physician's orders [REDACTED]. A review of Resident A's Weekly Summary Nurse Progress Notes dated (MONTH) 3, 10, 17, 24, and 31, (YEAR), and (MONTH) 7, 14, and 21, (YEAR), indicated Resident 1's skin was intact. The records further indicated required extensive assistance, was a two-person physical assistance, and was always incontinent. The records indicated blank skin assessments by the nurses. A review of Resident A's Weekly Skin assessment dated (MONTH) 24, (YEAR) indicated MASD of the coccyx extended to the left and right buttock, visible tissue worsening, [MEDICATION NAME] (thin) tissue present, moist, measured 7.6 centimeters (cm) and width 9.0 cm, and depth 0.2 superficial. The record indicated there was a length increase in size, no signs of infection noted with slight increase in drainage with slowly healing expected. A review of Resident A's Daily Body Check Report from the Certified Nurse Assistant (CNAs), dated (MONTH) 27 and 28, (YEAR), indicated Resident 1's skin report as blank responses from the findings section. The record indicated for the Licensed Vocational Nurses (LVNs) to conduct complete body checks on all problem areas noted and to report new findings/changes in condition to physician for instructions and document changes in the patient's chart. The Director of Nursing (DON) would review the findings and ensure that appropriate action would be taken and documentation was required and done. Resident 1 was on the list as one of the residents for daily body checks. A review of the Weekly Wound Meeting dated (MONTH) 28, (YEAR) indicated recurring diabetic ulcer to right heel. Wound was being followed by wound care for weekly wound evaluation and recommendation. Facility wound protocols initiated included decubitus diet, vitamin C, vitamins and minerals, zinc times 30 days, prostat 30 cubic centimeters (cc) twice daily, and resident also gets snacks three times daily between meals. There was no documented evidence of regarding the MASD or follow up from the physician regarding the coccyx wound identified on (MONTH) 18, (YEAR). There was no documented evidence of wound doctor consult for the coccyx wound. There was no documented evidence of Interdisciplinary Team (IDT, a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident) meeting pertaining to the new skin disorder, MASD, identified on (MONTH) 18, (YEAR) with no new recommendations from nursing, dietary, and wound care departments. A review of Resident 1's SBAR Communication Form and progress notes, dated (MONTH) 29, (YEAR), at 4:03 p.m., indicated Resident 1 had a change of condition of cough and low-grade fever. The record indicated Resident 1 had decreased consciousness (sleepy, lethargic) and increased weakness. The notes indicated the resident's vital signs were pulse 137 beats per minute (bmp) (Normal range 60 to 100 bpm), respirations 17 breath per minute (Normal range 12 to 20 breath per minute), temperature 102.5 degree Fahrenheit and 83 percent oxygen saturation ( level of oxygen found in a person's blood, measures by pulse oximetry). Resident 1's had decreased consciousness, abnormal lung sounds and chest congestion. The record indicated Resident 1 had blood in his sputum upon coughing. The nurses' notes indicated that [DATE] (emergency number) was called and Resident 1 was transferred to the general acute care hospital via ambulance. A review of Resident 1's Patient Transfer Record, obtained from GACH dated (MONTH) 29, (YEAR), at 2:56 p.m., indicated the reason for transfer was bloody sputum and productive cough. The record indicated that the resident had a MASD on the coccyx and bilateral (both) feet ulcers. On (MONTH) 11, (YEAR), at 11:40 a.m., Resident 1 was observed lying in bed in his room at the GACH. Resident 1 was unable to answer and respond when spoken too. There was a sign outside Resident 1's room that indicated Resident 1 was in contact (used for infections that were spread by touching the patient or items in the room) and droplet (used for diseases or germs that are spread in tiny droplets caused by coughing and sneezing) precautions. On (MONTH) 11, (YEAR), at 11:46 a.m., during an interview and concurrent record review of Resident 1's record with Registered Nurse (RN) at the GACH. The RN stated Resident 1 came into the hospital with an unstageable wound with slough in the sacral area (tailbone) and a right ankle stage IV wound. The GACH record dated (MONTH) 29, (YEAR), coccyx area pink, red, yellow slough, with foul odor scanty serosanguinous drainage. The record indicated Resident 1 had a black and purple wound in the left and right heel. According to Resident 1's Consultation Note from the GACH dated (MONTH) 1, (YEAR), indicated the following findings: 1. Altered mental status/sepsis 2. Stage IV and III coccyx 3. Stage IV right heel 4. Unstageable left heel 5. Malnutrition (inadequate protein-energy intake) related to unable to consume adequate nutrients versus wound healing. According to Resident 1's Consultation Notes from GACH dated (MONTH) 30, (YEAR) indicated the following findings from Infectious Disease: 1. Patient was brought in due to more lethargy and fever. He has pressure ulcer sacrum and right heel prior to admission. 2. Patient was started on broad-spectrum antibiotic with cefipime, [MEDICATION NAME] and [MEDICATION NAME]. 3. Infectious Disease (ID) was consulted to help with management. 4. Decubitus ulcer right heel and sacrum. According to Resident 1's Wound Nurse Evaluation, from GACH dated (MONTH) 1, (YEAR) indicated the following findings from the certified wound nurse: 1. Stage IV pressure injury in sacrum/coccyx with muscle visible. 2. Stage IV pressure injury in right heel posterior ankle. 3. Stable eschar over bony prominences [MEDICAL CONDITION] vs pressure, location bilateral feet, multiple sites. Resident 1 was admitted to the GACH from (MONTH) 29, (YEAR) for intravenous antibiotics and discharged (MONTH) 16, (YEAR) to another skilled nursing facility on hospice services. Resident 1 was found to be [MEDICAL CONDITION] presumed secondary to pneumonia (lung infection) and pressure injuries (sacrum and right heel). Family was very clear about not having any surgical intervention for his pressure injuries. On (MONTH) 12, (YEAR), at 2:56 p.m., Licensed Vocational Nurse-Treatment Nurse (LVN-TN) was interviewed. LVN-TN stated he was the one overseeing all of the facility's wound care for all of the residents. LVN-TN stated Resident 1 was up in the chair most of time at the facility and was not bedridden. LVN-TN stated Resident 1 was not alert enough to speak and make his needs known. LVN-TN stated that Resident 1 was seen by the wound doctor for his right heel ulcer that he had for some time. The LVN-TN stated Resident 1 developed a superficial wound in the coccyx area and it was the first time that it occurred, two weeks ago. LVN-TN stated it was superficial and pink. LVN-TN stated that there was no treatment for [REDACTED]. LVN-TN stated that Resident 1 had weight loss but he was not sure if the Dietician evaluated him. LVN-TN stated he was not sure if he was eating very much. On (MONTH) 12, (YEAR), at 3:12 p.m., the Registered Nurse (RN) 1 was interviewed. The RN 1 stated the weight committee had to evaluate how much residents were eating daily. The RN 1 stated the residents were weighed and if there was a significant weight change, then the Dietician should make recommendations. RN 1 stated Resident 1 needed to be manually fed and encouraged to eat. The RN 1 stated that Resident 1 did not want to get out of bed. The RN 1 stated Resident 1 had lots of meal refusals. The RN 1 stated the last recommendation was Prostat and RNA (restorative nurse assistant) program. The RN 1 stated the weight loss committee reviewed ,[DATE] lbs. weight loss weekly only. The RN 1 stated if Resident 1 lost greater than 7.5% lbs. that the doctor needed to review his case. On (MONTH) 17, (YEAR), at 12:13 p.m., LVN-TN 2 was interviewed. LVN-TN 2 stated she was normally assigned to Resident 1 during the day shifts. She stated Resident 1 would sleep during the day and was alert and would not respond. LVN-TN 2 stated Resident 1 developed a MASD on the coccyx area, which was extended to the right and left buttock. LVN-TN 2 stated it was pink, moist, macerated, with slight serosanguinous drainage. LVN-TN 2 stated the nurses were treating the wound with normal saline as needed, silvacollagen gel, and covered with foam dressing. LVN-TN 2 stated that she and CNA 1 identified the MASD on (MONTH) 18, (YEAR), and it got worse on (MONTH) 24, (YEAR). The LVN-TN stated the wound increased in size with an increase in the drainage. LVN-TN 2 stated the nurses were required to conduct weekly assessments of the wound to evaluate the size and worsening of the wound. On (MONTH) 17, (YEAR), at 12:31 p.m., the CNA 1 was interviewed. CNA 1 stated Resident 1 was quiet and confused. CNA 1 stated Resident 1 was a feeder, a heavy person, and very stiff. CNA 1 stated he would tense up when the staff would turn him. CNA 1 was asked if she noticed any skin changes on the resident and CNA 1 stated that the last two times Resident 1's bottom was covered with a patch or dressing so she could not tell what it looked like. CNA 1 stated that the last month, Resident 1 was eating less. On (MONTH) 17, (YEAR), at 2:45 p.m., the Minimum Data Set/Registered Nurse (MDS-RN) was interviewed. The MDS-RN stated that it was important for the nurses to talk to CNAs about turning and repositioning every two hours. The MDS-RN stated any change of condition for skin, such as a MASD with drainage, needed to be monitored for the first 72 hours every shift and the treatment nurse should evaluate the wound daily. The MDS-RN stated Resident 1's wound should be evaluated by the wound care doctor. The MDS-RN stated if the wound was opened with drainage, then the wound should have an incident report. The MDS-RN stated the wound should have been treated more aggressively. A review of facility's policy titled Pressure Ulcer Prevention and Treatment Addendum, revised (MONTH) (YEAR), indicated, It is the policy of this facility to conduct care plan conference initially and quarterly thereafter and as often as necessary when there is a significant change of residents' condition. The treatment nurses will assess all residents with existing pressure sores/wounds for new sores or wounds daily when providing treatment to those residents .The CNAs will sue the Skin Sheets to document any observed or noted new skin breakdown and immediately report to the licensed nurse immediately .The licensed nurse will then conduct a skin assessment, notifying the resident's physician for treatment order, notify the resident's RP and will address and document the skin problem identified in the resident care plan. Another facility's policy titled Pressure Ulcer Prevention and Treatment, revised (MONTH) (YEAR), indicated, It is the policy of this facility that all residents receive comprehensive care to prevent and treat pressure ulcers. An interdisciplinary plan of care is developed, implemented and updated for each resident with a pressure ulcer or at high risk for development of pressure ulcers .All residents are examined by a licensed nurse to identify the status of skin integrity, and assessed for pressure ulcer risk on admission. Licensed nurses and the IDT (interdisciplinary team) reassess resident's skin integrity and response to the plan of care no less than quarterly, and initiates changes as needed. In addition, all residents have their skin checked daily during routine ADL (activities of daily living) care with complete body checks done twice a week on the resident's shower days by the CNA .Based on the areas identified during the examination, the licensed nurses notify the MD for appropriate treatment which may include lab monitoring, dietary supplements, and pressure reducing devices .Dietary reviews and documents on residents with pressure ulcers monthly or as needed until healed. A registered dietician provides comprehensive nutritional assessment of residents with Stage III or IV ulcers monthly. The assessment and plan of care includes but not limited to: food or nutritional intake pattern; weight trends; lab values; protein and caloric needs and intake; response to plan of care; resident preferences and goals .Assessment and treatment of [REDACTED].Appropriate Medical Record and QI audits are utilized to insure integrity of the skin care program and outcomes as identified by the Director of Nursing and/or QA (Quality Assurance) Coordinator. Cross-reference to F692.

