Every finding on record at Mount San Antonio Gardens

Based on observation, interview, and record review, the facility failed to ensure,A. Adequate monitoring (supervision from staff) to prevent a fall for one of three sampled residents (Resident 6), who was at high risk for falls. B. Proper placement of sensor alarm (wireless bed alarms that alert staff when a patient gets up from the bed for staff to assist the resident, an intervention used to prevent falls) transmitters (paired with the sensor alarm receiver located inside the resident's rooms [in general]) used to detect the resident's motion for two of three sampled residents (Resident 32 and Resident 34), who were at high risk for falls. This deficient practice resulted in Resident 6 sustaining a fall on 6/15/2026 and had the potential to result in falls with injury to Resident 32 and Resident 34. Findings: A. During a review of Resident 6's admission Record (AR), the AR indicated Resident 6 was admitted to the facility on [DATE] with multiple diagnoses including dementia (a gradual decline in mental ability usually caused by a brain disease), generalized muscle weakness (overall reduction in physical strength throughout the body), and other abnormalities of gait and mobility (changes in the natural walking pattern or the ability to move freely.) During a review of Resident 6's Minimum Data Set (MDS- a resident assessment tool), dated 5/6/2026, the MDS indicated Resident 6 had severely impaired cognition (ability to understand and process information) and required substantial/ maximal assistance (helper does more than half the effort) for toileting hygiene and bathing. The MDS indicated Resident 6 required partial/ moderate assistance (helper does less than half the effort) for toilet transfers (the ability to get on and off a toilet or commode). During a review of Resident 6's Morse Fall Scale (MFS), dated 5/6/2026, the MFS indicated Resident 6 was at high risk for falling. The MFS indicated under Mental Status, an assessment of a resident's ability to go to the bathroom alone, Resident 6 overestimated or forgot limits. During a review of Resident 6's Progress Notes (PN) dated 6/15/2026 at 5:18 AM, the PN indicated Resident 6 was observed by [Certified Nursing Assistant (CNA) 2 and Registered Nurse (RN) 4] sitting on the floor with legs straight out and leaning on the right elbow. The PN indicated CNA 2 stated CNA 2 assisted Resident 6 to the bathroom and momentarily left Resident 6 on the toilet to check on another resident (unidentified) next door and when CNA 2 returned two to three minutes later, Resident 6 was sitting on the floor outside the bathroom door. During a review of Resident 6's Care Plans (CP), the CP initiated on 2/12/2025, revised 6/15/2026, indicated Residence 6 was at risk for recurrent falls. The CP's interventions indicated to minimize hazards and provide a safe environment. The CP, initiated 6/15/2026, indicated Residence 6 was at risk for further falls/ injuries due to Resident 6 being found sitting on the floor outside the bathroom door. The CP's interventions indicated to continue to educate staff not to leave Resident 6 unattended when toileting. During an interview on 6/23/2026 at 10:39 AM with Resident 37's Private Caregiver (PC) 1, PC 1 stated PC 1 had cared for Resident 37 for almost two years Monday through Friday for 6 hours a day starting at noon. PC 1 stated Resident 37's ability to walk started to decline this year beginning a couple months ago by Resident 37's attempts to sit down if a chair is in sight. PC 1 stated Resident 37 was on a toileting schedule and is taken to a toilet or offered toileting every 2 hours under PC 1's care. PC 1 stated Resident 37 was not able to verbalize when Resident 37 was done using the toilet and usually only smiled or giggled when responding to questions or directions. PC 1 stated PC 1 did not leave Resident 37 alone in the restroom to be able to provide assistance when needed by Resident 37. During an interview on 6/24/2026 at 3:15 PM with the Director of Nursing (DON), the DON stated Resident 6 was considered a high fall risk even prior to the fall that occurred on 6/15/2026 due to Resident 6's dementia. The DON stated the CNA [CNA 2] was not supposed to leave Resident 6 in the bathroom alone because Resident 6 had dementia and anything such as a fall could occur. The DON stated it was a general protocol of the facility not to leave residents [in general] alone in the restroom. During a review of the facility's policy and procedure (P&P) titled, Fall prevention and Management Program, dated 1/10/2025, the P&P indicated staff will monitor at risk residents closely during the following times: shift change; meal time; going from inside to the outside or reverse; wearing very new or very old shoes; standing up after sitting or lying down for a while; cold, fever or other acute illness; and using the bathroom, tub or shower room, etc. During a review of the facility's undated P&P titled, Safety and Supervision of Residents, the P&P indicated the facility strives to make the environment as free from accident hazards as possible. The P&P indicated resident supervision is a core component of the systems approach to safety. The P&P indicated the type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. B. During a review of Resident 32's AR, the AR indicated the facility admitted Resident 32 on 3/1/2024 with diagnoses that included age related osteoporosis (bone mass is lost faster than it's created as people age) and muscle weakness. During a review of Resident 32's CP, initiated on 2/19/2026, the CP indicated Resident 32 was at risk for falls. The CP's goal indicated the facility would minimize Resident 32's risk for falls. The CP's interventions indicated a motion sensor [transmitter] in [Resident 32's] room as a fall precaution and to check for proper function and placement of the [motion sensor transmitter]. The CP's interventions indicated to minimize hazards and provide a safe environment for Resident 32. During a review of Resident 32's MFS, dated 3/26/2026, the MFS indicated Resident 32 was at high risk for falls. During a review of Resident 32's MDS, dated [DATE], the MDS indicated Resident 32's cognition was intact. The MDS indicated Resident 32 required maximal assistance (helper lifts or holds trunk or limbs and provides more than half the effort) for toileting hygiene, personal hygiene, and toilet transfers. During a review of Resident 32's Order Summary Report (OSR), dated active as of 6/24/2026, the OSR indicated a physician order, dated 2/20/20206, indicating motion sensor [transmitter] in [Resident 32's] room for fall precautions. The order indicated to check the motion sensor [transmitter] proper function and placement. During a concurrent observation and interview on 6/23/2026 at 8:52 AM with Licensed Vocational Nurse 2 (LVN 2), Resident 32 was sitting on a wheelchair beside Resident 32's bed. The sensor alarm transmitter was on top of a shelf located in front of Resident 32's bed and was not facing Resident 32. LVN 2 stated the sensor alarm transmitter needed to be positioned facing Resident 32 for the sensor to detect Resident 32's motion. LVN 2 stated [facility practice was] the white sensor alarm receiver (activated by an audible sound triggered by motion in front of the sensor alarm transmitter) was kept on top of the medication carts for facility staff to respond [to the alarm]. During a review of Resident 34's AR, the AR indicated the facility admitted Resident 34 on 6/5/2020 with diagnoses that included age related osteoporosis and history of falling. During a review of Resident 34's MDS, dated [DATE], the MDS indicated Resident 34 understood verbal content and was able to express ideas and wants. The MDS indicated Resident 34 required moderate assistance (helper lifts, holds or supports trunk or limbs but provides less than half the effort) with toilet transfers and chair/bed-to-chair transfers. During a review of Resident 34's MFS, dated 6/1/2026, the MFS indicated Resident 34 was at high risk for falls. During a review of Resident 34's CP, initiated 7/4/2023, revised 6/15/2026, the CP indicated Resident 34 was at risk for falls. The CP's goal indicated the facility would minimize Resident 34's risk for falls. The CP's interventions indicated to check battery function and proper placement of the motion sensor [transmitter] in Resident 34's room as a fall precaution. The CP's interventions indicated to minimize hazards and provide a safe environment for Resident 34. During a review of Resident 34's OSR, dated active as of 6/24/2026, the OSR indicated a physician order, dated 8/28/2024, for motion sensor [transmitter] in [Resident 34's] room. The OSR indicated a physician order, dated 1/23/2026, to check battery function and proper placement of the motion sensor [transmitter]. During an observation on 6/24/2026 at 7:55 AM Resident 34 was sitting on the wheelchair eating breakfast. The sensor alarm transmitter was not facing Resident 34 and was facing toward the window. During a concurrent observation and interview on 6/24/2026 at 8:05 AM with CNA 5, the sensor alarm transmitter was not facing Resident 34. CNA 5 stated the sensor alarm [transmitter] needed to face Resident 34, so the alarm activated if Resident 34 attempted to get up from bed. During an interview on 6/24/2026 at 3:38 PM with the DON, the DON stated the sensor alarm [transmitter] needed to be positioned facing the residents (in general) for the alarm to work. The DON stated the alarm's purpose for use was to alert staff when the residents got out of bed or out of the wheelchair without asking for assistance from staff and for staff to assist the resident. During a review of the facility's undated product instruction manual, titled Wireless Door & Bed Alarm the manual indicated that for elderly/dementia [residents], install the transmitter at the patient's bedside and obtain the best installation position by repeatedly adjusting the sensing angle and range of the transmitter. The manual indicated the transmitter detects the infrared signal range released from body surface temperature. During a review of the facility's P&P, titled, Fall Prevention and Management Program, dated 1/10/2025, the P&P's policy indicated the facility was to provide high quality of care in a safe environment for the residents residing in the facility. The P&P indicated all residents will be assessed for falls using the Morse Fall Scale. The P&P indicated any resident at risk [for falls] will have fall interventions placed on the resident's CP.

Based on observation, interview, and record review, the facility failed to ensure three of five sampled residents (Resident 47, Resident 17 and Resident 30) received proper respiratory (relating to breathing) care in accordance with the facility's policy and procedures (P&P) and physician's orders by failing to:a. Post Oxygen in Use - No Smoking (signage) in the sign plate holder outside of Resident 17 and Resident 47's rooms in accordance with the facility's policy and procedure (P&P) titled, Oxygen Administration.b. Change Resident 30's nasal cannula (NC - a small plastic tube that fits into the person's nostrils and used to provide supplemental oxygen [02 - a colorless, odorless, tasteless gas essential for living) and 02 humidifier (a medical device attachment used during 02 therapy to add moisture to supplemental 02) every Sunday in accordance with the facility's P&P titled, Oxygen Administration.These deficient practices had the potential to result spark producing activities by visitors due to a lack of highly visible warning signage posted outside of the resident's rooms and the potential to result in a fire and burns to Resident 17 and Resident 47. Additionally, there was a potential for bacterial (microscopic, single celled living organism some can cause disease) infections, mold (an invasive microscopic fungus, can trigger an immune reaction, can actively grow and cause serious sometimes life-threatening infections) growth, and skin irritation to Resident 30 due to the facility using an old NC and humidifier.Findings:a. During a review of Resident 47's admission Record (AR), the AR indicated Resident 47 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease (COPD - a long-standing lung disease causing difficulty in breathing), unspecified, and heart failure, unspecified.During a review of Resident 47's Encounter - Office Visit (EOV), dated 6/22/2026, the EOV indicated Resident 47 did not have decision-making capacity.During a review of Resident 47's Order Summary Report (OSR), active orders as of 6/24/2026, the OSR indicated a physician's order, dated 6/19/2026, for O2 at five (5) LPM (liters per minute - the speed or volume of 02 a device delivers to a resident) via NC every shift for SOB (short of breath) continuously.During a review of Resident 47's Treatment Administration Record (TAR), dated 6/1/2026 - 6/30/2026, the TAR indicated Resident 47 was receiving 02 at 5 LPM via NC every shift for SOB continuously since readmission to the facility.During a review of Resident 17's AR, the AR indicated Resident 17 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including anemia (a condition where the body does not have enough healthy red blood cells), unspecified, and other specified symptoms and signs involving the circulatory (the body's delivery network that includes the heart, blood vessels and blood), and respiratory systems.During a review of Resident 17's History and Physical Examination (H&P), dated 6/1/2026, the H&P indicated Resident 17 was alert, but confused, could make immediate needs known, but was unable to make complex medical decisions.During a review of Resident 17's Minimum Data Set (MDS - a resident assessment tool), dated 4/9/2026, the MDS indicated Resident 17's cognitive (the ability to think and process information) skills for daily decision making were moderately impaired (decisions poor; cues/supervision required). The MDS indicated Resident 17 required substantial/maximal assistance (helper does more than half the effort) to setup or clean-up (helper sets up or cleans up with activities of daily living (ADL - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 17's OSR, active orders as of 6/24/2026, the OSR indicated, a physician's order, dated 6/15/2026, for O2 at two (2) LPM via NC, may titrate (adjusting the dose up or down) up to four (4) LPM every shift as needed to maintain 02 saturation (02 sat - a measurement indicating how much 02 the blood is carrying as a percentage) level to equal ninety two (92)%.b. During a review of Resident 30's AR, the AR indicated Resident 30 was originally admitted to the facility on [DATE] with multiple diagnoses including anemia unspecified, and heart failure, unspecified.During a review of Resident 30's Care Plan (CP), initiated 6/4/2026, the CP indicated Resident 30 was at risk for respiratory distress. The CP's indicated to change 02 tubing and humidifier every week.During a review of Resident 30's H&P, dated 6/5/2026, the H&P indicated Resident 30 was alert, oriented, and competent to make complex medical decisions.During a review of Resident 30's MDS, dated [DATE], the MDS indicated Resident 30's cognitive skills for daily decision making were intact. The MDS indicated Resident 30 required substantial/maximal assistance for setup or clean-up assistance with ADL. The MDS indicated Resident 30 was on 02 while a resident at the facility and was on intermittent 02 therapy on admission.During a review of Resident 30's OSR, active orders as of 6/24/2026, the OSR indicated a physician's order, dated 6/3/2026, for 02 at 2 LPM via NC at bedtime for comfort and an order indicating to change tubing [NC], humidifier and check the filter every week every night shift every Saturday.During a review of Resident 30's TAR, dated 6/1/2026 to 6/30/2026, the TAR indicated Resident 30 was receiving 02 at 2 LPM via NC administered at 9 PM at bedtime for comfort.a. During an observation and interview on 6/22/2026 at 10:16 AM with Private Caregiver (PC) 2, Resident 47 was in bed, frail and receiving 02 at 5 LPM with the NC and humidifier labeled with a date of 6/15/2026. PC 2 stated, Resident 47 was always on 02 at 5 LPM. There was no signage posted outside of Resident 47's room indicating 02 was in use.During a concurrent observation and interview on 6/22/2026 at 10:34 AM with Certified Nursing Assistant (CNA) 4, there was no signage posted outside of Resident 47's room. CNA 4 stated, when a resident was receiving 02, a signage was to be posted outside of the resident's room because it's [02] flammable.During an interview on 6/22/2026 at 10:45 AM with Licensed Vocational Nurse (LVN) 3, LVN 3 stated Resident 47 was admitted to the facility on Friday afternoon [6/19/2026] and a signage should have been posted outside of Resident 47's room. LVN 3 stated, posting signage [indicating 02 was in use] was important and was needed for safety purposes so visitors and staff knew Resident 47 was on 02.During an observation and interview on 6/22/2026 at 10:56 AM with Resident 17, Resident 17 was sitting in Resident 17's wheelchair with no 02 administration. Resident 17 stated, Resident 17 used 02 only when Resident 17 needed 02. Resident 17's room did not have signage [indicating 02 in use] posted outside of Resident 17's room.During a concurrent observation and interview on 6/22/2026 at 11:12 AM with LVN 3, LVN 3 stated LVN 3 would get the signage [indicating 02 was in use] to post outside of Resident 17's room.b. During observation and interview on 6/22/2026 at 11:24 AM with Resident 30, Resident 30 was in bed and was not receiving 02. Resident 30's bedside had a 02 concentrator, humidifier, and NC tubing with pink colored label stickers indicating, Change[d] Sunday 6/14/2026 and with the Patient Set-Up Bag [a bag used for keeping respiratory equipment clean and dry], dated 6/14/2026. Resident 30 stated, Resident 30 used pretty low amount of 02 during the night.During an interview on 6/23/2026 at 1:14 PM with LVN 2, LVN 2 stated the night shift [11 PM - 7 AM] was responsible for changing resident's (in general) NCs and humidifiers once a week every Sunday, for infection control and it's the policy also. LVN 2 stated Resident 30's NC and humidifier should have been changed on 6/21/2026.During an interview on 6/23/2026 at 2:07 PM with the Director of Nursing (DON), the DON stated NCs and humidifiers were to be changed every week on Sunday by the night shift and changing NCs and humidifiers was important for infection control and if there was a build-up like mucous, the resident would of course, not get enough oxygen.During an interview on 6/24/2026 at 9:38 AM with the DON, the DON stated posting signage [indicating oxygen was in use] outside of the resident's room for residents who were receiving 02 was vital for safety and to alert visitors not to light a candle and/or smoke.During a review of the facility's P&P titled, Oxygen Administration, date revised 6/2026, the P&P indicated, NC and face masks would be changed weekly (Sundays 11-7), regardless of PRN (as needed) changes, labeled with initials, date, and time. The P&P indicated, to post the Oxygen in use - No Smoking sign in the sign plate holder outside of the room.