Based on interview and record review, the facility failed to provide the needed nutritional care and services for one of three sampled residents (Resident 1) who had a poor meal intakes and a progressive weight loss, including but not limited to: 1. Evaluate Resident 1's poor meal consumption and for registered dietitian to make diet change recommendation as needed. 2. Notify the physician of Resident 1's progressive weight loss and significant weight loss of 14 pounds in less than three months. Resident 1 experienced a change of condition that required general acute care hospital (GACH) evaluation and was diagnosed of malnutrition. Findings: On (MONTH) 12, (YEAR), at 12:45 p.m., an unannounced complaint visit was conducted at the facility regarding a quality of care concern. According to the admission record, Resident 1 was admitted to the facility on (MONTH) 31, 2013, with [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS - a comprehensive assessment and screening tool) dated (MONTH) 13, (YEAR), indicated Resident 1's cognitive skills for daily decision-making were severely impaired, and required extensive assistance from staff with activities of daily living. The MDS indicated the resident did not have any pressure ulcers but had a [MEDICAL CONDITION]. A review of the Weights and Vitals Summary record indicated the following weight changes: - On (MONTH) 2, (YEAR), Resident 1 weighed 184 lbs. - On (MONTH) 8, (YEAR), Resident 1 weighed 179 lbs. - On (MONTH) 5, (YEAR), Resident 1 weighed 176 lbs. - On (MONTH) 19, (YEAR), Resident 1 weighed 170 lbs. (Significant weight loss of over 7.5% in than less three months). A total of 14-pounds weight loss in less than three months. A review of Resident 1's Nutritional Assessment Screening dated (MONTH) 3, (YEAR) indicated Resident 1 was on Pureed diet, CCHO (carbohydrate controlled diet), decubitus (pressure ulcer), and thin liquids and had dietary supplements of Glucerna 1 can twice daily and snacks three times daily. The record indicated Resident 1 required cueing, supervision, assistance with eating, and was not in a feeding program. The Dietician recommended increased nutritional needs due to wounds, monitor food intake, weights, and laboratory tests. The record indicated that on (MONTH) 7, (YEAR), the [MEDICATION NAME] level was 3.8 g/dL (gram per deciliter-reference range 3.5 to 5.2 gram/dL). ([MEDICATION NAME] is a blood test to detect whether a person is getting proper nutrition, specifically protein, it also a test to identify malnutrition). There was no documented evidence of any further dietician recommendations for significant weight loss of over 7.5% on (MONTH) 19, (YEAR). There was no documented evidence of further laboratory tests to monitor [MEDICATION NAME] levels. A review of the resident meal consumption recorded on the Documentation Survey Report from the Certified Nurse Assistants from (MONTH) 1, (YEAR), until (MONTH) 29, (YEAR), indicated Resident 1 had consumed less than 50 percent of his meal. For example: 1. During the month of (MONTH) (YEAR), the resident's food consumption was less than 50 percent 8 times for breakfast, 8 times for lunch and 6 times during dinner. 2. During the month of (MONTH) (YEAR), the resident's food consumption was not recorded. 3. During the month of (MONTH) (YEAR), the resident's food consumption was less than 50 percent 18 times for breakfast, 16 times for lunch and 13 times during dinner. A review of Resident 1's care plan titled The resident has nutritional problem or potential nutritional problems related to puree texture: therapeutic diet ., initiated on (MONTH) 7, (YEAR), indicated for facility staff to monitor and report if the resident was refusing to eat, to report to the doctor of significant weight loss greater than 7.5% in 3 months, provide and serve supplements as ordered, and for the registered dietician to evaluate and make diet change recommendations as needed. There was no documented evidence of the plan of care updated and or revised after the significant weight loss on (MONTH) 19, (YEAR). A review of the Weekly Wound Meeting dated (MONTH) 28, (YEAR) indicated facility wound protocols initiated to include decubitus diet, vitamin C, vitamins and minerals, zinc times 30 days, Prostat 30 cubic centimeters (cc) twice daily, resident also gets snacks three times daily between meals. A review of Resident 1's SBAR Communication Form and progress notes, dated (MONTH) 29, (YEAR), at 4:03 p.m., indicated Resident 1 had a change of condition of cough and low-grade fever. The record indicated Resident 1 had decreased consciousness (sleepy, lethargic) and increased weakness. The notes indicated the resident's vital signs were pulse 137 beats per minute (bmp) (Normal range 60 to 100 bpm), respirations 17 breath per minute (Normal range 12 to 20 breath per minute), temperature 102.5 degree Fahrenheit and 83 percent oxygen saturation ( level of oxygen found in a person's blood, measures by pulse oximetry). Resident 1's had decreased consciousness, abnormal lung sounds and chest congestion. The record indicated Resident 1 had blood in his sputum upon coughing. The nurses' notes indicated that 9-1-1 (emergency number) was called and Resident 1 was transferred to the GACH via ambulance. According to Resident 1's Consultation Note from the GACH dated (MONTH) 1, (YEAR), indicated malnutrition (inadequate protein-energy intake) related to unable to consume adequate nutrients versus wound healing. On (MONTH) 12, (YEAR), at 3:12 p.m., during an interview and concurrent record review of Resident 1's medical record with Registered Nurse 1 (RN 1), RN 1 stated the weight committee had to evaluate how much residents were eating daily. RN 1 stated that the resident was weighed weekly, monthly, and if there was a significant weight change, then the dietician will be notified and make recommendations. RN 1 stated dietitian did not see Resident 1 after (MONTH) 3, (YEAR), and Resident 1 had lots of refusals with food. RN 1 stated that the last recommendation was Prostat and RNA (restorative nurse assistant) program. RN 1 stated the weight loss committee reviewed 2-3 lbs weight loss weekly only. RN 1 stated if Resident 1 lost greater than 7.5% lbs in less than three months that the doctor needed to be notified. A review of the facility's policy titled Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol, revised (MONTH) 2012, indicated, the nursing staff will monitor and document the weight and dietary intake of residents in a format which permits readily available comparisons over time . The threshold for significant unplanned and undesired weight loss will be based on the following criteria . 3 months - 7.5 % weight loss is significant; greater than 7.5% is severe . The Physician will consider whether any assessment including additional diagnostic testing is indicated to help clarify the severity or consequences of weight loss and/or impaired nutrition . No lab tests are sensitive or specific enough for defining nutritional status that they should be ordered for everyone. Lab tests should be ordered of they are likely to substantially help establish current status or prognosis, causes of anorexia or weight loss, or choice of interventions; otherwise, routine ordering to assess or follow nutritional status is not indicated . Cause Identification . The Physician will review possible causes of anorexia or weight loss with the nursing staff and/or Dietician before ordering interventions . The Dietician will estimate caloric, nutrient and fluid needs and, with the Physician, will identify whether the resident's current intake is adequate to meet his or her nutritional needs . For individuals with recent or rapid weight loss (for example, more than a pound a day), the staff and physician should consider possible fluid and electrolyte imbalance as a cause The Physician with the help of the multidisciplinary team, will identify conditions and medications that may be causing anorexia, weight loss or increasing weight loss . Monitoring . The Physician and staff will closely monitor residents who have been identified as having impaired nutrition or risk factors for developing impaired nutrition . Evaluating the care plan to determine if the interventions are being implemented and whether they are effective in attaining the established nutritional and weight goals . Cross reference F686

Based on observation, staff interviews, review of facility documents including logs, policies and procedures, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. 1. The facility failed to monitor the cooling of a large beef roast and three large pieces of pork that had been prepared the day before. The exact time the food was placed in the refrigerator could not been determined but at 8:30 am on July 24, 2017, approximately 13 hours after the kitchen closed, the temperatures of the beef and pieces of pork ranged between 50.8 and 58.2 degrees Fahrenheit (F). The cooked beef and pork which are considered time/ temperature control for safety foods (formerly called potentially hazardous foods), were stored in the food danger zone for longer than six hours and prepared for service for residents on pureed diet. The meats were also being reheated for other residents after the registered dietitian had asked the FSD to discard it. This had the potential to affect all 22 residents who received pureed diet and all 196 who received food from the kitchen. 2. The facility failed store food in a safe manner. The facility stored food in a refrigerator that was not functioning properly. Salads, sandwiches, yogurt and other time- temperature control for safety foods were stored in the refrigerator that was 60 degrees Fahrenheit (F).The recommended refrigerator temperature is between 36 and 40 degrees F. Storage of food in the food danger zone could result in food borne illness. This had the potential to affect all residents in the facility that are served food from the kitchen. The facility census was 236. The food danger zone refers to temperatures above 41 degrees F and below 135 degrees F that allow the rapid growth of disease causing microorganisms that can cause foodborne illness. Foods held in the danger zone for more than .6 hours (if cooked and cooled) may cause a foodborne illness if consumed (Centers for Medicare and Medicaid, State Operations Manual). 3. The facility failed to ensure the dish machine was consistently spraying the dishes with adequate amount of sanitizer. Sanitizers and disinfectants are used on food contact surfaces to prevent foodborne illness. Sanitizers are used to reduce microorganisms to safe levels determined by public health codes and regulations. This had the potential to affect all residents who eat and those on tube feeding who receive water flushes from water from the pitchers at the bedside cleaned in the dish machine. The census was 236. 4. The facility failed to ensure its thermometers were properly calibrated. An uncalibrated thermometer was used to test the final cooking temperature of food. This resulted in burnt food and possibility of under cooked food which could cause food borne illness This had the potential to affect all 218 residents that receive food from the kitchen. Nursing home residents risk serious complications from food borne illness as a result of their compromised health status. Symptoms of food borne illness include diarrhea, vomiting, headaches, fever, and confusion, loss of appetite, abdominal cramping and pain. When those conditions persist they can lead to dehydration and may require hospitalization and in some cases death. Immediate jeopardy was declared on July 24, 2017 at 6:25 pm. The facility administrator, assistant administrator, director of nursing and registered dietitian was notified of the immediate jeopardy situation. The facility administrator and other staff present were informed of the lack of monitoring of the cooked meats and failure of the FSD to communicate to all staff about the change in menu resulting in the preparation of the pork for residents on pureed diets. The facility was also informed of the inconsistent sanitizing concentration of the dish machine, the use of the uncalibrated thermometer used in checking final cooking temperatures. The storage of food and poor monitoring of a non-functioning refrigerator was also discussed. An acceptable plan of action was accepted on July 24, 2017 at 10:06 pm. The plan was to replace Food service director (FSD) 1 with an interim FSD (FSD 2) and have RD 1 closely supervise day to day operation for two weeks while training the new FSD and food service workers. The clinical nutrition responsibilities of RD 1 were to be transferred to a contract RD (RD 2) during the two week period. The plan also included training on proper cooling method, thermometer calibration, food storage, preparation and storage will be provided to staff. The snack refrigerator was pulled out of service and replaced with a new one. Items in the old refrigerator were discarded. The immediate jeopardy was abated on 7/26/17 at 3:20 pm when the facility was able to demonstrate knowledge of proper cooling of food, thermometer calibration, and proper cooking procedures including correct final food temperatures. Cross refer F361, F362 and F456. Findings: During the tour of the facility kitchen on July 24, 2017 at 8:19 am, Food Service Worker (FSW) 1 was observed standing over a large piece of charred (badly burnt) meat, beef. This large piece of meat, weighing approximately 10 pounds was placed on a cutting board. Next to FSW1 on a cart were one large stainless steel pan with large piece of aluminum foil peeled back revealing a dark brown colored liquid (meat juices) with a large creamy yellow solid substance (fat) and smaller chunks of the same floating on top. There was also another stainless steel pan covered with aluminum foil. When the aluminum foil in the second pan was peeled back, it revealed three large pieces of meat. Surrounding each piece of meat were a similar large creamy yellow solid substance (fat) and some dark brown liquid oozing from underneath the fat. These were also charred. The observation revealed several of the Don'ts (what not to do) of proper cooling of previously cooked foods. The meats had not been transferred to shallow pans; they were in the same pans they had been roasted in, including the meat juices. The pans had been wrapped tightly instead of being uncovered and finally, the pieces of meat were not cut up into to speed up loss of heat and encourage faster cooling. According to the facility policy and procedure titled Cooling and Reheating Potentially Hazardous Food dated 2015, when potentially hazardous food will not be served right away it must be cooled as quickly as possible. The method is The Two Stage Method: Cool cooked foods from 140 degrees F to 70 degrees F within 2 hours. Then cool from 70 degrees F to 41 degrees F or less in an additional four hours for a total cooling time of six hours. The methods of cooling listed included: placing food in shallow pans, separating the food into smaller or thinner portions and using containers that facilitate heat transfer among other methods. The facility policy also recommended the use of the Cool Down Log to document proper procedure. The Cooling log instructions state to speed up cooling process included .remove meat from hot juice, .do not cover. FSW 1 in an interview on July 24, 2017 at 8:25 am, stated the largest piece of meat on the cutting board was beef and the smaller pieces still in the pan were pork. He further explained he was ready to slice up the beef and pork in preparation for lunch. FSW 1 was asked when the meat was cooked. He stated he was unsure when the meat was cooked because he had not worked the day before. FSW 1 stated he believes the AM cook may have cooked it and the PM cook took it out. FSW 1 was also asked if he took temperatures of any of the meats he was about to cut up. He stated he had not checked the temperature of the meats prior to slicing. The temperature of the beef was 50.8 degrees F while the pork was between 54.6 and 58.2 degrees (Pork 1 - 58 degrees F; 2 - 58.2 degrees F; 3 - 54.6 degrees F). FSW 1 was asked if the facility used a cooling log to monitor temperature of cooked items. He said yes. A review of the facility cooling log revealed no documentation of beef or pork for 7/23/17. The FSD 1 who joined the observation at 8:35 am and FSW 1 were told the temperatures of the meat items. At 8:42 am on 7/24/17, FSW 1 was observed placing sliced pieces of beef in a stainless steel pan and cutting and hand shredding finely cut pieces of beef in another pan. FSW 1 stated the finely chopped was for residents on ground diet. FSW 1 was asked in a concurrent interview what the temperature of the beef should have been before he cut it; he answered about 155 degrees F. At 11:15 am on July 24, 2017, hamburgers were observed cooking on the griddle. FSD 1 stated the facility registered dietitian (RD) had asked that the residents be served hamburgers instead since there was no evidence of proper cooling. FSD 1 stated however that the meat and pork were being reheated for safety. The FSD 1 pointed to pans in the oven. In an interview with RD on July 24, 2017 at 11:16 am, RD explained that she had directed the FSD 1 to dispose of the meat and serve hamburgers instead. The surveyor then informed RD the meats were in the oven and was being reheated for safety. RD returned to the kitchen and stated she stood with the staff to ensure that the meats had been discarded. It is unclear when FSD 1 would have served the meats if the surveyor had not informed RD 1 of the reheating of the meats. She also indicated that chicken was also being prepared for the residents who did not want pork. During trayline observation on July 24, 2017 at 12:10 pm, FSW 2 was observed setting up and getting items including pureed food items for lunch. There was a light brown colored food item in the pan on the steam table. FSW 2 was asked what the item was. He stated it was pureed pork. FSW 1 was asked what he had planned to serve residents on the pureed diet. FSW 1 stated pureed hamburger. FSW 2 was observed preparing the pureed pork in the food processor, adding water to it. He was asked who it was for; he stated it was for the residents on liquefied pureed diet. FSW 2 stated the pork had been pureed before the changes were made to the menu. The surveyor asked FSD 1 what the residents on pureed diet would be eating. FSD 1 said the hamburger. FSW 2 was observed to dish out the liquefied pureed pork two trays for residents on the blenderized pureed diet. These trays were then placed in the food cart for transport to the resident rooms. Observing this, the surveyor asked the food service worker to remove the two food trays form the food cart. FSD 1 was informed about the pork being prepared for residents. She stated that she had asked FSW 2 to prepare pureed hamburgers. FSD 1 was then observed picking up several hamburger pieces and pureeing them in the food processor then handing it to FSW 2. There had been no pureed hamburgers until it was brought to the attention of FSD 1. Thermometer On July 24, 2017 at 8:24 am, prior to the taking of food temperatures of the beef and pork, the surveyor and facility thermometers were calibrated in ice water. The surveyor's thermometer read 31.7 degrees F, while both of the facility thermometers read 20 degrees Fahrenheit. These thermometers were 12 degrees off. According to the United States Department of Agriculture, Food Safety and Inspection Services, a properly calibrated thermometer would read 32 degrees F (+/- 2 degrees) in ice water. In a concurrent interview, FSW 1 stated in response to the question regarding frequency of thermometer calibration that the facility thermometers are calibrated weekly. Review of the facility Weekly Thermometer Calibration Chart for June 2017 showed thermometer calibration daily. It was not clear which one was calibrated as both were out calibration. The employee whose initial was on the log could not be interviewed because according to FSD 1 she was on vacation. The out of calibration thermometer reading of 12 degree is of significance with the cooling of the meat because in the case of the meat, the facility thermometer would have read 41 degrees when it was actually 53 degrees F, a temperature in the food danger zone. The out of calibration was also a factor in the cooking of the hamburger because it resulted in dried out, burnt beef and chicken. FSD 1 failed to ensure the thermometer was calibrated. During cooking of the hamburgers at 12:00 pm, the thermometer used was the same one the surveyors had identified as out of calibration. The thermometer in ice water read 24 degrees F, instead of 32 degrees F. FSD 1 had explained in the concurrent observation and interview that the hamburger patties had been cooked first in the steamer, then browned on the griddle. The hamburgers were completely cooked through when they were taken out of the steamer. Observation of the cooking continued with the hamburgers on the griddle drying out and getting burnt. FSD 1 was asked what the final cooking temperature should be. She stated 155 degrees F. According to the United States Department of Agriculture Food Safety and Inspection Service, the safe minimum internal temperature for ground beef is 160 degrees F. The incorrect answer could have resulted in an undercooked hamburger that could result in food borne illness (cross refer F364). Dish Machine At 9:00 am, observation of the dish washing process revealed domes (a dome shaped plastic cover used to keep food temperatures constant) coming out of the machine with red colored and light brown food stain. FSW 3 was observed stacking and moving to place these domes on a drying cart. When the surveyor pointed to the food stains, FSW 3 returned the domes to be cleaned. FSW 3 was also asked about testing the dish machine to evaluate adequacy of the chemical sanitizer (chlorine). FSW 3 immersed the test strip into the water on the counter. The test strip was blackish blue, approximately 200 parts per million (ppm) according to the color chart on the test strip container. According to the Federal Food Code, the recommended chlorine level for proper sanitization is 50 ppm. FSW 2 was directed to check the level of sanitizer on the dish surface. A test of the dish surface revealed no color change, implying no sanitizer. The FSD 1 who was present during the observation stated the level of sanitizer should be 50 to 100 ppm. A third try revealed a light purple color, about 10 ppm. FSW 4 tested the concentration for the fourth time, it was between 10 and 50 ppm, but not up to 50 ppm. It was not clear how long the problem with the machine may have existed since the food service workers were not testing the sanitizer at the dish surface. The facility document titled Dishmachine Temperature Log (Low Temperature) dated June 2017 was reviewed. It revealed consistent recording of 100 ppm every meal throughout the month for the chemical concentration level. FSD 1 stated she will call the manufacturer. On July 24, 2017 at 1:50 pm, RD 1 provided documentation, Ware Wash Service Report from the repair company dated 7/24/17 indicating there was a problem with the final rinse solenoids and solenoids. The report documented the action taken replaced squeeze tube and a sanitizer delay to dishwasher to have a consistent sanitizer reading 100% of rack. There was another report titled Delivery/Invoice dated 7-3-17 by the chemical supply company, which lists parts/products. The document listed two items, one of then was 4 (quantity) 60-10 rinse jets it was not clear if these were ordered or replaced during the service call. FSD 1 who signed the invoice could not be interviewed about this invoice because she was no longer in the building. Refrigerator At 9:00 am on July 24, 2017, the display outside the (snack) refrigerator behind the trayline showed 37 degrees F. The internal thermometer read 59 degrees F. The surveyor thermometer was used to measure the ambient air temperature of the refrigerator. It revealed the temperature was 60.9 degrees F. FSD 1 was informed at 9:02 am, about the discrepancy between the internal and external thermometers. FSD 1 stated in a concurrent interview she would put a new thermometer and that the refrigerator temperatures were recorded daily at about 4:30 am by FSW 5. The form titled Refrigerator Temperature Monitoring dated July 2017 was reviewed. The form revealed the Snack refrigerator (ref #2) was 32 degrees for July 24, 2017. The form indicated temps should read< or equal 41 degrees F. Further review of the form, showed there was a day the refrigerator was 45 degrees, and there was no corrective action documented for the unusual temperatures as required by the form. At 1:27 pm on July 24, 2017, the temperature of the snack refrigerator was rechecked. It was 60 degrees. The FSD 1 had added a second thermometer inside the refrigerator and both thermometers read 60 degrees Fahrenheit. Inside the refrigerator were salads, egg and tuna sandwiches and yogurt. A check of the sandwiches showed the tuna salad was 52.4 degrees F and egg salad was 57 degrees F. FSW 6 who prepared the tuna salad stated she prepared it that morning and placed it in the refrigerator. The FSD 1 did not make it clear who and what time the sandwiches were prepared. FSD 1 on July 24, 2017 at 1:45 pm, stated the sandwiches are stored in refrigerator left overnight for residents who maybe hungry or have [DIAGNOSES REDACTED]. During trayline service, on July 24, 2017 starting 11: 30 am, food service workers were observed using the sandwiches as substitutes. FSD 1 failed to reassess the refrigerator to ensure it was working properly before food service workers were allowed to store food in it. On July 24, 2017 at 8:33 am, there were items in the walk-in refrigerator that were not labeled. These items were six sandwiches with a 7/24 date, there three other sandwiches with a 7/23 date. There was a tray labeled pureed fruit with a date of 7/23. The type of fruit it was not identified.