Based on observation, interview, and record review the facility failed to implement infection prevention and control measures for two of five sampled residents (Resident 37 and Resident 1) by failing to ensure:A. Certified Nursing Assistant (CNA) 5 wore personal protective equipment (PPE, protective clothing or equipment, designed to protect the wearer from injury or the spread of infection [the invasion and growth of germs in the body] or illness) while providing care to Resident 37 and Resident 1 who were under Enhanced Barrier Precautions (EBP, extra measures, like wearing gowns and gloves, used during high-contact care activities for residents who are at a higher risk of having or spreading germs that are hard to treat, like multidrug-resistant organisms [MDROs, bacteria that have become resistant to certain antibiotics [medication used to treat bacterial infections], and these antibiotics can no longer be used to control or kill the bacteria] e.g., residents with wounds or indwelling [resides, exist, or operates from within] medical devices).B. Licensed Vocational Nurse (LVN) 2 disinfected blood pressure equipment (BP, monitor and cuff used to check blood pressure) before and after use for Resident 1.These deficient practices had the potential to result in infections and the spread microorganisms (bacteria, virus, fungus) to Resident 1 and Resident 37. Findings: A. During a review of Resident 37's admission Record (AR), the AR indicated Resident 37 was admitted to the facility on [DATE] with multiple diagnoses including dysphagia (difficulty swallowing), gastrostomy (surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), transient ischemic attack (temporary blockage of blood flow to the brain), and cerebral infarction (a stroke, where a blockage interrupts blood flow to the brain leading to tissue death) without residual deficits. During a review of Resident 37's Minimum Data Set (MDS- a resident assessment tool), dated 6/15/2026, the MDS indicated Resident 37 had severely impaired cognition (ability to understand and process information) and was dependent (helper does all of the effort) on staff for personal hygiene and toileting. During a review of Resident 37's Order Summary Report (OSR), active orders as of 6/23/2026, the OSR indicated Resident 37 had a physician order, start date 5/1/2024, for EBP every shift for the presence of a gastrostomy tube. During a review of Resident 37's Care Plan (CP), initiated on 4/30/2024, the CP indicated Resident 37 was at risk for the development of MDROs and was on EBP for the presence of a gastrostomy tube (G-tube, a small flexible medical device inserted directly through the abdomen into the stomach). The CP's interventions indicated to initiate EBP and wear appropriate PPE (gown and gloves) during high contact care [activities]. During an observation on 6/22/2026 at 9:30 AM, Resident 37's doorway was observed with signage titled, Enhanced Barrier Precautions, from the Los Angeles County Department of Public Health (LACDPH), revised 2/23/2026. The signage indicated providers and staff must wear gloves and gowns for the following high-contact resident care activities: caring for devices and giving medical treatments. During an observation on 6/23/2026 at 11:03 PM with LVN 1 in Resident 37's room, LVN 1 was observed removing Resident 37's G-tube feeding from Resident 37's G-tube and delivered approximately five milliliters (ml – unit of volume) of water via Resident 37's G-tube while wearing only gloves for PPE. During a concurrent observation and interview on 6/23/2026 at 1:03 PM with LVN 1 in Resident 37's room, LVN 1 was observed administering water and medications to Resident 37 via Resident 37's G-tube without wearing a PPE gown. LVN 1 administered 30 ml of water via the piston syringe (tool used to pump liquids or gases, consisting of a tight-fitting plunger [piston] that slides up and down inside a hollow cylinder) to Resident 37's G-tube. During the time the water was draining via gravity (plunger is not used), Resident 37 coughed causing water in the piston syringe to spill out of the top of the syringe onto Resident 37. LVN 1 stated staff needed to wear gowns when performing patient care with Resident 37 including a gown to prevent anything potentially getting on a staff's clothing and [result] in the spread of infection. During an interview on 6/24/2026 at 3:15 PM with the Director of Nursing (DON), the DON stated all residents (in general) who had G-tubes were under EBP. The DON stated staff should be wearing a gown and gloves when touching a resident's G-tube because there could be splash back when administering medications. The DON stated EBP is a part of the facility's infection control because a G-tube is considered an opening and a staff's clothes could become contaminated and [result in the] spread infection to other residents. During a review of the facility's policy and procedure (P&P) titled, Infection Control Program, dated 2/8/2019, the P&P indicated to wear PPE as necessary to prevent exposure to spills or splashes of blood or body fluids or other potentially infectious materials. During a review of the facility's undated P&P titled, Enhanced Barrier Precautions, the P&P indicated EBP are infection control measures that involve gown and glove use during high-contact resident care activities for residents who have open wounds or indwelling devices or who have a known recent colonization or infection with a multidrug-resistant organisms MDROs in the facility. During a review of Resident 1's AR, the AR indicated the facility admitted Resident 1 on 3/3/2026 with diagnoses that included cerebral infarction and malignant neoplasm of the prostate (prostate cancer). During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1 usually understood verbal content and was usually able to express ideas and wants. The MDS indicated Resident 1 was dependent on toileting hygiene, oral hygiene, showers and baths. During observations on 06/23/2026 at the following times: At 10:05 AM, CNA 5 entered Resident 1's room with CNA 6, there was a sign posted at the doorway indicating Resident 1 was on EBP. CNA 5 and CNA 6 did not wear a gown prior to entering Resident 1's room. At 10:06 AM, CNA 5 emptied Resident 1's foley catheter (a device that helps drain urine from the bladder [hollow muscular balloon-like organ that stores urine]) then dumped the urine into the toilet. CNA 5 removed CNA 5's gloves then washed CNA 5's hands with soap and water. CNA 5 put gloves on and lowered Resident 5's head of the bed, removed the blanket from Resident 1, and started putting pants on Resident 1. At 10: 20 AM, CNA 5 and CNA 6 moved Resident 1 side to side to position a sling (a supportive fabric device that cradles an individual so a mechanical lift [a device used to help lift and move residents] can safely transfer the person between a bed, wheelchair, or toilet) underneath Resident 1. CNA 5 and CNA 6's clothes touched part of Resident 1's bed while turning Resident 1 side to side. CNA 5 hooked the sling to the mechanical lift and transferred Resident 1 from the bed to the wheelchair. CNA 5 and CNA 6 were not wearing gowns during the transfer. At 10:25 AM, CNA 5 changed Resident 1's bed linens and was not wearing a gown. During an interview on 6/23/2026 at 10:35 AM with CNA 5, CNA 5 stated CNA 5 did not need to wear a gown during Resident 1's transfer but needed to wear a gown when CNA 5 emptied the foley catheter. CNA 5 stated CNA 5 needed to wear proper PPE for infection control and to protect Resident 1. CNA 5 stated CNA 5 could pass bacteria to Resident 1 and to other residents. During an interview on 6/24/2026 at 3:35 PM, the DON stated Resident 1 was on EBP because Resident 1 had a foley catheter. The DON stated CNA's (in general) were in serviced (trained) on wearing proper PPE when providing care to residents who were on EBP. During a review of the facility's undated P&P titled Enhanced Barrier Precautions, the P&P indicated enhanced barrier precautions are infection control measures that involve gown and glove use during high contact resident-care activities for residents who have open wounds or indwelling (foley) devices or who have a known recent colonization or infection with an MDRO (when contact precautions do not apply). The P&P indicated PPE was used to reduce the risk of exposure to and the transmission of microorganisms including the use of gowns, gloves, face protection, and eye protection. The P&P indicated high contact activities included activities that placed the resident and the person helping them in close physical contact that increases the risk of transmission of MDRO between the resident and health care provider. The activities included: Bathing/showering Transferring Providing hygiene (brushing teeth, combing hair, and shaving). Changing linens Changing briefs Device care such as central line, urinary catheter, feeding tube, tracheostomy/ventilator. Wound care and dressing changes B. During an observations on 6/23/2026 at the following times, At 8:30 AM, LVN 2 took the BP equipment (monitor and cuff) on wheels from the hallway toward Resident 1's room. LVN 2 wheeled the BP equipment and entered resident 1's room. LVN 2 checked Resident 1's BP and did not disinfect the equipment before using for Resident 1. At 8:38 AM, LVN 2 exited Resident 1's room and wheeled the BP equipment with LVN 2. LVN 2 proceeded to prepare Resident 1's medications. LVN 2 did not disinfect the BP equipment. At 8:42 AM, LVN 2 entered Resident 1's room to administer Resident 1's medications. At 8:43 AM, LVN 2 exited the room and disinfected the medication tray used to administer Resident 1's medications. At 8:45 AM, LVN 2 walked towards another resident's (unidentified) room and wheeled the BP equipment away from Resident 1's room. At 9:17 AM, LVN 2 disinfected the medication cart then parked the medication cart across the Nurse's station. During an interview on 6/23/2026 at 9:30 AM, with LVN 2, LVN 2 stated the BP equipment was used to check BPs for multiple residents. LVN 2 stated the BP equipment was not dedicated (assigned) to one resident. LVN 2 stated LVN 2 forgot to disinfect the BP equipment [before and after using the equipment on Resident 1], LVN 2 stated LVN 2 needed to disinfect the BP equipment to prevent cross contamination (the process by which microorganisms are unintentionally transferred from one area/object to another with a harmful effect). During a review of the facility's P&P titled Cleaning and Disinfection of Resident-Care Equipment, revised 4/2026, the P&P indicated resident-care equipment can be a source of indirect transmission of pathogens (an organism that causes disease). The P&P indicated multiple-resident use equipment shall be cleaned and disinfected after each use. Most equipment may be cleaned/disinfected in the areas in which the equipment is used.