Based on observation, interview and record review, the facility failed to prevent an injury from a fall for one sample residents (Resident 1) by failing to: 1. Monitor and provide close and frequent supervision to Resident 1 who had a history of [REDACTED]. 2. Ensure the bed-alarm (a medical device that alerts staff when a patient attempts to get our bed) ordered by the physician was applied and regularly checked for functionality. 3. Ensure that fall prevention measures ordered by the physician were implemented based on a plan of care with the interventions known to all care givers. These deficient practices resulted in a traumatic fall to Resident 1 with a fracture to the left pelvic and left hip hematoma (a localized swelling that is filled with blood caused by a break in the walls of blood vessels due to a trauma). Resident 1 was transferred to the general acute care hospital (GACH), hospitalized for [REDACTED]. Findings: On December 13, 2016, the Department received an Entity Reported Incident (CA 253) of a fall Resident 1 sustained on December 7, 2016. Investigation of the complaint was initiated on December 27, 2016. A review of the admission record indicated Resident 1 was admitted to the skilled nursing facility (SNF) on November 15, 2016, with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-a comprehensive assessment and care screening tool) dated November 22, 2016, indicated Resident 1 had moderately impaired cognitive skills (the act or process of knowing, perceiving), required extensive assistance with one-person physical assist with bed mobility, transfer, toilet use and bathing, and limited one-person assist with walking in room and in corridor. The MDS also indicated the Care Area Assessment (CAA) for fall was triggered indicating a problem that would need further assessment and a development of a care plan. A review of the Fall Risk Assessment (as assessment tool used for screening fall risk) dated November 15, 2016, indicated Resident 1 had a score of 22. According to the fall risk assessment tool, a score of 10 or above represents a high risk for falls. However, the SNF did not develop a plan of care after the resident was identified at a high risk for fall. According to a primary care physician's History and Physical (H&P) Examination record, dated November 15, 2016, Resident 1 had fluctuating capacity to make decisions. The resident was admitted to the skilled nursing facility for Physical Therapy and Occupational Therapy and ongoing medical management. The anticipated length of stay was for one to two weeks. There were written physician orders [REDACTED]. 1. Bedside safety mat on the floor for safety, every shift. 2. Hi-Lo bed (a bed that can be raised and lowered to a desired height), for safety every shift. 3. Tab-alarm (a device that has a pull-string that attaches magnetically to the alarm with garment clip to the resident. When the resident attempts to rise out of their chair or bed the pull-string magnet is pulled away from the alarm this causes the alarm to sound, alerting the caregiver), while in bed for safety every shift. 4. Tab-alarm, while in wheelchair (W/C) for safety every shift. A review of Resident 1's clinical records did not indicate a plan of care that included the above physician orders [REDACTED]. A review of the facility's Policy and Procedure for Fall Management revised on July 2016, indicated a Fall Risk Assessment of score of 10 or above represents a high risk for falls and will require the development of a care plan with interventions designed to prevent falls. A review of another facility Policy and Procedures for Care Planning/Comprehensive, with a revised date October 2016, indicated residents triggered problem areas identified during assessment require further evaluation using Care Area Assessments. Each CAA that triggered must be assessed to evaluate the resident's strenghts, problems, and needs. These assessments provide the foundation upon which the Patient Centered Care Plan is formulated. However, the facility did not follow both policies and procedures that addressed the need for the development of care plan. On January 9, 2017, at 3:15 p.m., during a phone interview, the Director of Nurses (DON) stated in accordance to the facility's policy and resident's assessment information, there should have been a care plan specific for falls initiated when the resident was identified as a high risk for falls. According to the Licensed Nurses Progress note dated December 7, 2016, at 8:00 p.m. Licensed Vocational 1 (LVN 1) responded to a report from Certified Nursing Assistant 1 (CNA 1). When entering the resident's room, LVN 1 found Resident 1 lying on the floor. During an interview on December 27, 2016, at approximately 12 p.m., Registered Nurse 2 (RN 2), who was the Fall Coordinator, stated she was asked to assess Resident 1. According to RN 2, when she checked the bed-alarm after the resident had the fall, the bed-alarm was not turned on. During a phone interview on January 4, 2017 at 9:30 a.m., CNA 2 stated on the night the resident had a fall, she heard Resident 1 calling for help while she was providing care to another resident next to Resident 1's room. When CNA 2 entered Resident 1's room, she found the resident on the floor lying on her back and she reported to LVN 1. CNA 2 stated she did not hear a bed-alarm sound. During a phone interview on January 6, 2017, at 11:45 a.m., LVN 1 stated when she found Resident 1 on the floor, the resident was complaining of pain to her left hip. LVN 1 stated she did not hear the bed alarm prior to finding the resident on the floor. When asked who was responsible for ensuring the bed alarm was in working order, LVN 1 stated all nursing staff members are responsible for checking the bed alarms. A review of the Situation, Background, Assessment, Recommendation form (SBAR- a format used for communication between members of the health care team) dated December 7, 2016, at 8:00 p.m. indicated LVN 1 responded to a report by CNA 1 that Resident 1 had a fall. When LVN 1 entered the resident's room, Resident 1 was lying on her back on the floor. RN 4 was paged and came and assessed the resident. Resident 1 complained she could not move her lower extremities due to a pain rated at 8/10 (10 being the most severe pain) to the left hip. According to the pain assessment tool, a pain level rating of 8/10 meant severe pain. The physician was notified and orders were obtained to administer pain medication (Norco tablet 5-325 milligrams) and to transfer Resident 1 to the GACH emergency room for further evaluation. A review of the Nursing Home to Hospital Transfer Form dated December 7, 2016, 8:12 p.m., indicated Resident 1 was transferred to the GACH due to an injury from a fall. According to the transfer form, Resident 1 had a pain rated at 10/10 (very severe pain). A review of the History and Physical (H&P) examination record obtained from the GACH dated December 8, 2016, indicated on December 7, 2016, Resident 1 was admitted to the GACH Emergency Department, and was diagnosed with [REDACTED]. According to the H&P, Resident 1 also had left hip hematoma due to internal bleeding caused by the injury. Resident 1 was admitted to the GACH on December 8, 2016, and was treated for [REDACTED]. Resident 1 was hospitalized for [REDACTED]. On December 27, 2016, at approximately 11:30 a.m., in the presence of RN 3, Resident 1 was observed awake in bed. Resident 1 was not able to recall the details of the fall during the interview. On December 27, 2016, at approximately 11:00 a.m., during an interview RN 1 stated in order to prevent another fall, Resident 1 upon readmission to the SNF was placed in the Falling Star Program (a system in which a resident at risk for fall is identified and closely monitored) because of the resident's history of a fall with a fracture. RN 1 stated Resident 1's room was changed to be closer to the nurse's station, in order to provide close supervision and monitoring. RN 1 was unable to provide a care plan that was developed for the prevention of falls, prior to Resident 1's fall.

Based on observation, interview, and document review, the facility failed to establish a system to ensure there were adequate safeguards in place to ensure: 1. Controlled medications were locked and stored as indicated in the facility's policy and procedure with limited access to authorized licensed staff to minimize potential abuse, misuse, or diversion of controlled medications 2. Safe medication use for residents, when Fentanyl patches (potent long-acting narcotic pain medication (patch) applied to the skin) were available for use in the MedLocker/ Emergency MedCart (an automated dispensing cabinet (ADC) containing medications and supplies for an immediate use during a medical emergency According to Food and Drug Administration (FDA) black box warning (the strongest warning that FDA requires, and signifies that medical studies indicate that the drug carries a significant risk of serious or even life threatening adverse effects) inappropriate use of Fentanyl patches have been reported to cause severe and sometimes fatal breathing problems. 3. All the medications were removed from the MedLocker and reviewed for therapeutic appropriateness to assure accurate dispensing and administration, which had the potential to result in unrecognized medication errors (wrong patient, wrong medication, or wrong dose) or inconsistent administration of medication to residents. 4. Establish and implement a system to ensure security and accurate accountability of all medications in sufficient detail to enable an accurate reconciliation from receipt and administration, to disposition; and to direct the usage of the MedLocker to ensure only prescribed medication for a resident was removed after pharmacist review. 5. Ensure that controlled medications were periodically reconciled for accuracy by failing to ensure that there would be no discrepancy between the controlled drug inventory record and the Medication Administration Record [REDACTED]. These deficient practices had the potential to cause drug diversion (illegal distribution or abuse of prescription drugs or their use for unintended purposes). On June 20, 2016, at 8 p.m., the facility administrator, director of nursing (DON), Quality Assurance Nurse, and the Minimum Data Set Coordinator (MDSC) were verbally notified of the immediate jeopardy (IJ) situation regarding the failure to have control of all medications in the MedLocker in a manner to monitor medication supply available to the resident, monitor medication to readily identify loss, and diversion of controlled medications and review appropriateness of use of the MedLocker/Emergency MedCart for not only emergency medications but also for more than just the first used dose for the residents when routine medications were unable to be delivered in a timely manner to the facility. The facility provided an acceptable immediate plan of action on June 20, 2016, at 9:30 p.m. The remedy for the abatement of the IJ included: Immediate discontinuation of use of the MedLocker/Emergency MedCart as soon as possible (Scheduled for morning of June 21, 2016). Access to MedLocker/Emergency MedCart would be disabled for all users until pick-up. The Computer used to access the MedLocker/Emergency MedCart would be removed. The pharmacy would replace the MedLocker/Emergency MedCart with Emergency Kits (e-Kit). Emergency Kits would be delivered on June 20, 2016. Back-up local pharmacy was to be used for emergency situations and in anticipation that the ordered medications would not be delivered within four hours, to ensure timely delivery of medications. The Medical Director would be notified of the discontinuance of the use of MedLocker/Emergency MedCart. On June 21, 2016, at 8:15 p.m., the administrator and the DON were verbally notified that the Immediate Jeopardy was lifted. Findings: a. On June 14, 2016, at 12:55 p.m., during a medication area observation and interview with a Registered Nurse (RN 2) on Nursing Station 1, a MedLocker and an emergency MedCart was observed inside the nursing office. RN 2 stated the MedLocker/Emergency MedCart (MedLocker) serves all the facility's five nursing stations as an emergency kit (E-kit). RN2 stated it was the RN supervisor's and/or the IV (intravenous) nurse's responsibility to place multiple dose (multi-dose) bubble packs and vials (injectable medications) of medication received from the pharmacy into the MedLocker. Observed on the counter was a bag that contained a bubble pack of medication. RN 2 stated the bag contained 16 tablets of Oxycodone 5 milligrams (mg) and acetaminophen 325 mg ((Percocet 5/325 mg) a strong controlled medication for pain). RN 2 stated RN 1 received the medication from the pharmacy's delivery driver earlier in the morning (on June 14, 2016) and gave it to her to place into the MedLocker. RN 2 stated two nurses were not required to place or remove non-controlled or controlled medications from the MedLocker. RN 2 stated a second nurse would be required to waste (destroy) a medication or to verify a medication count discrepancy. On June 17, 2016, at 3:32 p.m., during an interview, in the presence of RN 2 and RN 5, RN 4 stated, Each licensed nurse in the facility had a code to access the MedLocker for removal of controlled and non-controlled medications for residents' use. RN 4 stated the RNs do not do a controlled medication audit of the MedLocker during the daily shift changes, in which the outgoing RN endorses (transfer responsibility) the key to the MedLocker to the oncoming RN. On June 20, 2016 at 10:15 a.m., during an interview, the director of nursing (DON) stated the Medlocker was for emergency drugs. The DON provided a medication list for the MedLocker that was dated December 12, 2014, the DON stated, This might be what is in the MedLocker. The DON stated the pharmacy does not provide a discrepancy report and she stated she had never seen one. The DON stated the dispensing pharmacist does not come to the facility to physically check the MedLocker. The DON also stated the consultant pharmacist does not check the MedLocker either, as it was not documented on her monthly consultant pharmacist ' s report. On June 20, 2016 at 10:40 a.m., during an interview, in the presence of the DON, RN 3 stated, If we do not have a medication, during a medication pass (MedPass) we will call the pharmacy and remove the medication from the MedLocker. If the medication is in the MedLocker we will notify the charge nurse and they will give the medication. There is no verification from the pharmacy that the medication order has been reviewed by the pharmacist prior to removal from the MedLocker or prior to the medication being administered to the residents. That would be a lot of medications for the pharmacist to review. RN 3 stated the MedLocker was used commonly for routine medication daily to meet the needs of the residents in the facility and may be accessed by everybody, as long as they had an access code. On June 20, 2016 at 11:50 a.m., the DON provided a list of licensed nurses that had active access codes for the use of the MedLocker. While reviewing the list the DON identified licensed nurses that were no longer employed by the facility The DON stated there were 95 non-employees that should have been removed from the system. The DON could not provide a report to indicate the last time the MedLocker had been audited by a. The DON stated some of the resigned employees had since returned to work part-time or on call and would use their original access code to use the MedLocker. The DON further stated some of the employees that no longer worked for the facility would occasionally come to visit residents. However 95 non-employees retained access codes to the MedLocker which increased the risk for abuse or drug diversion. On June 20, 2016 at 1:15 p.m., in the presence of the DON, RN 2 was observed sitting with the door opened in the nursing office. RN 2 stated the MedLocker computer system was down, in which the pharmacy was unable to view the MedLocker transactions. RN 2 stated the pharmacy had been notified and was working remotely to fix the computer. On June 20, 2016 at 3:22 p.m., RN 3 stated there were 93 licensed nurses that were no longer employed at the facility with active access codes to the MedLocker. RN 3 stated and their names and codes would be faxed to the pharmacy to be manually removed from the MedLocker. On June 20, 2016, at 3:31 p.m., during an interview the DON stated the facility's dispensing pharmacist (Pharmacist 1) oversees the MedLocker. On June 20, 2016 at 3:50 p.m., during a telephone interview in the presence of the DON, Pharmacist 1 stated the MedLocker was used for first dose, like an E-kit, but had a lot more medications than a traditional E-kit. Pharmacist 1 stated the pharmacy audits the Medlocker twice a day remotely and a consultant nurse should provide a monthly report to the DON or the administrator. During the telephone interview with Pharmacist 1, the DON told Pharmacist 1 she had not received any reports from the pharmacy consultant nurse. On June 20, 2016 at 3:50 p.m., Pharmacist 1 during an interview stated, the pharmacy may take more than four hours to deliver residents medications to the facility. Pharmacist 1 stated he was aware as a result the facility ' s nurses would remove more than the initial dose of medication from the MedLocker for residents. A review of the facility ' s policy titled, Drug Ordering and Receipt, indicated: · Medications are received from the pharmacy in a timely fashion. · Medications that are ordered Now or Stat, which are not available in the facility ' s emergency drug supply are available within one hour during normal pharmacy hours · Orders written after hours are available within two hours · Orders written for resident comfort will be available within four hours. On June 20, 2016, at 7:40 p.m., during a telephone interview pharmacist consultant (Pharmacist 2) stated she does not have access to the Medlocker or the transaction records. A review of the facility's undated policy and procedure titled, Stocked MedLocker Medications, indicated: · The Pharmacy determines the contents of this supply in conjunction with the Facility Administrator, Medical Director and QA (Quality Assurance) Committee · All medications in the MedLocker will be inspected monthly · The Pharmacy requires all medication orders to be faxed to the pharmacy prior to use of medication from the MedLocker · The user must remove only those medications that were ordered for the resident once the MedLocker door opens · Removal of additional medication will result in inventory discrepancies A review of the facility's undated policy and procedure titled, Policy and Procedures for Pharmaceutical Services - Controlled Drugs, indicated, Drugs with high abuse potential will be subject to special handling, storage, disposal, and record keeping .Controlled drug records are physically counted at the change of each shift (on-coming nurse to count, off-going nurse to review the records for accuracy). A review of the facility's policy and procedure for the MedLocker, revised 2011, titled, Performing shift counts, indicated, At the end of each count, print the Shift Count report. The report requires two signatures, one by the person performing the count and the second by the witness. Note: A witness is always required for a shift or narcotic (controlled medications) count. A review of the facility's undated policy and procedure titled, Policy and Procedures for MedLocker, indicated, Inactive Users access privilege- The Director of Nursing or MedLocker Super User will inactivate users who are no longer employed by the facility . A pharmacist reviews the discrepancy report. Any discrepancy is reported to the facility Director of Nursing and the pharmacy manager/director. A review of a Health and Safety Code Section 1261.6 titled, Automated Drug Delivery Systems, provided by the facility, included but not limited to the following: · (d)(1) Policies and procedures shall define access to the automated drug delivery system and limits to access to equipment and drugs. · (f)(6) After the pharmacist reviews the prescriber's order, access by licensed personnel to the automated drug delivery system shall be limited only to drugs ordered by the prescriber and reviewed by the pharmacist and that are specific to the patient. · (g)(3) Review of the drugs contained within, and the operation and maintenance of, the automated drug delivery system shall be done in accordance with law and shall be the responsibility of the pharmacy. The review shall be conducted on a monthly basis by a pharmacist and shall include a physical inspection of the drugs in the automated drug delivery system, an inspection of the automated drug delivery system machine for cleanliness, and a review of all transaction records in order to verify the security and accountability of the system. b. On June 20, 2016 at 1:15 p.m., an inspection of the MedLocker was conducted with a registered nurse (RN 2), in the presence of the director of nurses (DON), the Medlocker was observed to include, but not limited to the following medications: [REDACTED] · Fentanyl 25 microgram (mcg)/hour (hr)) patches (quantity of 10) in a drawer located under the slots and there were no cautionary labels or warnings outside the MedLocker or on the Fentanyl box. · Fentanyl 75 mcg/hr patches (quantity of five) in a drawer located under the slots and again there were no cautionary labels or warnings outside the MedLocker or on the Ziploc bag that contain the loose Fentanyl patches. · Oxycodone 5 mg tablets in slot 112 · Oxycodone 10 mg tablets in slots 11, 88, and in a drawer located under the slots. · Hydromorphone 2 mg tablets in slots 34, 77, and 108 During the inspection of the MedLocker and a concurrent review of the inventory report, dated June 20, 2016, RN 2 confirmed that five medications found in the MedLocker did not match with the report. The medications were: · Fentanyl 75 mcg/hr patches quantity of 5 in the MedLocker drawer under the slots. · Fentanyl 25 mcg/hr patches indicated a quantity of 5 patches not 10 as observed in the MedLocker. · Oxycodone 5 mg tablets · Oxycodone 10 mg tablets · Hydromorphone 2 mg tablets On June 20, 2016 at 1:39 p.m., after reviewing the medication list for the MedLocker, dated 12/12/14, in the presence of the DON, RN 3 stated he did not see Hydromorphone tablets listed and that the pharmacy has to update the MedLocker medication list to what is actually in stock. The facility ' s MedLocker inventory list did not include all medications that were in the MedLocker and failed to include three different Schedule II opioid medications (controlled substances that have the highest potential for abuse). On June 20, 2016 at 3:50 p.m., during a telephone interview, in the presence of the DON, Pharmacist 1 stated he was unaware the inventory report for the MedLocker did not include Oxycodone, Hydromorphone tablets, or the correct quantity for the two different strengths of Fentanyl patches that were observed in the MedLocker drawer. Pharmacist 1 stated Fentanyl patches could be considered an emergency medication and they should have been counted. Pharmacist 1 stated the MedLocker has glitches and they no longer have technical support for the computer system. Pharmacist 1 stated he does not do a physical inventory of the MedLocker in the facility and the medications in the MedLocker have not gone through a review committee for approval. According to DailyMed the U.S. Food and Drug Administration (FDA) approved manufacturer labeling, Fentanyl transdermal system (brand name: Duralgesic patch) contains a high concentration of a potent Schedule II opioid, Fentanyl. Schedule II opioid substances have the highest potential for abuse and associated risk of fatal overdose due to respiratory (breathing) depression. Fentanyl is 80 to 100 times more potent than morphine. In its August 2009 issue titled, Fentanyl PATCHES CONTAIN A VERY STRONG PAINKILLER, SO MISUSE CAN BE DEADLY, the Institute for Safe Medication Practices (a nationally recognized institution focusing on safe medication practices) indicated, Fentanyl is a very powerful pain reliever. It is only supposed to be prescribed for people with long-term (chronic) pain who have already been taking high doses of prescription opioid (narcotic) pain medicine for at least a week. Serious harm or death has resulted when this drug was taken in high doses by people who have not been taking other prescription opioid pain medicine for 7 days or more. According to the maker of the Fentanyl patch, the following are the U.S. Food and Drug Administration (FDA) boxed warning (strongest warning) and indication for use: The FDA has required a boxed warning to be included in the literature accompanying each package of Fentanyl patch. It indicates, Serious, life-threatening, or fatal respiratory depression may occur with use of DURAGESIC, even when used as recommended . Because of the risk of respiratory depression, DURALGESIC is contraindicated (should be avoided; inadvisable) . in non-opioid tolerant patients . Fentanyl patch is indicated for the management of pain in opioid tolerant patients, severe enough to require daily, around-the-clock, long-term opioid treatment and for which alternative treatment options are inadequate. Patients considered opioid-tolerant are those who are taking, for one week or longer, at least 60 mg of morphine daily, or at least 30 mg of oral Oxycodone daily, or at least 8 mg of oral Hydromorphone daily, or an equianalgesic (producing the same degree of pain relief) dose of another opioid. The patches are NOT to be used to treat sudden, occasional or mild pain, or pain after surgery. According to DailyMed, Oxycodone, like other opioids (Oxycodone, morphine, Hydromorphone, and Fentanyl), have been diverted for non-medical use. Careful record-keeping of prescribing information, including quantity, frequency, and renewal requests is strongly advised. Respiratory depression is the chief hazard in elderly or debilitated patients . Proper assessment of the patient, proper prescribing practices, periodic reevaluation of therapy, and proper dispensing and storage are appropriate measures that help to limit abuse of opioid drugs. According to DailyMed, appropriate use of the Hydromorphone hydrochloride tablets must be decided by careful evaluation of each clinical situation. Hydromorphone Hydrochloride Tablets, USP contain Hydromorphone, which is a potent Schedule II controlled opioid agonist. Schedule II opioid agonists, including morphine, Oxycodone, and Fentanyl, have the highest potential for abuse and risk of producing respiratory depression that might result in death. A review of a Health and Safety Code Section 1261.6 titled, Automated Drug Delivery Systems, provided by the facility, included but not limited to the following: · (g)(3) Review of the drugs contained within, and the operation and maintenance of, the automated drug delivery system shall be done in accordance with law and shall be the responsibility of the pharmacy. The review shall be conducted on a monthly basis by a pharmacist and shall include a physical inspection of the drugs in the automated drug delivery system, an