Based on observation, interview, and record review, the facility failed to ensure a baseline care plan (CP) was developed and implemented within forty-eight hours of admission for one of five sampled residents (Resident 47), who was on supplemental oxygen (02 - a colorless, odorless, tasteless gas essential for living) therapy.This deficient practice had the potential to result in unmet individualized needs for Resident 47 and the potential to affect the resident's physical and psychosocial well-being.Findings:During a review of Resident 47's admission Record (AR), the AR indicated Resident 47 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease (COPD - a long-standing lung disease causing difficulty in breathing), unspecified, and heart failure, unspecified.During a review of Resident 47's Encounter - Office Visit (EOV), dated 6/22/2026, the EOV indicated Resident 47 did not have decision-making capacity.During a review of Resident 47's Order Summary Report (OSR), active orders as of 6/24/2026, the OSR indicated a physician's order, dated 6/19/2026, for oxygen at five (5) LPM (liters per minute - the speed or volume of 02 a device delivers to a resident) via nasal cannula (NC - a small plastic tube that fits into the person's nostrils, used to provide supplemental 02) every shift for SOB (short of breath) continuously.During a review of Resident 47's Treatment Administration Record (TAR), dated 6/1/2026 - 6/30/2026, the TAR indicated Resident 47 was administered 02 at 5 LPM via NC every shift for SOB continuously since readmission to the facility.During an observation and interview on 6/22/2026 at 10:16 AM with Private Caregiver (PC) 2, Resident 47 was in bed, frail and receiving 5 LPM of 02 via NC. PC 2 stated Resident 47 had always received 02 at 5 LPM. During a concurrent interview and record review on 6/23/2026 at 2:07 PM with the Director of Nursing (DON), Resident 47's medical records via PCC (Point Click Care - electronic health record) were reviewed. The DON stated Resident 47 was admitted on [DATE] with an order for 02 at 5 LPM via NC every shift for SOB continuously. The DON stated a baseline CP for Resident 47 had to be created upon admission and creating a CP was important for staff to provide [appropriate] care and interventions to Resident 47 because Resident 47 was on 02, that's respiratory.During a concurrent interview and record review on 6/24/2026 at 11:47 AM with the DON, Resident 47's medical records via PCC were reviewed. The DON stated a document titled Baseline Care Plan was created for Resident 47. The Baseline CP indicated it was completed on 6/22/2026 by the Social Worker (SW), the Minimum Data Set Nurse (MDSN), the Life Enrichment Director (LED) and the Registered Dietician (RD). The DON stated a [baseline] CP consisted of a problem, a goal, and interventions. The DON stated Resident 47's Baseline CP did not have a goal or interventions for Resident 47 that addressed resident 47 was receiving 02 therapy.During a review of the facility's policy and procedure (P&P) titled, Base Line Care Plan, date revised 12/29/2021, the P&P indicated the facility would develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality of care. The P&P indicated the baseline care plan would be developed within 48 hours of a resident's admission.

Based on observation, interview, and record review, the facility failed to ensure one of four corner areas (Corner Area 1) in the facility's kitchen was free of pests on 6/22/2026.This deficient practice had the potential to result in foodborne illness (an illness caused by eating contaminated food) for the residents consuming the food prepared in the facility's kitchen. Findings:During a kitchen tour observation and interview on 6/22/2026 at 8:53 AM, with the Dining Services Manager (DSM), there was a separate area inside the kitchen used for baking and trays with freshly baked cookies placed in a cart. The separate area had unidentified debris and an insect that was not moving on the floor at the back of the oven. The DSM stated there was a dead insect behind the oven and the dead insect was a cricket. The DSM stated all areas of the kitchen needed to be cleaned because food debris or other dirt could attract pest into the kitchen.During an interview on 6/24/2026 at 3:50 PM with the Administrator (ADM), the ADM stated all areas of the kitchen needed to be clean.During a review of the facility's undated Dining Services Master Cleaning Schedule (DSMCS), the DSMCS indicated sweeping the floors with a broom ensuring sweeping under equipment, counters, and racks to gather all debris on the floor to be completed daily.During a review of the facility's Policy and Procedure (P&P) titled Sanitation and Infection Control Cleaning Services dated 1/2024, the P&P indicated the daily cleaning schedule delineates how often equipment must be cleaned and whose responsibility it is to clean each specific piece of equipment or area. The P&P indicated heavy cleaning such as under equipment, walls and floors, and major equipment can be planned on a weekly basis.

Based on observation, interview, and record review, the facility failed to ensure sensor alarms (wireless bed alarms that alert staff when a patient gets up from the bed so staff can go and assist the patient, used to prevent falls) were functioning for, two of four sampled residents (Resident 2 and Resident 3), who were at high risk for falls.This deficient practice had the potential to result in falls and injuries to Resident 2 and Resident 3. Findings:During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 4/20/2021, with diagnoses that included dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning), other abnormalities of gait, and mobility.During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool), dated 1/8/2026, the MDS indicated Resident 2 was able to express ideas and wants, understood verbal content, and had problems with short-term and long-term memory. The MDS indicated Resident 2 was dependent on activities of daily living.During a review of Resident 2's Morse Fall Scale dated 1/8/2026, the scale indicated Resident 2 was at high risk for falling.During a review of Resident 2's care plan (CP), revised 1/8/2023, the CP indicated Resident 2 was at risk for falls related to impaired balance, impaired mobility, and trying to get out of bed unassisted. The CP's interventions included a motion sensor [alarm] in Resident 2's room.During a review of Resident 3's AR, the AR indicated the facility admitted Resident 3 9/25/2025, with diagnoses that included history of falling and muscle weakness.During a review of Resident 3's CP, initiated 9/26/2025, the CP indicated Resident 3 was at risk for recurrent falls related to impaired balance and impaired mobility. The CP indicated on 12/23/2025, Resident 3 was assisted slowly to the floor (assisted fall) due to Resident 3 trying to walk without calling for [staff assistance] and Resident 3's legs gave out while walking. The CP's interventions included a motion sensor [alarm].During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had intact cognition and required maximal assistance (helper lifts or holds trunk or limbs and provide more than half the effort).During a review of Resident 3's Change in Condition (COC), dated 12/23/2025 at 9 AM, the COC indicated an unidentified Certified Nursing Assistant (CNA) reported Resident 3 had a fall. During a review of Resident 3's Morse Fall Scale (widely used, evidenced based nursing tool designed to assess a patient's risk of falling), dated 12/30/2025, the scale indicated Resident 3 was at high risk for falling.During a concurrent interview and observation on 1/22/2026 at 10:54 AM, CNA 2 stated CNA 2 had 2 alarms for Resident 2 and Resident 3. CNA 2 pulled out 2 white alarms from inside CNA 2's pocket.During an interview on 1/22/2026 at 1:16 PM, CNA 1 stated the sensor alarms needed to be positioned facing the resident (in general) to monitor and detect the resident's motion. CNA 1 stated [it was facility practice for] CNA's (in general) to carry a white device (paired with the sensor alarms located inside resident rooms) and respond when the device made an audible sound (triggered by motion in front of the sensor alarm), by checking (visually) on the resident.During an interview on 1/22/2026 at 2:25 PM, the Director of Nursing (DON), the DON stated CNAs (in general) needed to carry sensor alarms with them all the time.During an interview on 1/22/2026 at 2:30 PM, with the DON, the DON stated the response time for the sensor alarms was an immediate response (as soon as the alarm was heard) to see what was going on with the resident. The DON stated if the CNA was busy and could not respond, the CNA should leave the alarm with the nursing staff.During a concurrent observation and interview on 1/22/2026 at 2:37 PM with LVN 2, LVN 2 entered Resident 2's room, the sensor alarm was placed on top of the table facing Resident 2 who was lying in bed. LVN 2 moved in front of the sensor to activate the alarm. LVN 2 waited inside Resident 2's room waiting for CNA 2 to respond to the sensor alarm and CNA 2 did not come to check on Resident 2. LVN 2 then moved outside Resident 2's room and CNA 2 did not respond to the sensor alarm. LVN 2 stated if CNA 2 was busy with another resident, CNA 2 needed to call out from that room to let LVN 2 know Resident 2's alarm was activated for LVN 2 to check on Resident 2. During an observation on 1/22/2026 at 2:37 PM to 2:41 PM with LVN 2, LVN 2 was standing outside Resident 2's room, there was no audible alarm sound. CNA 2 did not come to check on Resident 2 and CNA 2 did not communicate to LVN 2 CNA 2 was busy.During an observation on 1/22/2026 at 2:44 PM, LVN 2 entered Resident 3's room, Resident 3 was lying in bed, and a sensor alarm was positioned on top of the table and facing Resident 3. LVN 2 moved in front of the sensor to activate the alarm.During an observation on 1/22/2026 at 2:44 PM to 2:45 PM while waiting outside Resident 3's room, there was no audible alarm, CNA 2 did not come to check on Resident 3 and CNA 2 did not communicate to LVN 2 CNA 2 was busy.During an observation on 1/22/2026 at 2:46 PM, CNA 2 was inside the staff lounge.During an observation on 1/22/2026 at 2:48 PM with CNA 2, CNA 2 moved in front of Resident 2's sensor and the alarm located inside CNA 2's pocket did not sound. CNA 2 entered Resident 3's room (located across from Resident 2's room) and moved in front of the sensor, the alarm did not sound. CNA 2 checked the alarm and pressed a button followed by an audible alarm sound. CNA 2 stated the alarm might have turned off while inside CNA 2's pocket.During an interview on 1/22/2026 at 3:06 PM with the DON, the DON stated staff needed to respond to sensor alarms immediately when the alarms were activated.During a review of the facility's sensor alarm's undated Product Description (PD), the PD indicated elderly care alarms is a wireless bed alarms for elderly that alerts you when a patient gets up from bed and go and assist her to prevent from fall when she stands up.During a review of the facility's Policy and Procedure (P&P), titled Fall Prevention and Management Program, dated 1/10/2025, the P&P's policy indicated the facility is to provide high quality care in a safe environment for the residents residing in the community. The P&P indicated the program identifies the factors that place residents at risk for falls, promotes proactive healthcare practices for resident care planning, using the least restrictive method possible to keep the resident safe and identifies the main components of an effective fall prevention program. The P&P indicated these components include fall risk assessment, identifying risk factors, implementing interventions, documentation, evaluation, regular reassessment and re-evaluation.

Based on observation, interview, and record review, the facility failed to ensure the provision of necessary care and services for one of one sampled resident (Resident 15) when, a. Licensed Vocational Nurse (LVN) 1 failed to notify the Medical Doctor (MD, Resident 15's phycisian) promptly (immediately) of Resident 15's Change of Condition (COC, a sudden clinically important deviation in the resident's health or functioning that requires further assessments and interventions) on 5/28/2025. This deficient practice had the potential to result in life-threatening consequences and untimely medical treatment for Resident 15. Findings: a. During a review of Resident 15's admission Record (AR), the AR indicated the facility admitted Resident 15 on 1/18/2020, with diagnoses that included chronic obstructive pulmonary disease (COPD, long standing group of diseases that cause airflow blockage and breathing-related problems, make it difficult to breathe) and systolic congestive heart failure (the heart cannot effectively contract with each heartbeat). During a review of Resident 15's Minimum Data Set (MDS - a resident assessment tool), dated 5/5/2025, the MDS indicated Resident 15's cognition (ability to think and process information) was severely impaired. The MDS indicated Resident 15 required maximal assistance (helper lifts or holds trunk or limbs and provides more than half the effort) with toileting and personal hygiene. During a review of Resident 15's COC, dated 5/28/2025 at 7:26 PM, the COC indicated Resident 15 had shortness of breath (SOB) and increased fatigue. The MD was notified and new physician orders that included Levaquin 750 milligrams (mg, unit of measurement) oral tablet (antibiotic, medication to treat infections), an increased dose of Methylprednisolone (used in the treatment of COPD, particularly during flare-ups by reducing inflammation in the airways) oral tablet from 8 mg. to 16 mg for 14 days. During a review of Resident 15's Medication Administration Record (MAR), dated 5/2025, the MAR indicated albuterol sulfate inhalation was routinely administered at 8 AM to Resident 15. During an observation on 5/28/25 at 9:18 AM, Resident 15 was lying in bed, breathing was shallow and fast, and Resident 15 was receiving oxygen. During an observation on 5/28/2025 at 1 PM, Resident 15 was lying in bed, breathing was fast and shallow and was receiving oxygen. During an interview on 5/30/2025 at 1:08 PM, Certified Nursing Assistant 2 (CNA 2) stated on 5/28/2025 at the start of CNA 2's shift [6:30 AM], Resident 15 looked confused, did not look good and Resident 15 was not too responsive. CNA 2 stated CNA 2 notified LVN 1 who checked Resident 15's oxygen level and administered a breathing treatment to Resident 15. During an interview on 5/30/2025 at 2:45 PM, with LVN 1, LVN 1 stated, on 4/28/2025, LVN 1 administered oxygen to Resident 15 to maintain Resident 15's oxygen level. LVN 1 stated LVN 1 administered the routine breathing treatment (albuterol). LVN 1 stated Resident 15 did not normally have shortness of breath. LVN 1 stated LVN 1 did not notify the MD immediately of Resident 15's COC on 4/28/2025. During an interview on 5/30/2025 at 3:07 PM, the Activities Assistant (AA) stated Resident 15's daily routine included going outside Resident 15's room and tending to Resident 15's plants. The AA stated on 5/28/2025, the AA did not see Resident 15 because Resident 15 stayed in bed. During an interview on 5/30/2025 at 3:15 PM, Registered Nurse 1 (RN 1) stated signs and symptoms of respiratory distress included low oxygen saturation, the use of accessory muscles used for breathing, and breathing fast. RN 1 stated when a resident (in general) exhibited these symptoms, it was considered a COC, and the licensed nurse needed to notify the physician immediately. RN 1 stated changes in respiratory status needed immediate treatment because the resident's status could go bad quickly. During an interview on 5/30/2025 at 4:29 PM, the Director of Nursing stated a COC needed to be reported promptly [immediately] to the physician to get proper treatment. During a review of the facility's Policy and Procedure (P&P) titled Change of Condition dated 10/2015, the P&P indicated to observe and report any condition change to the attending physician so proper treatment will be implemented. The P&P indicated the facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and/or status.

Based on observation, interview, and record review, the facility failed to ensure adequate perineal (an area lower in the body located between the thighs) care was provided for, one of one sampled resident (Resident 9), who had a history of urinary tract infections (UTI, an infection in any part of the urinary system: kidneys, bladder, or urethra [tube through which the urine leaves the body], sits just in front of the vaginal opening) and as indicated in the facility's Policy and Procedure (P&P) titled, Perineal Care. This deficient practice had the potential to result in a UTI and a physical decline to Resident 9. Findings: During a review of Resident 9's admission Record (AR), the AR indicated the facility admitted Resident 9 on 7/6/2017, with diagnoses that included disorders of the bladder, neurocognitive disorder with lewy bodies (a disease associated with abnormal deposits of a protein called Lewy bodies, affects chemicals in the brain. These changes, in turn, can lead to problems with thinking, movement, behavior, mood, and other body functions). During a review of Resident 9's Minimum Data Set (MDS - a resident assessment tool) dated 4/9/2025, the MDS indicated Resident 9 sometimes understood verbal content and sometimes was able to express ideas and wants. The MDS indicated Resident 9 was dependent (helper does all the effort) with all activities of daily living ( ADLs- activities such as bathing, dressing and toileting a person performs daily) including personal and toileting hygiene. The MDS indicated Resident 9 frequently had urine and bowel (long tubed-shaped organ in the abdomen that completes the process of digestion) incontinence (involuntary leakage of bodily fluids, inability to control bladder [urine reservoir] or bowel movements). During a review of Resident 9's Clinical Laboratory results indicated the following: On 4/3/2025, the urine culture identified E. coli (type of bacteria commonly found in the GI [gastrointestinal, refers collectively to the organs of the body that play a part in food digestion] tract) present in the urine. On 5/8/2025, the urine culture identified yeast (fungal cells) in the urine. During an interview on 5/28/2025 at 3:20 PM, Resident 9's family member (FM) stated the FM was concerned about Resident 9's recurrent UTIs. During a concurrent observation and interview on 5/30/2025 at 9:38 AM, with the FM. Certified Nursing Assistant 1 (CNA 1) transferred Resident 9 from the wheelchair to the commode (piece of furniture containing a concealed chamber pot used as a portable toilet for individuals with mobility issues) using a mechanical lift (lift, a mobility tool designed to help residents with mobility challenges). The FM stated Resident 9 sat on the commode for 30 minutes once Resident 9 was up and out of bed to allow Resident 9 to urinate and/or have a bowel movement. During a concurrent observation and interview on 5/30/2025 at 10:16 AM, with Registered Nurse (RN) 1, CNA 1 cleaned the perineal area from front to back using wipes. CNA 1 folded the wipes halfway, wiped Resident 9 from front to back, and wiped Resident 9 again. CNA 1 transferred Resident 9 from the lift back to Resident 9's bed. RN 1 applied clotrimazole (antifungal medication) external cream to Resident 9's left and right groin area. RN 1 stated the medication was an antifungal cream. RN 1 stated the groin area looked better, and the area was not as reddened. RN 1 stated Resident 9's left groin area was pink in color. During an interview on 5/30/2025 at 1:41 PM, CNA 1 stated when cleaning [Resident 9] after urination, CNA 1 cleaned from front to back. CNA 1 stated CNA 1 needed to use new clean wipes when cleaning Resident 9 from front to back a second time. During an interview on 5/30/2025 at 2:05 PM, RN 1 stated when cleaning the perineal area, the CNA would clean from front to back and if staff would clean the front side again using the same wipes, bacteria from the back, from the anal area could contaminate the front. During a review of the facility's P&P titled, Perineal Care, dated 9/2022, the P&P indicated it is the practice of the facility to provide perineal care to all incontinent residents in order to promote cleanliness and comfort, prevent infection, skin irritation and to observe resident's skin condition. The P&P indicated for females, open packaged product and obtain the wet cloth, separate the resident's labia (fleshy folds of skin that make up the external female genitalia) with one hand, and cleanse perineum with the other hand by wiping in direction from front to back (from pubic area toward the anus). The P&P indicated repeat on the opposite side using separate section of the washcloth or new disposable wipe. The P&P indicated to clean urethral meatus and vaginal orifice using clean a portion of washcloth or new disposable wipe with each stroke. The P&P indicated to pat dry with a towel. During a review of the Centers for Disease Control and Prevention's (CDC, national public health agency of the United States) topic on Urinary Tract Infection Basics, dated 1/22/2024, the CDC indicated UTI's are common infections that happen when bacteria, often from the skin or rectum (responsible for storing and transporting stool) enter the urethra and infect the urinary tract. https://www.cdc.gov/uti/about/index.html

Based on observation, interview, and record review, the facility failed to ensure safe and appropriate use of side (bed) rails for one of one sampled resident (Resident 8) when, 1. The facility failed to complete a side rail assessment that aligned with the physician's order indicating bilateral half [½-equal part] rails times four and did not reflect the side rails used for Resident 8. 2. The facility failed to obtain a side rail consent for Resident 8 that reflected the physician's order for the use of side rails. Resident 8's side rail consent indicated the use of quarter [¼- one of four equal parts of something] side rails to two sides, The consent did not reflect four quarter side rails used for Resident 8. Additionally, there was no documented evidence that indicated the risks and benefits for the use of all four quarter side rails were explained to Resident 8's responsible party (RP). This deficient practiced placed Resident 8 at risk for injury. (Cross Reference F842) Findings: During a review of Resident 8's admission Record (AR), the AR indicated the facility admitted Resident 8 on 1/18/2018, with diagnoses including dementia (a progressive state of decline in mental abilities), hypertension (HTN-high blood pressure), and dysphagia (difficulty swallowing). During a review of Resident 8's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 3/25/2025, the MDS indicated Resident 8 had severe cognitive (the ability to think and process information) impairment. The MDS indicated Resident 8 was dependent (helper does all of the effort) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and dependent with mobility. During an observation on 5/28/2025 at 09:54 AM, Resident 8 was observed lying in bed in a semi-Fowler's position (when a person lies on their back with the head and upper body raised at an angle of about 30 to 45 degrees). All four quarter (¼-one of four equal parts of something) rails were noted to be up (raised) and in a locked position - two on each side of the bed, at the head and foot of the bed. During a concurrent interview and record review on 5/29/2025 at 11:09 AM, with LVN 1, Resident 8's Side Rail Assessment, dated 3/24/2025 was reviewed. LVN 1 stated the side rail assessment indicated, full side rails on two sides'' were selected as the type of side rail to be used for Resident 8. LVN 1 stated a full side rail was a long, continuous rail running the entire length of the bed on one or both sides. LVN 1 stated when both sides had full-length rails, it was considered full rails on two sides. During a concurrent interview and record review on 5/29/2025 at 11:09 AM, with LVN 1, Resident 8's Order Summary Report (OSR), the OSR indicated a physician's order dated 4/8/2025, reviewed with LVN 1. LVN 1 stated the active physician's order for Resident 8 indicated bilateral (both sides) half (½-equal part) [side] rails times four to provide comfort and security. LVN 1 stated this setup included two half-length rails on each side of the bed - one toward the head and one toward the foot - totaling four rails. During a concurrent interview and record review on 5/29/2025 at 11:09 AM, with LVN 1, Resident 8's Side Rail Consent Form, dated 4/8/2025 was reviewed. LVN 1 stated Resident 8's side rail consent form indicated the use of quarter (¼) rails on two sides. LVN 1 stated (¼) rails on two sides referred to shorter bed rails that were typically used to assist with repositioning or bed mobility, that covered a small portion of the bed used at the head or foot - not a combination of both on all four sides. LVN 1 stated Resident 8's current side rails were placed as indicated in the physician's order of two half-length rails on each side of the bed - one at the head and one at the foot - for a total of four side rails. LVN 1 stated Resident 8's side rail consent form did not accurately reflect resident 8's current bed rail configuration. LVN 1 stated this represented a discrepancy between the side rail consent form and the physician's order. LVN 1 stated that the consent form obtained did not match the physician's directive nor did it reflect the actual side rail configuration in use. There was no documented evidence that indicated the risks and benefits for the use of all four quarter side rails were explained to Resident 8's responsible party (RP). During an interview on 5/29/2025 at 11:09 AM, LVN 1 stated the inconsistencies between Resident 8's side rail assessment, physician's order, and the side rail consent form resulted in a lack of clarity regarding the actual type of side-bed rail to be used and whether the resident's representative was fully informed and consented to the correct intervention. During an interview on 5/30/2025 at 11:30 AM, with the Director of Nursing (DON), the DON stated when bed rails were considered for use, the facility was required to complete a bed rail assessment to determine the clinical necessity, identify any risks, and evaluate alternatives. The DON stated any inconsistencies between each document could result in the wrong type of rail implemented or the resident and family not being fully informed of what type of rail was used. The DON stated this opened the door to potential safety issues or other physical injuries related to improper use of side rails. The DON stated it was very important the side rail assessment accurately reflected Resident 8's current physical and cognitive needs, and for the assessment to align with the physician's order. The DON stated if a mismatch occurred, it could lead to the use of a rail configuration that was not properly evaluated for safety or clinical appropriateness. The DON stated the side rail consent form should match the physician's order and match the bed rail configuration implemented for Resident 8. The DON stated this ensured the resident (in general) or their representative (when a resident is not able to make own decisions) understood and agreed to the exact type of side rails used. The DON stated the side rail assessment and consent form needed to be revised. During a review of the facility's policy and procedure (P&P) titled, Side Rails, undated, the P&P indicated that if it is determined that side rails are appropriate, the risks and benefits of side rail use will be explained to the resident or their representative and written informed consent for the use of side rails will be obtained. During a review of the facility's policy and procedure (P&P) titled, Charting & Documentation, undated, the P&P indicated that documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. During a review of the facility's policy and procedure (P&P) titled, Informed Consent, revision dated 9/2023, the P&P indicated it is the policy of the facility to uphold the rights of residents to participate in the planning and decision-making process concerning their care and treatment. When situations arise that involve complex decisions, the facility will verify that informed consent has been obtained prior to any medical intervention or treatment is initiated, including, bot not limited to, administration of psychotherapeutic medications, application of a physical restraint or the prolonged use of a device that may lead to the inability to regain use of a normal body function and for transfer and discharge. Until such time as devices are identified by statue or regulation that led to the inability to regain use of a normal bodily function are defined this portion of the policy will not be enacted. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, revision dated 8/2013, the P&P indicated the resident has the right to be fully informed in advance about the care and treatment and of any changes in that care or treatment that may affect the resident's well-being, and unless adjudged incompetent or otherwise found to be incapacitated under the laws of the State, participate in planning care and treatment changes in care and treatment.

Based on observation, interview, and record review, the facility failed to ensure accurate documentation for the use of side (bed) rails, for one of one sampled resident (Resident 8), as indicated in the facility's policy and procedure (P&P), titled, Charting & Documentation, The facility failed to: 1.Complete a side rail assessment aligned with the physician's order to indicate bilateral half [½-equal part] rails times four, the assessment did not reflect the side rails used for Resident 8. 2.Obtain a side rail consent for Resident 8 that reflected the physician's order for the use of side rails. Resident 8's side rail consent indicated the use of quarter [¼- one of four equal parts of something] side rails to two sides, The consent did not reflect four quarter side rails used for Resident 8. This deficient practice had the potential to lead to inconsistent and/or inaccurate treatments provided to Resident 8. (Cross Reference F700) Findings: During a review of Resident 8's admission Record (AR), the AR indicated the facility admitted Resident 8 on 1/18/2018, with diagnoses including dementia (a progressive state of decline in mental abilities), hypertension (HTN-high blood pressure), and dysphagia (difficulty swallowing). During a review of Resident 8's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 3/25/2025, the MDS indicated Resident 8 had severe cognitive (the ability to think and process information) impairment. The MDS indicated Resident 8 was dependent (helper does all of the effort) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and dependent with mobility. During an observation on 5/28/2025 at 09:54 AM, Resident 8 was observed lying in bed in a semi-Fowler's position (when a person lies on their back with the head and upper body raised at an angle of about 30 to 45 degrees). All four quarter (¼-one of four equal parts of something) rails were noted to be up (raised) and in a locked position - two on each side of the bed, at the head and foot of the bed. During a concurrent interview and record review on 5/29/2025 at 11:09 AM, with LVN 1, Resident 8's Side Rail Assessment, dated 3/24/2025 was reviewed. LVN 1 stated the side rail assessment indicated, full side rails on two sides'' were selected as the type of side rail to be used for Resident 8. LVN 1 stated a full side rail was a long, continuous rail running the entire length of the bed on one or both sides. LVN 1 stated when both sides had full-length rails, it was considered full rails on two sides. During a concurrent interview and record review on 5/29/2025 at 11:09 AM, with LVN 1, Resident 8's Order Summary Report (OSR), the OSR indicated a physician's order dated 4/8/2025, reviewed with LVN 1. LVN 1 stated the active physician's order for Resident 8 indicated bilateral (both sides) half (½-equal part) [side] rails times four to provide comfort and security. LVN 1 stated this setup included two half-length rails on each side of the bed - one toward the head and one toward the foot - totaling four rails. During a concurrent interview and record review on 5/29/2025 at 11:09 AM, with LVN 1, Resident 8's Side Rail Consent Form, dated 4/8/2025 was reviewed. LVN 1 stated Resident 8's side rail consent form indicated the use of quarter (¼) rails on two sides. LVN 1 stated Resident 8's side rail consent form did not accurately reflect resident 8's current bed rail configuration. LVN 1 stated this represented a discrepancy between the side rail consent form and the physician's order. LVN 1 stated that the consent form obtained did not match the physician's directive nor did it reflect the actual side rail configuration in use. During an interview on 5/29/2025 at 11:09 AM, LVN 1 stated the inconsistencies between Resident 8's side rail assessment, physician's order, and the side rail consent form resulted in a lack of clarity regarding the actual type of side-bed rail to be used and whether the resident's representative was fully informed and consented to the correct intervention. During an interview on 5/30/2025 at 11:30 AM, with the Director of Nursing (DON), the DON stated when bed rails were considered for use, [documents should] accurately reflect Resident 8's current physical and cognitive needs, and the assessment should align with the physician's order. The DON stated if a mismatch occurred, it could lead to the use of a rail configuration that was not properly evaluated for safety or clinical appropriateness. The DON stated the side rail consent form should match the physician's order and match the bed rail configuration implemented for Resident 8. The DON stated the side rail assessment and consent form needed to be revised. During a review of the facility's policy and procedure (P&P) titled, Charting & Documentation, undated, the P&P indicated that 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 follow safe and proper food storage practices in accordance with professional standards for food service safety and the facility's policy and procedure (P&P) by failing to label/date food items in one of one kitchen (Kitchen 1). This deficient practice could result in a risk for serious complications from food borne illness (illness caused by the ingestion of contaminated food or beverage) and/or affect the quality and palatability of food given to the residents. Findings: During a concurrent observation and interview on [DATE], at 8:02 AM., with the Purchasing Clerk (PC) during the initial tour of Kitchen 1, the following were observed on the top open shelf of the preparation counter area: 1. An unlabeled 20 oz (ounces, unit of weight) Lawry's Salt-Free 17 Seasoning with less than one fourth contents remaining with a label date Received date [DATE] 2. An unlabeled 16 oz Sysco Imperial Ground Nutmeg with three quarters contents remaining. 3. An unlabeled 26 oz Sysco Imperial Granulated Garlic with two thirds content remaining. In addition, there was an unlabeled orange and an apple wrapped in [NAME] wrap on top of the counter, stored in a steel wire fruit basket. Inside Refrigerator 10, there was a plastic bag of frozen potato wedges and a plastic bag of frozen onion rings that were unlabeled. Inside Refrigerator 3, there were 2 boxes of fresh apples, 3 boxes of fresh oranges, 1 box of fresh lemons, 1 bin of fresh white onions, 1 bin of fresh red onions, and 2 unlabeled 1-gallon Sysco Ultra Premium Lime Juice one with one fourth contents remaining, the other with one third contents remaining. The PC stated, the food items should have been labeled with opened dates to ensure the facility was not using any expired foods. The PC stated, it was important to know the expiration dates and not to serve expired foods because it [expired food] can cause someone to get sick, could cause food borne illness, and could affect the taste of the food. During an interview on [DATE] at 8:22 AM., with the Cold Food Prep (CFP), the CFP stated, the food items were labeled with the arrival date for the facility to know when the food item expired if it's good or bad and to prevent serving expired food items to prevent residents from getting sick, I wouldn't want them to get sick. During a review of the facility's P&P titled, Labeling and Dating, dated ,d+[DATE], the P&P indicated, all foods would be appropriately wrapped, labeled, and dated based on food storage guidelines. The P&P indicated, all foods were labeled, dated, and securely covered and use-by dates were monitored and followed. During a review of the facility's undated P&P titled, Food Safety Management System, revision date [DATE], the P&P indicated, storage guidelines for quality were as follow: Fresh apples=3 to 5 months in the refrigerator; no guidelines indicating for dry storage Fresh lemons=2 to 5 weeks in the refrigerator Fresh oranges=5 to 6 weeks in the refrigerator; 3 to 4 days in dry storage Spices, ground=6 to 12 months in dry storage.

Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 23) was accurately assessed for elopement risk. This deficient practice had the potential to result in inadequate treatment and care services rendered to Resident 23. Findings: During a review of Resident 23's Admission Record (AR), the AR indicated Resident 23 was admitted to the facility initially on 4/4/2022 with diagnoses including dementia (a decline in mental ability severe enough to interfere with daily life), osteoarthritis (degeneration of joint cartilage and the underlying bone) and repeated falls. During a review of Resident 23's Nursing-Elopement Risk Assessment ([NAME]), dated 3/20/2023, indicated Resident 23 had a history of leaving the facility. During a review of Resident 23's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 2/13/2024 indicated Resident 23 was cognitively intact and able to make needs known. During a review of Resident 23's History and Physical (H&P), dated 3/14/2024, the H&P indicated Resident 23 was alert and able to make decisions regarding routine medical decisions and immediate needs. During a review of Resident 23's Progress Note (PN), effective date 3/19/2024 timed at 4:54 PM, the PN indicated on 3/19/24, Resident 23 was witnessed outdoors without calling for assistance. The PN indicated Resident 23 was being monitored for elopement/exit seeking [behavior] and Resident 23 had a history of not asking for assistance to spend time outdoors. During a review of Resident 23's care plan (CP), initiated 9/26/2022, the CP indicated on 3/19/2024, Resident 23 went outside to get fresh air without [staff] assistance. The CP include the following problems: poor safety awareness, preferred to be independent beyond Resident 23's ability and verbalized wanting to leave and come back (to the facility) without assistance. During a review of Resident 23's Behavior Monitoring-Medication Administration Record (MAR), for the month of April 2024, the MAR indicated Resident 23 attempted to leave the facility without assistance on 4/23/2024 and 4/27/2024. During a review of Resident 23's Order Summary Report (OSR), active orders as of 5/1/2024, the OSR included a physician's order, dated 3/20/2024, that indicated to apply wander tag to prevent [Resident 23] from leaving the facility without assistance. The OSR included a physician's order, dated 4/11/2024, that indicated to monitor the number of episodes of leaving without assistance to go outside for fresh air every shift. During a review of Resident 23's [NAME], dated 5/14/2024, the [NAME] indicated Resident 23 was not an elopement risk. During an interview with Registered Nurse 1 (RN 1) and concurrent review of Resident 23's paper and electronic chart on 5/16/2024 at 11:11 AM, RN 1 stated Resident 23 wore an ankle monitor guard because Resident 23 had a history of, and expressed, wanting to go outside of the facility without supervision. RN 1 stated the ankle monitor was used to alert staff when Resident 23 was near the exit doors. RN 1 stated Resident 23 was an elopement risk because Resident 23 vocalized Resident 23 wanted to leave the facility. RN 1 stated accuracy of assessment was important to ensure proper interventions were in place and staff was aware of Resident 23's behavior. During an interview and concurrent review of Resident 23's paper and electronic records with the Director of Nursing (DON), on 5/16/2024 at 12:15pm, the DON stated the elopement assessment dated [DATE], was incorrect. The DON stated Resident 23 was found outside of the courtyard 3/2024 and attempted to leave the facility twice on 4/23/24 and 4/27/24. During a review of the facility's policy and procedure (P&P), titled Elopement/Missing Resident and Absentee Notification Plan, revised 3/8/2024, the P&P indicated an elopement risk assessment is conducted by staff for residents identified with risk factors: prior history of elopement, or diagnosis of Alzheimer's, dementia, or other cognitive impairment. The P&P indicated the assessment would be done within 24 hours of admission, quarterly, or when there is a significant change of condition by the charge nurse.

Based on observation, interview, and record review, the facility failed to implement infection control practices to ensure a safe, sanitary, and comfortable environment in accordance with the facility's policy and procedure (P&P) by failing to properly store dirty laundry for one of five sampled residents (Resident 33). This deficient practice had the potential to result in cross contamination (process by which bacteria can be transferred from one area to another) and/or the development and transmission of disease and infection amongst residents and staff. Findings: During a review of Resident 33's Admission Record (AR), the AR indicated, Resident 33 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (also known as a stroke, damage to tissues in the brain due to a loss of oxygen to the area), unspecified, essential primary hypertension (high blood pressure) and unspecified atrial fibrillation ( an irregular, often very rapid heart rate that commonly causes poor blood flow). During a review of Resident 41's History and Physical Examination (H&P), dated 5/12/2024, the H&P indicated, Resident 33 was alert but confused, could make immediate needs known, but was unable to make complex medical decisions. During a review of Resident 33's Minimum Data Set (MDS, an assessment and screening tool), dated 4/4/2024, the MDS indicated, Resident 33's cognitive (ability to think and process information) skills for daily decision making was moderately impaired. The MDS indicated, Resident 33 was dependent (helper does all of the effort) for toileting hygiene. During an observation on 5/13/2024 at 8:58 AM., Resident 33 was awake and alert, sitting on a wheelchair in the hallway by the nursing station. A closed bag of dirty laundry including bed linen was observed on top of the toilet seat in Resident 33's restroom. During a concurrent observation and interview on 5/13/2024 at 9:05 AM., with Certified Nursing Assistant (CNA) 1, a closed bag of dirty laundry including bed linen was on top of the toilet seat of Resident 33's restroom. CNA 1 stated, it was hospice (a type of health care that focuses on the care, comfort, and quality of life of a person with a serious illness who is approaching the end of life) staff who came in early in the morning to help with Resident's 33 care. CNA 1 stated, the hospice staff had already been at the facility when CNA 1 arrived to the facility at 6:40 am_ CNA 1 stated, the hospice staff was supposed to put the bag of dirty laundry in the dirty linen barrel. During an interview on 5/16/2024 at 11:12 AM., with the Infection Preventionist Nurse (IP), the IP stated, hospice staff came to the facility and helped with [resident] care. The IP stated the hospice staff was supposed to put the bag of dirty laundry in the dirty linen barrel and not leave it [bag of dirty laundry] on the toilet seat because it's contamination and for infection control [purposes]. During a review of the facility's undated P&P titled, Infection Prevention & Control Program, the P&P indicated, an infection prevention and control program was established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. During a review of the facility's P&P titled, Personal Laundry, revised date 7/10/2023, the P&P indicated, the purpose of the P&P procedure was to provide a process for the safe and aseptic handling, washing, and storage of laundry. The P&P indicated; all soiled laundry must be placed directly into a closed laundry hamper bag.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 12) received treatment and care in accordance with the facility's policies and procedures (P&P) by failing to ensure Resident 12's skin tear and edema (swelling caused by too much fluid trapped in the body's tissues) were monitored and cared for adequately. This deficient practice resulted in no improvement to Resident 12's skin tear and edema and caused Resident 12 to feel worried, in addition, the failure had the potential to result in a physical decline to Resident 12. Findings: During a review of Resident 12's Admission Record (AR), the AR indicated, Resident 12 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including unspecified atrial fibrillation (an irregular, often very rapid heart rate that commonly causes poor blood flow), essential primary hypertension (high blood pressure) and other specified disorders of bone density and structure, unspecified site. During a review of Resident 12's Care Plan (CP) titled, Risk for developing pressure ulcers, bruising, and other types of impaired skin integrity, date initiated 2/23/2024, the CP indicated, one of the interventions was to assess skin integrity during care. During a review of Resident 12's CP, titled, At risk for skin breakdown, weight loss, formation of contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and tightness of the joints), joint limitation, increase pain, intractable pain, isolation, and reduced social interaction, date initiated 2/27/2024, the CP indicated, one of the interventions was to assess skin condition. During a review of Resident 12's CP, titled, Skin tear proximal left ankle clarification of location from left ankle date initiated 5/2/2024, the CP indicated, one of the interventions was to Geri (skin) sleeves to be applied to legs daily and removed at bedtime every day and evening shift for Skin Maintenance. During a review of Resident 12's History and Physical Examination (H&P), dated 3/1/2024, the H&P indicated, Resident 12's skin had erythema (redness of the skin caused by injury or another inflammation-causing condition) with mottling (blotchy, red-purplish marbling of the skin). The H&P indicated, Resident 12 had generalized weakness and was alert and oriented. During a review of Resident 12's Minimum Data Set (MDS, an assessment and screening tool), dated 3/1/2024, the MDS indicated, Resident 12's cognition (ability to understand and process information) was intact. The MDS indicated, Resident 12 was at risk for developing pressure ulcers/injuries (injury to skin and underlying tissue resulting from prolonged pressure on the skin) and Resident 12 had no ulcers/wounds/skin problems on Resident 12's feet. During a review of Resident 12's Change in Condition (COC), dated 5/2/2024, timed at 4:05 PM., the COC indicated, noted skin tear to [Resident 12's] left ankle and edema +2 (a grading system to determine the severity of the edema on a scale from +1 to +4, none to severe) on BLE (bilateral lower extremities, both legs) with some weeping (fluid leaking out directly from the skin) on the LLE (left lower extremities). During a review of Resident 12's Interdisciplinary Team (IDT, a team of health care professions who work together to establish plans of care for residents), dated 5/3/2024, timed at 12:58 PM., the IDT indicated, Resident 12 had pitting edema (when an indentation remains after pressing swollen skin) and had fragile skin and recommended [putting on] geri sleeves (to protect the skin) on the BLE and continue the plan of care for skin breakdown. The IDT indicated, Resident 12 was at risk for further skin breakdown due to anticoagulant (blood thinner) therapy, poor fluid/dietary intake, aging process, fragile skin, impaired balance, impaired mobility, poor safety awareness, impaired vision, and ambulating without assistance. During a concurrent observation and interview on 5/13/2024 at 1:46 PM., with Resident 12 in Resident 12's room, Resident 12 was ambulating (walking) slowly independently. Resident 12's legs were open to air, appearing light purple in color, had edema (more edema on the left side) on both legs, and had minimal weeping. Resident 12 had a bandage on the left inner ankle and stated, the facility was not doing anything about Resident 12's legs and Resident 12 was disappointed, concerned, and felt the staff had neglected the edema on her legs. Resident 12 asked, What are they doing? Why is it not healing? Resident 12 stated, the swelling was small when Resident 12 was admitted to the facility but got worse and was not better. Resident 12 stated, it's been a month and thought Resident 12 should see a dermatologist (a medical doctor who specializes in treating the skin, hair, and nails). Resident 12 stated, the staff told Resident 12 to only elevate her legs, but really nothing. During an interview on 5/13/2024 at 2:05 PM., with the Personal Caregiver (PCG), the PCG stated, the PCG reported Resident 12's edema 2 weeks ago after the PCG noticed the left foot was bigger than the right foot. During a concurrent observation and interview on 5/14/2024 at 3:10 PM., with Resident 12, Resident 12 was up in Resident 12's room using a rollator walker (a walker with a built-in seat). Resident 12's legs were swollen, open to air, with the left side worse than the right side. Resident 12 stated, nobody had checked on Resident 12's swollen legs and the evening [shift] staff would look at it they always pass it on. During a concurrent interview and record review on 5/15/2024 at 9:58 AM., with the Quality Assurance Nurse (QAN), Resident 12's Physician Orders (PO), were reviewed. The PO indicated, Geri (skin) sleeves [were] to be applied to the legs daily and removed at bedtime every day and during the evening shift for Skin Maintenance ordered on 5/3/2024. The QAN stated, Resident 12 did not have a geri sleeve on and this was important to protect Resident 12's skin. During an observation on 5/15/2024 at 10:26 AM., with the QAN, Resident 12's legs were observed. Resident 12 had no geri sleeves on. Resident 12's legs were swollen, the left leg had a dry kerlix (dressing used to cover wounds) dressing wrapped around the left ankle, and the dressing was constricting the area. The QAN removed the kerlix dressing and Resident 12's left leg had a dark purplish, blackish discolored section with a skin tear/wound and scanty weeping. During an interview on 5/15/2024 at 10:30 AM., with Resident 12, Resident 12 stated, the staff had not told Resident 12 about [Resident 12 wearing] geri sleeves and Resident 12 had not heard about a geri sleeve. During a concurrent interview and record review on 5/15/2024 at 11:24 AM., with Registered Nurse 1(RN 1), Resident 12's PO, were reviewed. The PO indicated, a Geri sleeves to be applied to the legs daily and removed at bedtime every day and evening shift for Skin Maintenance ordered on 5/3/24. RN 1 stated, RN 1 was aware of Resident 12's edema and skin tear on Resident 12's left ankle. RN 1 stated, the order for a geri sleeve was not carried out. RN 1 stated, it was important to carry out the PO because the geri sleeve was an extra layer [added] to protect Resident 12's skin. During a concurrent interview and record review on 5/15/2024 at 11:51 AM., with the Assistant Director of Nursing (ADON), Resident 12's medical records (MR), were reviewed. The ADON stated, there was no skin assessment done on Resident 12 and a skin assessment should have been done for a skin tear that was either not responding well to the treatment or worsening. The ADON stated, Resident 12's skin tear should have been assessed due to not responding to the treatment, change in edema, and [the staff] should have reached out to the doctor [to obtain] further recommendations. The ADON stated, the geri sleeve could have minimized further skin [breakdown] and for protection. During a review of the facility's undated P&P titled, Skin-Open Wound, Skin Tears, Bruises, Abrasions, Edema and Minor Breaks, Care Of, the P&P indicated, the purpose of the P&P procedure was to guide the prevention and treatment of abrasions, skin tears, bruises, edema, swelling and minor breaks in the skin. The P&P indicated, to review the resident's care plan, current orders, and diagnoses to determine resident needs. During a review of the facility's P&P titled, Quality of Care - Quality of Life, dated 2015, the P&P indicated, OBRA (Omnibus Reconciliation Act of 1987) emphasized the need for all health care providers to follow and uphold the Residents Rights which stresses Quality of Care for residents. The standard stresses the need to care for all residents in a manner and in such an environment as will promote maintenance or enhancement of the Quality of Life for each resident. The P&P indicated, performing safe and effective care included recognizing changes in residents' condition and reporting them promptly and performing care correctly as assigned. During a review of the facility's P&P titled, Skin Integrity/Wound Care Program, date revised 12/14/2018, the P&P indicated, residents who have suffered loss of skin integrity receive appropriate treatment.