inspection of the automated drug delivery system machine for cleanliness, and a review of all transaction records in order to verify the security and accountability of the system. c. On June 17, 2016, at 3:32 p.m., during an interview, in the presence of RN 2, RN 5 and RN 6, RN 4 stated, The facility do not need to fax a physician's orders [REDACTED]. RN 5 stated the pharmacist does an audit of the MedLocker only when there was a medication discrepancy. RN 5 stated if the pharmacy does an audit it was not given to them (RNs 2, 4, 5 and 6), but provided a report to the director of nursing (DON) or administrator. A review of the facility's MedLocker Emergency Kit Usage Report, dated June 1, 2016, indicated six doses of Hydromorphone 2 mg was removed from the MedLocker for RSR 51 as follow: May 14, 2016 at 4:56 a.m., dispensed by a licensed vocational nurse (LVN 19) May 14, 2016 at 9:06 a.m., dispensed by LVN 11 May 14, 2016 at 1:18 p.m., dispensed by LVN 11 May 14, 2016 at 6 p.m., dispensed by LVN 18 May 14, 2016 at 9:30 p.m., dispensed by LVN 4 May 15, 2016 at 1:23 a.m., dispensed by LVN 19 A review of the facility's MedLocker Drug Supply Log Sheet that indicated removal and administration of Hydromorphone 2 mg for RSR 51 documented that four doses not six were removed from the MedLocker: May 14, 2016 at 4:56 a.m., one tablet dispensed May 14, 2016 at 9:06 a.m., one tablet dispensed May 14, 2016 at 1:18 p.m., one tablet dispensed May 15, 2016 at 1:23 a.m., two tablets dispensed, with half a tablet being wasted There was no documentation on the facility's MedLocker Drug Supply Log Sheet or the pharmacy's MedLocker Emergency Kit Usage Report to account for or to explain the discrepancy for the May 14, 2016 ' s 6 p.m. and 9:30 p.m. documented dose removal and administration of Hydromorphone for RSR 51 by LVN 18 and LVN 4 respectively. On June 20, 2016 at 10:15 a.m., during an interview, the DON stated the Medlocker was for emergency drugs. The DON stated the pharmacy does not provide a discrepancy report and she stated she had never seen one. The DON stated the dispensing pharmacist does not come to the facility to physically check the MedLocker. A review of the facility's Policy and Procedures for MedLocker, revised 2011, indicated, All discrepancies are investigated within seventy-two (72) hours of identification of the discrepancy. A pharmacist reviews the discrepancy report. Any discrepancy is reported to the facility's Director of Nursing and the pharmacy manager/director. However, neither the facility nor the pharmacy documented a discrepancy that was observed from May 14, 2016 that was observed over 30 days later on June 20, 2016. d. On June 17, 2016 at 3:47 p.m., in the presence of RNs 4, 5, and 6, RN 2 demonstrated the process of removing a medication from the MedLocker for a resident. RN 2 was observed randomly selecting a resident (RSR 50) from Nursing Station 3 and stated the resident does not have an order on file for Hydrocodone with acetaminophen 10 mg/325 mg ((Norco), a controlled medication for pain). RN 2 was able to input RSR 50's name and remove a multi-dose controlled medication bubble pack from the MedLocker labeled for Norco. There was no prompt for a second nurse required for the removal of the Norco, although RSR 50 did not have a physician's orders [REDACTED]. A review of the MedLocker/Emergency Kit Item Usage Detail Report, dated June 20, 2016, with a print time of 12:12 p.m., indicated on June 17, 2016, timed at 3:47 p.m., one tablet of Norco was dispensed to RSR 50 by RN 2 with the facility ' s medical director documented as the prescribing physician. The MedLocker/Emergency Kit Detail Report failed to accurately document that RN 2 did not dispense the medication to RSR 50, but had returned the Norco medication to the MedLocker on June 17, 2016. A Review of the facility provided Health and Safety Code Section 1261.6 titled, Automated Drug Delivery Systems, included but not limited to the following: · (d)(1) Policies and procedures shall define access to the automated drug delivery system and limits to access to equipment and drugs. · (f) (6) After the pharmacist reviews the prescriber's order, access by licensed personnel to the automated drug delivery system shall be limited only to drugs ordered by the prescriber and reviewed by the pharmacist and that are specific to the patient. e. According to the admission record, RSR 38 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of RSR 38's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated April 17, 2016, indicated the resident usually made self-understood, was able to understand others, required limited one-person assist with transfer, dressing, personal hygiene, bathing, and moving between locations in her room and the adjacent corridor on the same floor, and if in a wheelchair, self-sufficiency once in the chair. The MDS also indicated the resident was not steady, was only able to stabilize with staff assistance when moving from seated to standing position, moving on and off toilet, and transferring between bed and chair or wheelchair. A review of the physician order [REDACTED]. 1. Clonazepam 0.5milligram (mg) by mouth daily at bedtime manifested by over concern about health dated April 29, 2013 (discontinued) 2. Clonazepam 0.25 mg by mouth at bedtime for anxiety manifested by over concern about health dated January 15, 2015 (discontinued February 1, 2016) 3. Clonazepam 0.25 mg by mouth at bedtime for excessive restlessness related to anxiety disorder due to known physiological condition dated February 1, 2016 (discontinued February 20, 2016) 4. Clonazepam 0.25 mg by mouth daily at bedtime manifested by over concern about health related to anxiety disorder due to known physiological condition dated February 20, 2016 According to the United States National Library of Medicine, Clonazepam is a schedule IV (low potential for abuse) controlled substance which may cause convulsions, psychosis, hallucinations, behavioral disorder, tremor, abdominal, and muscle cramps if discontinued abruptly. Adverse reactions include, but are not limited to Confusion, depression, hallucinations, slurred speech, shortness of breath, palpitations, urinary retention, muscle weakness, pains, dehydration, and anemia. (https://dailymed.nlm.nih.gov) A review of the controlled medication record and the MAR indicated [REDACTED] 1. On [DATE], a dose of Clonazepam was recorded as administered to the Resident. However, the resident was on a therapeutic leave to the GACH on this date and the disposition of one dose of Clonazepam was unknown. A review of the census list indicated that RSR 38 was transferred out to the General Acute Care Hospital (GACH) on January 29, 2016, and returned to the facility on [DATE]. 2. On February 3, 5, 6, and 7, 2016, The MAR indicated [REDACTED]. On June 20, 2016 at 5: 45 p.m., during an interview, licensed vocational nurse (LVN) 3 stated that she reviewed RSR 38's clinical record and could not find any clonazepam record between February 2 and February 7, 2016. 3. On February 2, 2016, the MAR indicated [REDACTED]. 4. On February 9, 2016 the space was left blank on the MAR. The controlled drug indicated the medication was administered. 5. On February 10, 2016, the controlled medication indicated that three doses of clonazepam were administered which did not follow the physician's orders [REDACTED]. On June 21, 2016 at 5:47 p.m., during an interview, LVN 13 stated she meant to write February 10, 11, 12, 2016 and it was an error in documentation. 6. On February 19, 2016 the MAR indicated [REDACTED]. During an interview with LVN 3 on June 20, 2016 at 4 p.m., she stated that she reviewed RSR 38's clinical record and could not find any documented evidence that clonazepam was disposed and that a second licensed nurse witnessed the disposition of the medication. 7. On April 1, 2016, a dose of clonazepam was recorded as administered to the Resident on the MAR. However, there was no documentation for this date on the controlled medication record. 8. On May 15, 2016, a dose of clonazepam was recorded as administered to the Resident on the MAR. The controlled medication record, however, did not have that date recorded. 9. The controlled medication record indicated that the resident received two doses of clonazepam on June 15, 2016 while the MAR indicated [REDACTED] A review of the facility's undated policy and procedures titled Med Pass under Section V, Disposal of medications, syringes, and needles, indicated the following: 1. The nurse has to enter the following information on the narcotic drug record immediately after a dose of a controlled drug is administered: date and time of the administration, dose administered, and the signature of the nurse that administered the dose. 2. If a dose is prepared for the administration, but is refused or held for any reason, the dose must be destroyed. Signatures of two licensed nurses are required on the narcotic drug record for that dose.

Based on observation, interview, and record review, the facility failed to ensure that the residents' environment was free of accidents hazard for eight out of 30 sample residents (Residents 5, 6, 11, 12, 14, 23, 28, 29) and two random sample residents (RSRs 35, 38) by failing to: 1. Ensure that the physical therapist observed safety precautions while ambulating Resident 23 in order to prevent an injury from a fall. Resident 23 had a fall while Physical therapist 1 (PT 1) preformed therapeutic exercise and gait training ambulation and sustained a fracture of the left hip. 2. Ensure that PT 1 followed the facility's policy to apply gait belts during gait training ambulation and access to a wheelchair to prevent the resident from falling to the floor and sustain an injury. 3. Implement safety measures and precautions as directed on the residents' plan of care, the physician's orders [REDACTED]. 4. Ensure that the medication cart that contained miscellaneous medications and parked at the doorway was locked and protected when unattended in order to prevent the potential accident hazard if accessed by residents and unauthorized person(s). These deficient practices resulted in fracture of Resident 23's left hip with severe pain due the fracture that required a transfer to the general acute care hospital (GACH) and a surgical repair of the fractured bone under a general anesthesia. Resident 23 was hospitalized from May 31, 2016, to June 6, 2016 and discharged to the skilled nursing facility. Findings: a. A review of the Admission Record, Resident 23 was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Admission Minimum Data Set (MDS a comprehensive assessment tool) dated May 9, 2016, indicated Resident 23 was cognitively intact and had the ability to make her needs known and understood others, required extensive assistance during activities and required staff to provide weight-bearing support/assistance with activities of daily living (ADLs), required two persons physical assist with transfers (moving between surfaces to from: bed to standing position), walking in her room, had un-steady gait while standing and walking, had a weight and height of 182 pounds and was 5 feet 4 inches respectively. The Care Area Assessment (CAA) Summary was triggered for falls indicating the need for further assessment and the development of a plan of care. According to Fall Risk Assessment, dated April 26, 2016, Resident 23 had a total score of 14 which was considered in a High Risk Category due to gait and balance problems while standing and decreased muscle coordination. A review of Resident 23's Physical Therapy Plan of Care dated April 26, 2016, indicated the resident's current Level of Function/Short Term Goal(s): Resident unable to use front wheeled walker and unable to perform safe ambulation at this time due to generalized pain and decreased functional activity tolerance. The goal of the care plan indicated Resident 23 will progress to gait training with front wheeled walker for 25 feet and moderate assistance with two people and verbal instruction/cues in order to increase level of independence. The care plan indicated the goal would be achieved by May 2, 2016. A review of Resident 23's Plan of Care dated May 26, 2016, titled Decreased functional mobility, decreased overall strength and balance, high risk for falls. The care plan had a goal to increase mobility, increase overall strength and balance and decrease fall risk. The interventions included, gait training to increase mobility and increase level of independence to be performed by a physical therapist. The target date to achieve the goal was September 5, 2016. A review of Resident 23's physician's orders [REDACTED]. A review of Resident 23's SBAR (Situation, Background, Assessment and Recommendation) report dated May 31, 2016 at 6:49 p.m., indicated Resident 23 had a change of condition due to a fall while ambulating with physical therapy. Under licensed Nurses Assessment: Resident 23 was assisted to the floor by the Physical Therapist (PT). Resident 23 complained of a pain to the left leg rated at 10 out of 10 (severe pain) on a pain scale of 0-10/10. Resident 23 stated she fell while walking with PT just went down with the PT assistance. At 7 p.m., the physician was notified and an order for [REDACTED]. A review the Medication Administration Record (MAR) dated, May 31, 2016, at 7 p.m., indicated Resident 23 was medicated with Norco (a strong pain medication) for severe pain. According to the facility's Licensed Nurses Progress Notes dated May 31, 2016 at 10: 39 p.m., an x-ray was done. The x-ray result that indicated Resident 23 had a fracture of the left hip, was provided