Based on observation, interview, and record review, the facility failed to follow infection control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) for two of two sampled residents (Resident 284 and 7) and for the laundry room soiled clothing in accordance with the facility's policy and procedure and federal guidelines by failing to: a. Ensure Certified Nursing Assistant 1 (CNA 1) and CNA 2 performed hand hygiene (procedures that included the use of alcohol-based hand rubs [containing 60%-95% alcohol] or hand washing with soap and water) before entering Resident 284's room, putting on gloves, and providing care to Resident 284. b. Ensure two of two laundry baskets located in the laundry room contained the soiled clothing in closed containers. c. Ensure Resident 7's pair of knee-high stockings were hung to dry in a clean area, Resident 7 had a venous ulcer (wound on leg or ankle caused by abnormal or damaged veins) located on the left second toe and was actively receiving wound treatment. These failures had the potential to result in the spread of infections throughout the facility and the development of infections to Residents 284 and 7. Findings: a. During a review of Resident 284's Admission Record indicated, Resident 284 was admitted to the facility on [DATE] with diagnoses that included urinary tract infection (UTI- infections that happen when bacteria, often from the skin or rectum, enter the urethra, and infect the urinary tract) and type II diabetes mellitus (DM2- a condition that happens because of a problem in the way the body regulates and uses sugar as fuel). During a review of Resident 284's Skilled Nursing Facility History and Physical, dated 5/23/2023, indicated Resident 284 was alert and oriented to person, place, and time and Resident 284's mental status was at baseline. During a review of Resident 284's care plan, initiated 5/23/2023, indicated Resident 284 was at risk for recurrent UTI's related to a history of a recurrent UTI diagnosis and antibiotic therapy. During an observation and interview on 5/24/2023, at 3:30 pm, CNA 1 and CNA 2 put on gloves without performing hand hygiene and entered Resident 284's room. CNA 2 stated CNA 2 had just gone to the restroom and washed their hands, but CNA 2 was not able to state whether CNA 2 touched anything before entering Resident 284's room. CNA 1 stated it was important to perform hand hygiene before [performing] patient care to prevent infections. During an interview on 5/24/2023, at 3:47 pm, Licensed Vocational Nurse 1 (LVN 1) stated staff were supposed to perform hand hygiene upon entering resident rooms and before putting on gloves. LVN 1 stated the facility had to stop the spread of infection for the staff and for the residents to keep everyone safe. During an interview on 5/26/2023, at 12:05 PM, the Infection Preventionist Nurse (IPN) stated staff were supposed to perform hand hygiene before and after performing resident care, in between care, when staff got anything soiled, before putting on or removing gloves, and before and after eating. The IPN stated hand hygiene was important to prevent further infections and contamination. During a review of the facility's policy and procedure (P&P) titled, Hand Hygiene, dated 10/2015, indicated the purpose was to prevent the spread of infections. The P&P indicated that employees must wash their hands for at least 15 seconds using soap water before and after direct contact with residents and before assisting residents with personal care. The P&P indicated to use ABHR [alcohol-based hand rub] before and after direct contact with residents, after contact with a resident's intact skin and after contact with objects in the immediate vicinity of the resident. During a review of the Centers for Disease Control and Prevention (CDC)-Hand Hygiene Guidance for Healthcare Settings, reviewed 1/30/2023, indicated healthcare personnel should use or wash with soap and water immediately before touching a patient, after touching a patient or the patient's immediate environment and immediately after glove removal. https://www.cdc.gov/handhygiene/providers/guideline.html 36943 b. During a concurrent observation and interview on 5/24/2023, at 9:09 am, in the laundry room, with Laundry Aide 1 (LA 1), LA 1 stated the facility laundered residents' personal laundry and personal bedding. LA 1 stated the soiled linen area included the area directly in front of the two washing machines. Two white laundry baskets with holes on all four sides of the basket were placed on the floor in front of the washing machines. Both white laundry baskets contained soiled clothing and were not covered. LA 1 stated the facility had a situation in the past in which the soiled clothing contained in the white laundry baskets belonged to a resident (unknown) who was unknowingly positive for Coronavirus-19 (COVID-19, highly contagious virus that can affect lungs and airways). During a follow-up observation on 05/24/2023, at 10:14 am, in the laundry room, the two white baskets that contained dirty linen were in front of the washing machines. There were double stacked dryers directly to the right of the washing machines. A wooden clothing rack was positioned directly to the right of the top dryer. LA 1 put on a pair of disposable gloves and transferred clothing, except one vest and one undergarment, from the washer to the bottom dryer. LA 1 placed the vest and undergarment on hangers which were hung on the clothing rack. During a concurrent observation and interview on 5/24/2023, at 10:30 am, in the laundry room, with the Infection Preventionist Nurse (IPN), the IPN stated soiled linen and clothing should be contained in a bag to prevent [cross] contamination. The IPN stated soiled clothing should be contained in a bag after being sorted. The IPN observed the soiled clothes in the two white laundry baskets located on the floor. The IPN stated the soiled clothes could potentially contaminate the clean linen hung on the clothing rack. During a review of the facility's P&P titled, Personal Laundry, revised on 7/10/2003, indicated All soiled laundry must be placed directly into a closed laundry hamper bag. 42307 c. During a concurrent observation and interview on 5/23/2023, at 12:05 p.m., with CNA 7, in Resident 7's restroom, a pair of knee-high stockings were hanging on the pipe of the toilet. CNA 7 stated the knee-high stockings shouldn't be there. CNA 7 stated, the evening shift did it. They wash it cuz she use every night. CNA 7 stated, the washed knee-high stockings could get contaminated and should have been hung on the towel rack to dry. During a review of Resident 7's Admission Record (AR), the AR indicated, Resident 7 was originally admitted to the facility on [DATE] and last admitted on [DATE] with multiple diagnoses including atrial fibrillation (irregular rapid heart rate), hypertension (high blood pressure), and anemia (low red blood count). During a review of Resident 7's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/20/2022, the MDS indicated, Resident 7 was moderately impaired with cognitive skills (ability to think and reason) for daily decision making. During a review of Resident 7's History and Physical Examination (H&P), dated 3/17/2023, the H&P indicated, Resident 7 was alert and able to make decisions regarding routine medical decisions and immediate needs. During a review of Resident 7's Order Summary Report (OSR), with active orders as of 5/1/2023, the OSR included an order, dated 4/24/2023, indicated Venous ulcer to left second toe cleanse with wound cleanser pat dry apply Xeroform [absorbent dressing used for low draining wounds, maintains a moist wound environment, promotes wound healing] than gauze secure with bandage every evening shift for wound care for 14 days. During a review of Resident 7's Treatment Administration Record (TAR), dated May 2023, the TAR indicated, Resident 7 had a venous ulcer located on the left second toe that was being treated. During an interview on 5/26/23, at 12:05 p.m., with the IPN, The IPN stated, the washed pair of knee-high stockings should not be hung on the pipe of the toilet, for infection control reasons. The IPN stated, staff should hang it in a hanger, something clean, not on the pipe. During a review of the facility's undated P&P titled, Personal Laundry, revised 7/10/2020, the P&P indicated, to provide a process for the safe and aseptic handling, washing, and storage of laundry. During a review of the facility's P&P titled, Infection Prevention and Control Program, revised April 2023, indicated, to provide a safe, sanitary, comfortable environment, and help prevent the development and transmission of communicable diseases and infections. The P&P further indicated, educating staff, and ensuring that they adhered to proper techniques and procedures.

Based on observation, interview, and record review, the facility failed to provide services to maintain mobility (ability to move) for two of six sampled residents (Resident 21 and 20) with limited range of motion (ROM, full movement potential of a joint [where two bones meet]) and mobility. a. For Resident 21, who was left-hand dominant with left sided weakness, the facility failed to complete Rehabilitation Screening Forms in accordance with the facility's policy and provide and provide an adequate exercise program to maintain Resident 21's ROM in both arms as indicated by the Occupational Therapy (OT, profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) discharge recommendations, dated 1/22/2022. b. For Resident 20, the facility did not have any documented evidence Resident 20 performed sit to stand transfers three times per week to maintain mobility. These failures had the potential to result in Resident 21 and Resident 20 to experience a decline in ROM and mobility. Findings: a. During a review of Resident 21's Admission Record indicated the facility originally admitted Resident 21 on 5/19/2021 and was readmitted on [DATE]. The Admission Record indicated Resident 21's diagnoses included Parkinson's disease (progressive disease of the nervous system resulting impaired movement), fusion (surgical connection) of the cervical region (neck) of the spine, and left shoulder osteoarthritis (bone disease that progresses over time, resulting in joint pain and stiffness). During a review of Resident 21's physician orders, dated 11/22/2022, indicated RNA for left arm AROM every day five times per week as tolerated. An additional physician's order for Resident 21, dated 11/22/2022, indicated RNA for right arm AROM every day five times per week as tolerated. During a review of Resident 21's OT Daily Encounter Notes (OT treatment notes) for 1/2022 indicated Resident 21 performed arm active assistive range of motion (AAROM, use of muscles surrounding the joint to perform the exercise but required some help from a person or equipment) exercises on 1/7/2022, 1/11/2022, 1/13/2022, 1/14/2022, and 1/18/2022. During a review of Resident 21's OT Discharge Summary, dated 1/22/2022, indicated recommendations for a Restorative Nursing Program (RNP, nursing program that uses restorative nursing aides [RNAs] to help residents maintain their function and mobility) for AAROM exercises. During a review of Resident 21's care plan for ROM, initiated on 1/26/2022, indicated to provide RNA treatments as ordered for right arm active range of motion (AROM, performance of ROM of a joint without any assistance or effort of another person) and left arm AROM every day five times per week as tolerated. During a review of Resident 21's clinical record, the record did not include any Rehabilitation Screening Forms. During a review of Resident 21's Minimum Data Set (MDS, a comprehensive assessment and care planning tool), dated 5/11/2023, indicated Resident 21 had clear speech, clearly expressed ideas and wants, understood verbal content, and was cognitively intact (clear ability to think, understand, learn, and remember). The MDS indicated Resident 21 required supervision (oversight, encouragement, or cueing) for eating and personal hygiene and extensive assistance (resident involved in activity while staff provide weight-bearing support) for bed mobility, transfers between services, dressing, and toilet use. The MDS indicated Resident 21 had functional ROM limitations in both arms and both legs. During a concurrent observation and interview on 5/24/2023, at 9:19 am, in Resident 21's room, with Restorative Nursing Aide 1 (RNA 1), Resident 21 sat in a cushioned armchair while performing arm and legs exercises. Resident 21 repeatedly lifted the right arm in front of the body (shoulder flexion) to approximately shoulder height (90 degrees of motion). Resident 21 repeatedly lifted the right arm away from the body (shoulder abduction) to less than shoulder height. Resident 21's left shoulder flexion was limited to approximately half-way to shoulder height and stated, this is as much as I can do. Resident 21 then performed left shoulder abduction exercises but stopped at four repetitions due to Resident 21's difficulty lifting the arm away from the body. RNA 1 stated Resident 21's left side was weaker than the right side. During an interview on 5/24/2023, at 9:41 am, RNA 1 stated Resident 21 performed AROM exercises to both arms. During an interview on 5/25/2023, at 8:55 am, in Resident 21's room, Resident 21 stated Resident 21's left side became weaker two years ago due to neck stenosis (spaces in the spine narrow and create pressure on the spinal cord). Resident 21 stated Resident 21 underwent neck surgery to prevent Resident 21 from having quadriplegia (weakness or paralysis in both arms and both legs) but the left sided weakness did not improve. Resident 21 stated the weakness to the left side was problematic since Resident 21 was left-hand dominant. During a concurrent interview and record review on 5/25/2023, at 1:04 pm, with the Director of Rehabilitation (DOR), the DOR reviewed Resident 21's OT Discharge Summary, dated 1/22/2022. The DOR stated the OT recommendations for Resident 21 included RNA for AAROM exercises. The DOR stated Resident 21 would benefit from AAROM program if Resident 21 had limited AROM. The DOR stated Resident 21 could potentially develop joint stiffness or impaired mobility if Resident 21 was not assisted to perform the full available ROM in each joint. The DOR stated Resident 21's limited ROM in the arms, including the weakness in the left dominant arm, was not reported. The DOR stated Resident 21 would benefit from an OT evaluation. During an interview on 5/26/2023, at 9:56 am, the DOR stated the Rehabilitation Screening Forms (in general) were not located in the facility's electronic documentation system. During a concurrent interview and record review on 5/26/23, at 10:16 am, with the Director of Nursing (DON) and the Director of Medical Records (DMR), the DON and DMR reviewed Resident 21's clinical record. The DON and DMR did not locate any Rehabilitation Screening Forms in the electronic documentation system or in Resident 21's physical (paper) clinical records. The DON stated the Rehabilitation Screening Forms were not completed for Resident 21 and there was no documentation in the clinical record. During a review of the facility's policy titled, Rehabilitation Screening, approved on 7/13/2018, indicated the Rehabilitation screen provided a benchmark (reference point) of patients' status for future comparison and will facilitate care planning to meet the patient's individual needs. The policy further indicated a Rehabilitation Screening Form will be completed for all residents upon admission, readmission, annually, after a fall, change of condition, and as necessary. b. During a review of Resident 20's Admission Record indicated the facility admitted Resident 20 on 11/23/2022. The Admission Record indicated Resident 20's diagnoses included mild cognitive (ability to think, understand, learn, and remember) impairment of uncertain or unknown etiology (cause), bilateral (both sides) knee osteoarthritis, and difficulty in walking. During a review of Resident 20's MDS, dated [DATE], indicated Resident 20 had clear speech, clearly expressed ideas and wants, understood verbal content, and had severe cognitive impairments. The MDS indicated Resident 20 was not steady and only able to stabilize balance with staff assistance for moving from a seated to standing position, walking, and surface-to-surface transfers. During a review of Resident 20's Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) Discharge Summary, dated 3/29/2023, indicated Resident 20 required moderate assistance (25-50% physical assistance) to ambulate (walk) 20 feet using a rollator walker (assistive walking device with four wheels, a seat, and brakes). The PT recommendations included a restorative nursing program (RNP, nursing program that uses restorative nursing aides [RNAs] to help residents maintain their function and mobility) for ambulation. During a review of Resident 20's physician's orders, dated 3/30/2023, included RNA for ambulation three times per week with rollator walker and moderate assistance. During a review of Resident 20's physician's orders, dated 4/4/2023, indicated to discontinue RNA for ambulation three times per week with rollator walker and moderate assistance. During a review of Resident 20's physician's orders, dated 4/4/2023, indicated an RNA transfer program three times per week for sit to stand exercises using grab bars. During a review of Resident 20's Restorative Nursing Assistant Flow Sheet (record of RNA sessions) for 4/2023 and 5/2023 did not indicate Resident 20's RNA program for sit to stand exercises using grab bars. During a review of Resident 20's physician's orders, dated 5/15/2023, indicated to discontinue RNA for sit to stand exercises using grab bars. Further review of Resident 20's physician's orders, dated 5/16/2023, indicated to perform active assistive range of motion (AAROM, use of muscles surrounding the joint to perform the exercise but required some help from a person or equipment) to both legs three times per week as tolerated. During an interview on 5/25/2023, at 10:58 am, Restorative Nursing Aide 2 (RNA 2) stated, Resident 20 performed sit to stand transfers with RNA 2 using the rollator walker. RNA 2 stated, Resident 20 complained of increased knee pain and could not perform the sit to stand exercise even after being given pain medications. RNA 2 stated, Resident 20's RNA orders were recently changed to AAROM for both legs. During a concurrent interview and record review on 5/25/2023, at 2:33 pm, with the DOR, the DOR reviewed Resident 20's clinical record. The DOR stated, the PT Discharge Summary, dated 3/29/2023, recommended RNA for ambulation. The DOR stated, Resident 20's physician's orders for RNA ambulation was discontinued on 4/4/2023 due to pain in both knees. The DOR stated, Resident 20's RNA order was changed on 4/4/2023 to perform sit to stand transfers. The DOR reviewed Resident 20's RNA Flow Sheet for 4/2023 and 5/2023. The DOR stated, Resident 20's RNA Flow Sheet did not include any documentation for sit to stand transfers. The DOR stated the sit to stand transfers were not completed if it was not documented. During a concurrent interview and record review on 5/26/2023, at 9:16 am, with the DMR, the DMR stated, Resident 20's clinical record did not have any documentation that indicated RNAs performed sit to stand exercises with Resident 20. During a review of the facility's undated P&P for Activities of Daily Living (ADLs) indicated the facility will ensure a resident's abilities in ADLs do not deteriorate unless unavoidable which included a resident's ability to transfer and ambulate.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 21), who was a writer, was provided with adequate furnishing to accommodate the use of a personal computer when Resident 21's desk broke. This failure resulted in Resident 21 not being able to use his personal computer to continue writing a book and had the potential to result in a decline of Resident 21's psychosocial well-being. Findings: During a concurrent observation and interview on 5/23/2023, at 11:20 am., Resident 21 was in his room and a desktop computer monitor was on the floor with a keyboard on top of a stool located next to a desk. Resident 21 stated, the computer had been on top of a desk but Resident 21 backed up on the desk pretty hard, am hoping maintenance will take care of it. Resident 21 stated he was supposed to see the Social Worker (SW). During a concurrent observation and interview on 5/24/2023, at 8:31 am., Resident 21 was in his room, the desktop computer monitor was on the floor with the keyboard on top of a stool. Resident 21 stated, backing his wheelchair onto the desk where the computer was place, and the equipment came tumbling down. The facility took the desk, to put it back together about a month ago. Resident 21 stated, not being able to use his computer, certainly restricts me, am trying to finish a book, on technology. Resident 21 stated, the facility had offered for Resident 21 to use the bedside table but it's very awkward, it's better to put it in one place, the desk. During a review of Resident 21's Admission Record (AR), indicated, Resident 21 was originally admitted to the facility on [DATE] and last admitted on [DATE] with multiple diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily life), insomnia (a common disorder of persistent problems falling and staying asleep) and paraplegia (paralysis that occurs in the lower half of the body). During a review of Resident 21's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/11/2022, indicated, Resident 21 was cognitively intact (ability to think and reason) for daily decision making. During a review of Resident 21's History and Physical Examination (H&P), dated 9/9/2022, the H&P indicated, Resident 21 had the capacity to make decisions. During a review of Resident 21's Progress Notes (PN), dated 5/7/2023, timed at 1:40 pm., the PN indicated, Resident 21's wife came to the nursing station to inform Licensed Vocation Nurse 4 (LVN 4), Resident 21 ran into his desk with his power chair (electric wheelchair). The PN indicated, Resident 21 would like the desk left as is until maintenance could look at it. The PN indicated, message was left for maintenance to follow up. During an interview on 5/25/23, at 10:00 am., with the SW, the SW stated, Resident 21 backed up into his desk with his power chair last week. The SW stated, Resident 21 's desk was made of fiberglass and maintenance said the desk was not salvageable. The SW stated, Resident 21 was offered a larger room and Resident 21's wife was getting a desk and enlisted the facility's interior designer to help with the new room. The SW stated, Resident 21 and wife have an appointment next week with IT (Information Technology, a professional of data or computer system). During an interview on 5/25/23, at 12:29pm., with the Maintenance Supervisor (MS), the MS stated, maintenance was not aware about Resident 21's broken desk. The MS stated, the facility did not usually fix resident's personal belongings and instead notified family. The MS stated, the SW would usually follow up on these matters. During an interview on 5/25/23, at 1:43 pm., with the General Maintenance (GM), the GM stated, maintenance was not aware about Resident 21's broken desk. The GM stated, when he checked in with the SW today, the SW stated EVS (Environmental Services, non-clinical healthcare staff like housekeeping) threw it away, so I never saw it. During a concurrent interview and record review on 5/25/23, at 2:45 pm., with the SW, Resident 21's PN, dated 5/16/23, timed at 11:00 am. and 5/17/23, timed at 1:58 p.m., were reviewed. The PN did not indicate, any documentation regarding Resident 1's broken desk or any accommodations provided by the facility. The SW stated, if it was not documented, it was not done. The SW stated, it was important to document to ensure the facility honored resident preferences. During an interview on 5/25/23, at 2:55 pm., with Licensed Vocation Nurse 1 (LVN 1), LVN 1 stated, staff reported to family, the SW, and contacted maintenance either by email or phone call in the event a resident's personal property got damaged. During a review of the facility's policy and procedure (P&P) titled, Accommodation of Needs, revised March 2021, the P&P indicated, The resident's individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or other resident's would be endangered.

Based on observation, interview, and record review, the facility failed to ensure privacy and a dignified environment for two of two sampled residents (Residents 18 and 284), as indicated in the facility's policy and procedure titled, Dignity, when, a. Resident 18's privacy curtain was not closed during toilet use. b. Resident 284's privacy curtain was not closed during removal of Resident 284's pants and during toilet use. These failures resulted in violation of Resident 18 and 284's right to dignity and privacy. Findings: a. During a review of the resident 18's Admission Record indicated, the facility admitted Resident 18 on 12/9/2020 with diagnoses that included high blood pressure, reduced mobility, and high cholesterol. During a review of the Resident 18's History and Physical (H&P), dated 12/9/2022, indicated Resident 18 was alert, oriented, and was competent to make complex medical decisions. During a review of Resident 18's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 4/10/2023, indicated Resident 18 was cognitively intact (ability to understand and make decisions) and was able to make needs known. Resident 18 required supervision for transfers (how the resident moves between surfaces: bed, chair, wheelchair, standing position), locomotion on and off the unit (how residents move between locations in their room and adjacent corridor on the same floor), personal hygiene, and toilet use. During an observation on 5/23/2023, at 12 pm, Resident 18 was in the restroom sitting on the toilet. Resident 18's room door was slightly open, and the privacy curtain was not drawn shut. Resident 18's body was exposed. During an interview on 05/25/2023, at 9:31 am, Resident 18 stated the curtain was used for privacy because the bathroom door did not close all the way and got stuck when attempting to close. Resident 18 stated she did not have privacy and it felt like Resident 18 was on main street because people walked up and down the hallway and Resident 18 felt like the staff could see Resident 18 when in the bathroom. During an interview on 5/25/2023, at 9:58 am, Licensed Vocational Nurse 2 (LVN 2) stated privacy was important to protect resident's dignity and self-respect. 46687 b. During a review of Resident 284's Admission Record indicated, Resident 284 was admitted to the facility on [DATE] with diagnoses that included left pubis fracture (break in pelvis bone), left acetabulum fracture (break in hip bone), and repeated falls. During a review of Resident 284's Skilled Nursing Facility History and Physical, dated 5/23/2023, indicated Resident 284 was alert and oriented to person, place, and time and Resident 284's mental status was at baseline. During a review of Resident 284's care plan, initiated 5/23/2023, indicated Resident 284 had self-care deficits and was at risk for unavoidable decline for bed mobility, dressing, and toileting. Interventions included to assisted Resident 284 with toileting or incontinent (lack of voluntary control over urination or defecation [discharge of feces from the body]) care as needed and no strenuous exercise. During an observation and interview on 5/24/2023, at 3:25 pm, CNA 1 was removing Resident 284's pants on Resident 284's bed. The door to the room was shut and the privacy curtains alongside the sliding glass door, which lead to a patio, was left open. CNA 1 stated staff, visitors, and residents could walk on the patio. CNA 1 stated she removed Resident 284's pants so Resident 284 could be more comfortable while in bed. CNA 1 stated the privacy curtain needed to be closed all the way when changing Resident 284 to give Resident 284 privacy, or people could see Resident 284's private areas. During an interview on 5/24/2023, at 3:45 pm, Licensed Vocational Nurse 1 (LVN 1) stated the privacy curtain by the window/sliding glass door and restroom must be shut when staff were changing the residents (in general) or performed any patient care tasks. LVN 1 stated [if privacy curtains were not closed] someone could see the resident's private areas, and this could make the residents feel embarrassed. During an observation on 05/26/23, at 12:02 pm, CNA 5 was in the restroom located in Resident 284's room. Resident 284's room door and privacy curtain were open, and Resident 284 was being helped on to the toilet. CNA 5 exited the room leaving the room door and privacy curtain open and stated she would be back. During an observation on 05/26/23, at 12:06 pm, CNA 5 came back into Resident 284's room and into the restroom and CNA 5 did not close the room door or restroom curtain before assisting Resident 284 up from the toilet. During an interview on 5/26/2023, at 12:10 pm, CNA 5 stated she assisted Resident 284 to the toilet. CNA 5 stated the room door or bathroom privacy curtain was to be closed when Resident 284 was in the restroom. CNA 5 stated she did not ensure either were closed because Resident 284's responsible party (RP) was in the room. CNA 5 stated it was important to provide privacy while Resident 284 was using the restroom because Resident 284 was exposed, and someone could see her in a vulnerable position and make Resident 284 feel uncomfortable. During a review of the facility's policy and procedure (P&P) titled, Dignity, revised 2/2021, indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The P&P also indicated staff will promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