to a physician, and an order to transfer the resident to the general acute care hospital (GACH) was obtained at 10:58 p.m. On the same date at 11:20 p.m. On June 21, 2016 at 12:50 p.m., Resident 23 was observed in bed. During an interview Resident 23, stated while she was ambulating with the physical therapist she went down to the floor from a standing position and stated . I broke my left hip. Resident 23 stated she was in a lot of pain, specially when the x-ray technician took multiple x-rays. During the interview Resident 23 when asked stated she was not wearing a transfer/gait belt at the time of the ambulation but the Physical Therapist applied the gait belt to lift her up from the floor after the fall. Resident 1 stated, this was first fall she had in the facility and she had to have a hip surgery. On June 21, 2016 at 4:30 p.m., during an interview, PT 1 stated he did not use a gait transfer belt on the resident. PT 1 stated the resident fell to the floor during therapeutic ambulation. According to PT 1 he had to use a gait belt to lift Resident 23 from the floor after the resident had the fall because the resident was heavy (182 pounds). When asked, PT 1 stated during the ambulation, he was behind Resident 23 by himself and there was no one following them (PT 1 and Resident 23) with a wheelchair to be used as needed if the resident got tired and wanted to sit and rest. PT 1 it is the judgement of the Physical Therapist to use a two-person assist and a third person who can push the wheelchair behind the Resident. On June 21, 2016 at 11:23 a.m., RSR 40, who was Resident 23's former roommate during an interview stated on May 31, 2016, at approximately at 5 p.m., she heard PT 1 encouraging Resident 23 to walk even though she did not feel like walking. Resident 23 agreed to walk. During the walk, PT 1 had a belt (gait belt) over his right shoulder but he did not apply the belt to resident 23. When asked she also stated PT 1 did not have a wheelchair with him behind Resident 23 while he assisted Resident 23 walking to be used when needed. RSR 40 stated Resident 23 bumped up against her bedside table where I was sited having a dinner. PT 1 was behind Resident 23 and she saw her falling down to the floor. PT 1 then took off the gait belt from his shoulder and applied it on Resident 23 to lift her up from the floor. Then with the help of others staff members, Resident 23 was assisted back to bed. RSR 40 also stated she heard Resident 23 ask PT 1, Weren't you supposed to have a wheelchair behind me and put the belt on me .? According to RSR 40 she heard PT 1 responding . Yes I was supposed to. On June 22, 2016 at 1:33 p.m., during an interview, the Administrator, stated Resident 23 had a fall and sustained an injury due to Physical Therapist 1 improper handling of Resident 23 during ambulation. According to the administrator, PT 1 was terminated immediately on June 20, 2016, because Resident care and safety is our (the facility's) top priority, and we are taking all the necessary steps to insure a incident like this does not happen again. The facility will continue to train and in-service the physical therapist and other staff members including RNA's (Restorative Certified Nursing Assistants) on a regular basis. A review of the facility's Incident Report, dated May 31, 2016 at 7 p.m., indicated Resident 23 had a fall while being ambulated by the Physical Therapist. According to the incident report the Charge Nurse Investigation Statement indicated the resident had a fall and one of the casual factors identified was Care-giver technique (the use of gait belts and to contact guard assist (CGA-hand on the resident) during Physical Therapy ambulation. The report also indicated Resident 23 was provided Passive Range of Motion (PROM) to left leg that was painful. Resident 23 complained of a pain to the left leg rated at 10 out of 10 (severe pain) on a pain scale of 0-10/10.under Action taken to prevent reoccurrence of this incident was the use of a two-persons ambulation. Under Witness Statement: Physical Therapist 1 (the PT 1 involved in the fall with Resident 23). On May 31, 2016, at 6 p.m., assisted and witness fall in Resident's room. A review of the facility's undated policy and procedure titled, Gait Training, indicated gait belts will be utilized as indicated by the Physical Therapist (P.T). A review of the Emergency Department Admission Record dated June 1, 2016 at 1:26 a.m., indicated Resident 23 was brought to the emergency room with chief complaint was left hip pain due to an injury she sustained from a fall resulting in fracture of the proximal (nearer to the center of the body) left femur. Resident 23 was admitted to the hospital with [REDACTED]. A review of the Operative Report, dated June 1, 2016, indicated Resident 23 had a surgical procedure known as ORIF of the left hip (ORIF- is an open reduction hip fracture surgery, with internal fixation) under general anesthesia to repair the fractured hip. A review of the literature indicated a surgery procedure performed under a general anesthesia has post-operative risk and complications that included bleeding, infection, heart attack, pneumonia, kidney failure (during or after an operation), pulmonary embolism (blood clots in the lungs). In addition, postoperative patients may feel weak, particularly with voluntary breathing. As a result, portion of the lung may collapse and put the patient at risk for low blood oxygen unless they are provided breathing treatment with incentive Spirometer (a plastic device with a mouthpiece to move the piston upwards trying to reach a goal height for the piston. Savel, Richard H. Postoperative Care. Hospital Medicine, 2nd Ed. Philadelphia: Lippincott, Williams, & Wilkins, 2005. 261-269). According to the discharge summary, Resident 23 was hospitalized from May 31, 2016 to June 6, 2016 and discharged to the skilled nursing facility. b. According to the admission record, Resident 11 was originally admitted to the facility on [DATE] and was readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 11's physician order [REDACTED]. A review of the Minimum Data Set (MDS- a standardized comprehensive assessment screening tool) dated May 19, 2016, indicated that Resident 11 had moderately impaired cognitive skills for daily decision making, and needed extensive assistance with bed mobility, transfer, dressing, eating, toilet use, personal hygiene, and was totally dependent on staff for locomotion off unit with one person physical assist. The MDS also indicated Resident 11 had two falls since readmission to the facility. Resident 11 used a walker and a wheelchair for mobility with the assistance of staff. A review of the Care Plan dated May 4, 2016, indicated that Resident 11 was at a high risk for falls due to a history of multiple falls and weakness. The interventions included the the use of low bed, tab alarm in bed and in wheelchair and bedside safety mat. Another plan of care dated May 11, 2016, indicated to use a blue armband on the resident for alerting staff of resident's increased risk for falls, which was not the color the resident was supposed to use as indicated in the facility's Fall Prevention Program policy and procedure. According to the policy, residents assessed at a high risk for falls will be identified with a yellow armband. A review of Fall Risk Assessment with an effective date of May 30, 2016, indicated that Resident 11 had a score of 19 placing the resident in the high risk for falls category. A review of a list of resident who were placed on the Falling Star program (a means to identify residents at risk for falls) dated June 13, 2016, indicated Resident 11 was on the at risk list and should have had a yellow armband and a yellow star on name plate for alerting staff of resident's fall risk. On June 14, 2016, at 12:15 p.m., during observation in Resident 11's room was noted the resident had a low-bed with floor mat placed only right side and the resident did not have a yellow armband identifier as indicated on the physician' order and the facility; policy. On June 14, 2016, at 1:15 p.m., during an interview, LVN 9 (Licensed Vocational Nurse 9) stated that the facility did not have enough floor mats, and that the facility had ordered more on June 14, 2016. She further stated that Resident 11 should have had a floor mat placed on both sides of her bed. On June 16, 2016 at 11:40 a.m., during an interview, LVN 1 stated, Resident 11 was in the falling start program and needed to have a yellow arm band as identifier. The care plan should be updated to yellow arm band instead of blue. LVN 1 further stated that the floor mat should have been on both sides of the residents bed due to resident being at risk for increased falls. On June 20, 2016 at 10:50 a.m., during an interview, RN 2 (Registered Nurse 2) stated that Resident 11 had an actual fall on March 1, 2016 and orders were added for tab-alarm on bed and wheelchair with a high/low bed. Resident had a fall on May 10, 2016, during out on pass to the see a physician with family member, and education to family member was provided. Resident had another fall on May 30, 2016 by falling off of her wheelchair, and orders for self release seat belt were followed. RN 2 further stated that the resident should have had a yellow armband on her wrist, and the resident should have had floor mat on both sides of bed and not just one. RN 2 further stated that the reason the resident had only one floor mat placed on the right side was because the resident would get out of bed from the right side. A review of the facility's policy and procedure for Fall Management System with a revision date of November 2014, indicated a Fall Risk Assessment score of 10 or above represents a high risk for falls and will require the development of a care plan with interventions implemented designed to prevent falls. Residents identified at risk for falls will be evaluated for further preventive measures. One or more measures will be used including a safety mat. A review of the facility's policy and procedure for Fall Prevention Program with a revision date of November 2014, indicated that when a resident is assessed as at risk for falls, the facility will implement a program that visually identified the resident to allow all staff to maintain an awareness of the risk. It also indicated that the visual identifier is placed on the nameplate outside the resident's room and on his/her arm as an armband. It also indicated that residents with more than on fall in the month or three in 90 days and/or a fall with injury or fracture will be placed the the Falling Star Program with visual identified of a star on nameplate outside the resident's room and yellow arm band on resident's arm. c. According to the admission record, Resident 12 was originally admitted to the facility on [DATE], and was readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS- a standardized comprehensive assessment screening tool) dated May 13, 2016, indicated that Resident 12 was cognitively intact and able to make decisions of daily living, was able to understand and make self-understood, needed extensive assistance with bed mobility, eating, and personal hygiene, with one person physical assist, and was totally dependent on staff for transferring with two person physical assist, was totally dependent for locomotion on unit, toilet use, and bathing with one person physical assist. A review of Resident 12's physician's orders [REDACTED]. On June 15, 2016, between the hours of approximately 9 a.m. and 12:15 p.m., Resident 12 was observed in his room in bed and while on a wheelchair. It was noted that the resident did not have a tab-alarm applied the bed or while in a wheelchair as indicated in physician's orders [REDACTED]. A review of Fall Risk Assessment with an effective date of June 14, 2016, indicated that Resident 12 had a score of 11 placing the resident in the high risk for falls category. A review of Resident 12's care plan initiated on March 22, 2016, indicated the resident was at a high risk for falls due to but not limited to history of falls, generalized muscle weakness, and osteoporosis. Interventions included to use appropriate device as ordered. A review of Resident 12's MAR (medication administration record) for the month of June 2016, indicated for the resident to have a tab alarm while in bed and wheelchair every shift for safety which included an order date of March 21, 2016, was documented as being implemented. On June 15, 2016 at 8:10 a.m., during an interview, LVN 7 stated she was not sure about the alarms the resident was supposed to have because the resident was in bed most of the time. LVN 7 further stated that from what she knew the facility was ordering more floor mats to be used for residents at risk for fall. On June 15, 2016 at 8:20 a.m., during an interview, the Maintenance Supervisor stated that the facility was short on floor mats and that more were ordered and the facility was waiting for the floor mates arrival. On June 15, 2016 at 11:15 a.m., during an interview, the Central Supply Supervisor stated he placed an order for [REDACTED]. He further stated that he was told to order more because the facility needed them., During review of the order slip for the floor mats, order date for both indicated June 14, 2016 and that the items will be delivered in 3 to 5 business days. On June 16, 2016 at 11 a.m., during an interview, DSD (director of staff development) stated if the resident has an order for [REDACTED]. If a resident have orders for for foor mates, the floor mats have to be placed on boths sides of the residents' bed. If some resident's have the floor mat on one side of bed only, than the care plan should indicate which side the resident needs to have the floor mat on. DSD further stated if care plan does not indicate which side the floor mat should be on and which side is used by the resident, than how will the staff know where to place it. We will address that issue and speak with CNA's. On June 16, 2016 at 11:15 a.m., during an interview, the DON (director of nurses) stated, floor mats should be placed on both sides of the bed, and the facility is in the process of purchasing more mats because the mats were not sufficient enough. A review of the facility's policy and procedure for Fall Management System with a revision date of November 2014, indicated a Fall Risk Assessment score of 10 or above represents a high risk for falls and will require the development of a care plan with interventions implemented designed to prevent falls. Residents identified at risk for falls will be evaluated for further preventive measures. One or more measures will be used including, a personal alarm on the beds and/ or wheelchair, high/low bed, and safety mat. d. According to the admission record, Resident 28 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 28's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated October 20, 2015, indicated the resident sometimes made self-understood, was sometimes able to understand others, required extensive two or more-person assist with transfer, one-person assist with toilet use and personal hygiene. The MDS also indicated the resident was not steady, was only able to stabilize with staff assistance when moving from seated to standing position, walking, moving on and off toilet, and transferring between bed and chair or wheelchair. A review of the clinical record indicated Resident 28 had a fall on May 17, 2016 and June 1, 2016. The clinical record did not indicate Resident 28 sustained any injury. A review of the Fall Risk assessment dated [DATE], indicated Resident 28 had a score of 25. According to the assessment tool, a score 8 and higher indicates the resident is a high risk for fall. A review of the physician order [REDACTED]. A review of the revised plan of care dated June 15, 2016, for resident requires sitter select when in bed and wheelchair, indicated interventions to apply the alarm as order and monitor the alarm for good working condition. A review of the revised plan of care dated June 16, 2016, for high risk for further falls related to history of fall, impaired cognition, poor safety awareness, with goal to minimize the risk for falls in the next three months, indicated interventions to use sitter select in bed and wheelchair as ordered. On June 17, 2016 at approximately 9:05 a.m., during observation, Resident 28 was sitting in his wheelchair next to Nursing Station 4. Sitter select alarm was not observed applied to the wheelchair. On July 17, 2016 at approximately 9:15 a.m., during an interview, Licensed vocational nurse (LVN) 3 stated the sitter select (alarm) should have been used. On July 17, 2016 at 9:25 a.m., during an interview, LVN 1 stated the tab-alarm was changed to the sitter select alarm because Resident 28 had a history of [REDACTED]. LVN 1 also stated that the sitter select alarm was more sensitive and would alarm with little movement. A review of the facility's revised policy for fall management system dated November 2014 indicated a fall risk assessment score of 10 or above represents a high risk for falls and will require the development of a care plan with interventions implemented designed to prevent falls. Residents identified at risk for falls will be evaluated for further preventative measures. e. According to the admission record, Resident 14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 14's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated August 10, 2015, indicated the resident was cognitively intact, required extensive two or more person assist with bed mobility, transfer, and toilet use, and required one person assist when moving between locations in her room and the adjacent corridor on the same floor, and if in a wheelchair, self-sufficiency once in the chair. The MDS also indicated the resident was not steady, was only able to stabilize with staff assistance when transferring between bed and chair or wheelchair. A review of the Fall Risk assessment dated [DATE], indicated Resident 14 had a score of 8. According to the assessment tool, a score of 8 and higher indicates the resident is a moderate risk for fall. A review of the plan of care initiated on August 4, 2015, for at risk for falls related to weakness, multiple fractures history in the neck, unsteady balance, indicated a goal to reduce the risk for falls/injury for three months. Interventions included low bed, electronic alarm, and bedside safety mat. A review of the physician order [REDACTED]. On June 16, 2016 at approximately 1:15 p.m., during observation, Resident 14 was lying in bed, awake, and verbally responsive. The tab alarm was not observed. During an interview with LVN 12 present at the time of the observation, she stated the tab alarm should have been at the bedside and clipped on the resident. On June 16, 2016 at approximately 1:17 p.m., Resident 14 stated she did not have the tab alarm at the bedside, and did not know its use. f. According to the admission record, RSR 38 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of RSR 38's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated April 17, 2016, indicated the resident usually made self-understood, was able to understand others, required limited one-person assist with transfer, dressing, personal hygiene, bathing, and moving between locations in her room and the adjacent corridor on the same floor, and if in a wheelchair, self-sufficiency once in the chair. The MDS also indicated the resident was not steady, was only able to stabilize with staff assistance when moving from seated to standing position, moving on and off toilet, and transferring between bed and chair or wheelchair. A review of the Fall Risk assessment dated [DATE], indicated RSR 38 had a score of 10. According to the assessment tool, a score of 10 indicates the resident is high risk for fall. A review of the physician order [REDACTED]. 1. Bedside safety mats for safety every shift dated February 1, 2016. 2. Personal alarm while in bed for safety every shift dated April 18, 2016. 3. Personal alarm while in wheelchair for safety every shift dated April 18, 2016 A review of the plan of care initiated on July 17, 2015, for low risk for falls related to [DIAGNOSES REDACTED], antihypertensive, antidepressants, indicated interventions that included following facility fall protocol, high-low bed, personal monitor bead and wheelchair, and electronic alarm. During an observation on June 20, 2016 at 10:07 a.m., RSR 38 was sitting in his wheelchair, awake, alert, and was participating in an activity in the dining room (near station 3). A personal alarm was not observed. On June 20, 2016 at 10:13 a.m., during an interview, LVN 3 stated RSR 38 needed a tab alarm because he had history of getting up and the alarm was for fall precautions. At the time of the interview, LVN 3 looked inside RSR 38's room and could not find any tab alarm. On July 20, 2016 at approximately 1:40 p.m., during observation, a bedside safety mat was not observed on the right side of RSR 38's bed. During an interview with certified nurse assistant (CNA) 5 present at the time of the observation, she stated that it was the facility protocol to put a safety mat on each side of the bed while the resident is in bed. A review of the facility's revised policy for fall management system dated November 2014 indicated a fall risk assessment score of 10 or above represents a high risk for falls and will require the development of a care plan with interventions implemented designed to prevent falls. Residents identified at risk for falls will be evaluated for further preventative measures. One or more measures will be used: (a) Personal alarm on the beds and/ or wheelchair (b) High/low bed (c) Sitter select for bed and/or wheelchair (d) Safety mat (e) Mattress on the floor (f) Posey soft rails and (g) Bean bag chair. g. On June 13, 2016, at 9: 25 a.m., during the initial tour of the facility in the presence of the Licensed Vocational Nurse 8 (LVN 8), Resident 5 was observed sitting on her bed with both feet resting on the floor mat to her right side of the bed. There was no floor mat on the left side. There was a personal alarm hanging to the right half side rail and not attached to the resident. On the same date and time, during an interview with Resident 5, she stated she has been in the facility for five years. Nobody, explained the use and the purpose of the personal alarm to her. Resident 5 demonstrated by standing up from bed and the alarm was not triggered to sound to alert the staff. When the alarm was checked it was noted that it was not turned on. On June 13, 2016, at 9: 50 a.m., during an interview with LVN 8, present during the observation, she stated the personal alarm should have been attached to the resident and also turned on. According to the admission record Resident 5 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) (a comprehensive assessment tool) dated May 24, 2016, indicated the resident was moderately

Based on observation, review of clinical record, facility policy and procedures and staff interviews, the facility failed to ensure that one sampled resident, Resident 6, did not have an unplanned weight loss. Resident 6 sustained a significant and unplanned weight loss of 8.5 lbs or 4.97% in a month for one out of 27 sample residents (6). Finding: Resident 6 is a [AGE] year old female admitted on [DATE] with [DIAGNOSES REDACTED]. nutrition to patients who cannot obtain nutrition by swallowing), and phasia (Partial or total loss of the ability to articulate ideas or comprehend spoken or written language, resulting from damage to the brain). The resident's admitting orders included [MEDICATION NAME] (feeding formula) 1.2 at a rate of 60cc /hr to provide 1200 cc/ 1400 calories via a feeding tube to run from 1300 (1 p.m.) to 0900 (9 a.m.). She was admitted weighing 171 pounds with a BMI (body mass index) of 28.3. Normal 18 -25. The registered dietitian (RD) assessed her nutritional needs on 06/21/12 and determined that her needs were as follows: 1560 to 1950 calories, 62 to 78 grams of protein and 1950 to 2340 cc of fluid. Based on this assessment, her tube feeding order was not meeting her nutritional needs. The tube feeding was providing 1440 calories, 120 to 510 calories less than her assessed need. There was no recommendation by the RD to increase her tube feeding intake. On 6/28/12 Resident 6 weighed 169 lbs. She had a weight loss of 2 lbs. on 7/02/12 165, a further weight loss of 4 lbs. in a week. On 7/16/12 she weighed 162.5 lb. a total weight loss of 8.5 lbs. or 4.97% of her body weight in less than a month. Clinical record review showed that a weight variance meeting was held due to the unplanned weight loss on 7/2/12. There were no new documented recommendations by the interdisciplinary team. The RD was not present at this meeting. No intervention was provided by the RD since the weight loss. In an interview on 07/24/12 at approximately 3:40 pm, the director of nursing (DON) who was present at the meeting she stated that the DSS attended the weight variance meeting and it was the DSS's responsibility to refer the resident to the RD. The DSS was interviewed on 7/24/12 at approximately 11:30 am, she stated that she had attended the meeting and had referred the resident to the Diet Technician, Registered (DTR). She stated she had placed the information on a post-it ? note on the DTR's desk. The DTR denied receiving the information. In an interview with the registered dietitian on 07/24/12 at approximately 3:00 pm, she stated that she was on vacation when the weight variance meeting was held and was not aware of Resident 6's weight loss. In addition, she stated that Resident 6's physician does not like to increase tube feeding when patient is on intravenous antibiotic. Observations on 07/24/12 at approximately 11:20 am revealed that the tube feeding was labeled 07/24/12 and hung at 5:00 am. There was approximately 1450 cc left in the bottle. There should have been approximately 1380 cc left in the bottle. Review of the Intake and Output record showed that the resident always received the correct amount of tube feeding. At approximately 3:40pm on 07/24/12, an interview was conducted with the charge nurse who was responsible for the care of Resident 6.There was approximately 1320 cc left in the bottle. She indicated that she turned on the pump and had cleared the information from the previous feeding but did not document information. The charge nurse explained that the documentation was a mathematical calculation of what the resident should have received not the actual because the numbers from the pump are never recorded At approximately 1:58pm on 07/25/12, the DON was interviewed on the facility documentation policy on residents on tube feeding. She stated that the facility was in the process of revising its tube feeding policy. The facility failed to prevent Resident 6 from losing weight. They lacked an effective system to communicate with the RD. They lacked an effective system to document amount of tube feeding infused. The RD failed to offer interventions when the amount of tube feeding was determined to be less than Resident 6's assessed needs. These failures resulted in an unplanned weight loss of 8.5 lbs. or 5% weight loss in a month.