Based on observation, interview, and record review, the facility failed to ensure, for one of one sampled resident (Resident 4), an adequate supply of oxygen (02 [a colorless, odorless, tasteless gas essential for living]) in Resident 4's portable oxygen cylinder tank. This failure had the potential to result in the oxygen cylinder tank to run out of oxygen, no delivery of supplemental oxygen, and hypoxia (an absence of enough oxygen or low level of oxygen in the tissues to sustain bodily functions) to Resident 4. Findings: During a review of Resident 4's Admission Record (AR), the AR indicated, Resident 4 was originally admitted on [DATE] and last admitted on [DATE] with multiple diagnoses including right heart failure, hypertension (high blood pressure), and dependence on supplemental oxygen. During a review of Resident 4's History and Physical Examination (H&P), dated 9/24/2022, the H&P indicated, Resident 4 was alert but confused, could make immediate needs known, but was unable to make complex medical decisions. During a review of Resident 4's Care Plan (CP), initiated 9/26/2022, revised 4/14/2023, the CP indicated, Resident 4 was at risk for respiratory distress. The interventions included oxygen at 2 LPM (Liters per Minute, unit of measurement) via nasal cannula ([NC] a device consisting of a lightweight tubing used to deliver supplemental oxygen), may titrate (slowly increase) up to 4 LPM. During a review of Resident 4's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 10/3/2022, the MDS indicated, Resident 4 was severely impaired with cognitive skills (ability to think and reason) for daily decision making. During a review of Resident 4's Order Summary Report (OSR), with active orders as of 5/1/2023, the OSR indicated, an active order dated 11/7/2022 for oxygen at 2 LPM via NC and titrate up to 4 LPM every shift continuously to maintain oxygen saturation (the amount of oxygen you have circulating in your blood) level equal or greater than 92%. During a review of Resident 4's Treatment Administration Record (TAR), dated May 2023, the TAR indicated, Resident 4 was receiving oxygen at 3 LPM by NC. During a review of the facility's in-service lesion plan titled, Following MD Orders for Oxygen, dated 1/30/2023, the in-service indicated, oxygen tanks should be checked every shift and as needed during rounds and changed as needed. During a review of Resident 4's physician Progress Notes (PR), dated 5/3/2023, the PR indicated, Resident 4 was being followed by the physician for chronic (a condition persisting for a long time or constantly recurring) right heart failure with oxygen dependence and delivered by nasal cannula. During a concurrent observation and interview on 5/23/2023, at 11:00 a.m., with Licensed Vocational Nurse 4 (LVN 4), in the activities living room, Resident 4 was sitting up on a wheelchair in front of a table with a puzzle in front and two other residents along with the Life Enrichment Director (LED) were present. Resident 4 was awake and alert but confused. Resident 4 was receiving oxygen at 2 LPM by NC and the pressure gauge needle of the portable oxygen cylinder indicated REFILL. LVN 4 stated, it looks like it should be changed. LVN 4 stated, Resident 4 may not be getting enough oxygen and this could cause confusion and lack of oxygen to the brain. LVN 4 stated, the facility did not have a Respiratory Therapist (RT, member of a health care team that evaluates, treats and cares for patients with breathing and cardio-respiratory problems). LVN 4 stated, I will get a new tank. During an interview on 5/26/23, at 7:25 a.m., with the Director of Nursing (DON), the DON stated, there was a little bit of oxygen left when the portable oxygen cylinder indicated REFILL. The DON stated, the nurses should have checked it because if the cylinder goes empty, it caused lack of oxygen to the resident. During a review of the facility's undated policy and procedure (P&P) titled, How to Use an Oxygen Tank, the P&P indicated, check the pressure gauge to verify that there is enough oxygen in the tank (full is approximately 2,000 psi [pounds per square inch]).

Based on observation, interview, and record review, the facility failed to ensure, for one of one sampled resident (Resident 6), the correct low air loss (LAL, a mattress designed to distribute body weight and prevent and treat pressure wounds) mattress setting was used per Resident 6's weight. This failure had the potential to result in the development of pressure injuries (PIs, localized damage to the skin and underlying tissue, primarily caused by prolonged pressure on the skin, shear (mechanical force that causes skin to break of), or friction [surfaces rub against each other]) to Resident 6. Findings: During a review of Resident 6's Admission Record indicated she was admitted on [DATE] with diagnoses that included contractures (shortening and hardening of muscles, tendons, and other tissue) on the right and left elbow, contractures of the left and right hand, Parkinson's Disease (affects movement and often includes tremors), and pemphigoid (rare skin condition causing large, fluid-filled blisters). During a review of Resident 6's History and Physical (H&P), dated 2/19,2023, the H&P indicated, Resident 6 was non-verbal and did not have the capacity to make medical decisions. During a review of Resident 6's Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 4/6/2023, indicated Resident 6 had severe cognitive impairment (processes of thinking and reasoning), and Resident 6 was totally dependent for bed mobility and activities of daily living (ADL). During a review of Resident 6's care plan, revised on 4/14/2023, indicated Resident 6 was at risk for developing pressure ulcers and due to impaired mobility and severe cognitive impairment. The interventions included checking the function of Citadel Patient Therapy System Bed (LAL) every shift. During a concurrent observation and interview on 5/24/2023, at 11:45 am. Resident 6's LAL mattress was set at 250 pounds (lbs.). Licensed Vocational Nurse 3 (LVN 3) stated the LAL mattress setting was based on the resident's weight and the setting on the bed was programed by the nurses. LVN 3 stated the appropriate setting for Resident 6's LAL mattress was 165 lbs. LVN 3 stated sometimes the buttons on the LAL mattress accidentally get pushed. LVN 3 stated the correct LAL setting was important because it helped prevent breakdown of the skin and if the setting was correct, it would not prevent skin breakdown. During a concurrent interview and record review of the manufacturer guidelines on 5/25/2023, at 2:48 pm., the Director of Nursing (DON) stated LAL mattress settings depended on manufacturer guidelines and the facility programmed according to the weight of the residents. The DON stated it was important for a resident's LAL mattress setting to be programmed based on the weight because the purpose of the mattress was to protect the skin and prevent pressure ulcers. The DON stated Resident 6's LAL mattress setting was incorrect and set at 250 lbs. and should have been set at 165 lbs. During a review of the Citadel Patient Therapy System, Instructions for Use (manufacturer's guidelines), dated 12/2015, indicated to press the height/weight preset button to select the preset that most closely corresponds to the patient's body type and weight. During a review of the facility's policy & procedure (P&P) titled, Support Surface Policy, dated 4/2023, the P&P indicated, During rounds licensed nurse will observe low air loss (LAL) mattress setting is correct.

Based on interview and record review, the facility failed to provide two- person assist during transfer, review and revise the plan of care, and ensure staff does not move the resident's foot prior to a licensed nurse assessment after the fall for one of one sampled resident (Resident 43). As a result, Resident 43 had a fall on 10/21/18 and sustained fracture (broken bone) to the right tibia and fibula (the two bones in the leg below the knee) and underwent surgery. Findings: A review of Resident 43's Admission Record indicated Resident 43 was readmitted to the facility on [DATE]. Resident 43's [DIAGNOSES REDACTED]. A review of Resident 43's Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 9/20/18, indicated Resident 43 had no cognitive impairment and required extensive assistance (staff provided support with bearing weight, at times full staff performance of activity) for transfer. A review of Resident 43's care plan for falls related to impaired balance and non-compliant with asking for assistance, dated 9/24/17, indicated a goal for Resident 43 to minimize falls and related injuries by providing RNA (restorative nursing programs- provide specific treatments to residents so to restore and maintain the strength, coordination and skills to ambulate and perform functional activities of daily living) sit to stand exercises daily and a two person assist with transfers to a commode. A review of another care plan for ADL functional/rehabilitation potential, dated 9/25/17, indicated Resident 43 was at risk for decline in ADL. The goal for Resident 43 was to return to prior level of function by providing RNA (restorative nursing programs- provide specific treatments to residents so to restore and maintain the strength, coordination and skills to ambulate and perform functional activities of daily living) exercises as ordered by the physician, monitor any change of condition and report it to the physician. A review of two Rehabilitation Screening Form for Resident 43 indicated the following: 1. The first form, dated 6/17/18, indicated the assessment was a result of Resident 43's fall in the room. The recommendations were RNA program and assist resident in transfers, use a gait belt (a device used by caregivers to transfer a resident who have problems with balance) snugly, do sit to stand exercises after transfer back to bed and may at times need two person assist. 2. The second form, dated 7/11/18, indicated it was an annual assessment with recommendations to continue with RNA ambulation with a walker. During an interview on 1/29/19 at 12:57 p.m., Resident 43 stated she had lost three months of her life. When asked why, Resident 43 stated she had a wound to her right heel as a result of a fracture. Resident 43 stated she sustained the fracture because she was dropped by an inexperienced staff that helped her during a transfer. Resident 43 stated the incident happened on 10/21/18, on a Sunday morning. During an interview on 1/30/19 at 8:37 a.m., the Director of Nursing (DON) stated Resident 43's fall happened when Resident 43's certified nursing assistant (CNA) was on break. The DON stated CNA 1 was covering the floor for breaks, when she saw Resident 43's call light was on. Upon entering, Resident 43 asked CNA 1 for assistance to get up. CNA 1 told Resident 43 she was going to get help but Resident 43 told CNA 1 not to get help. CNA 1 assisted Resident 43 with the transfer. During the transfer, Resident 43 told CNA 1 she was dizzy and her legs were giving out. CNA 1 was unable to hold Resident 43 and lowered the resident to the floor and called for help. The DON stated CNA 1 remembered Resident 43's foot was turned. Then the licensed nurse came to assess Resident 43. The DON stated Resident 43 was transferred to the acute care hospital and returned after having surgery with non-weight bearing status. The DON stated upon Resident 43's return from the acute care hospital, Resident 43 reported to the staff (MDS nurse, rehab staff, DON and Administrator) that CNA 1 had dropped her. The DON stated she then interviewed staff and usual caregivers. The DON stated the staff reported that Resident 43's character was my way or no way and does not want staff to use gait belt. Resident 43 picks and chooses what staff she prefers to use the gait belt. During the same interview with the DON, a concurrent review of Resident 43's record was conducted. The DON verified the care plan for non-compliance with transfers included an intervention to provide a two- person assist. During an interview on 1/31/19 at 9:41 a.m., CNA 2 stated she had cared for Resident 43 for 1.5 years. CNA 2 stated Resident 43 was non-compliant with care. When asked about Resident 43's care prior to the fall on 10/21/18, CNA 2 stated about two months prior to the fall, she started working with the lift (machine to help transfer) because Resident 43 was having difficulties with the transfers. CNA 2 stated she never did the transfers by herself because the pivot turn was hard and required two persons. CNA 2 stated Resident 43's care was different every day; Resident 43 did not want to use the lift with some staff. CNA 2 stated Resident 43's condition started to change prior to the fall due to weakness in her legs and Resident 43's legs would give out. CNA 2 stated RNA stopped walking Resident 43 because her legs would give out. CNA 2 stated physical therapy assessed Resident 43 because Resident 43 was scared to fall. CNA 2 stated she reported the change in condition (weakness and refusal to use the lift) to the charge nurse. During a review of Resident 43's medical record on 1/31/19 at 10:27 a.m., the Resident Progress Note, dated 6/17/18 at 2:08 p.m., indicated a CNA notified the charge nurse that during a transfer from the power chair to the commode, Resident 43's knees gave out and was eased to the floor. The Skilled Nursing Resident Care Plan Conference, dated 6/21/18, indicated Resident 43 was at risk for falls and injury due to the use of [MEDICATION NAME] (medication that helps make more urine and to lose salt and excess water from the body) and the recommendation included to provide RNA sit to stand exercise. During the same record review, the RNA flowsheet from 6/1/18 to 10/31/18, indicated the following changes in Resident 43's care: 1. On the flowsheet, dated 7/1/18 to 7/31/18, indicated two RNA orders, one for ambulation with front wheel walker since 10/26/17 and a sit to stand exercise order since 6/18/18. On 7/6/18, the RNA documented the sit to stand exercise was on hold until Resident 43 was seen by her physician. There was no documented follow up. 2. On the flowsheet, dated 9/1/18 to 9/30/18, there was a change in RNA care from 9/3/18 to 9/20/18. The documentation indicated Resident 43 had refused RNA ambulation with the front wheel walker from Monday to Friday for three consecutive weeks due to weakness to the legs. A review of the Resident Progress Notes, dated 10/21/18 at 2:20 p.m., indicated at 11:39 a.m., the nurse was called to Resident 43's room and saw Resident 43 sitting on the floor. The notes indicated the CNA and Resident 43 stated the resident was eased to the floor due to Resident 43's knees giving out. During an interview on 1/31/19 at 12:07 p.m., CNA 1 stated she was hired 7-8 months ago. When asked about Resident 43's fall on 10/21/18, CNA 1 stated she was covering for the other CNAs during their breaks when she saw Resident 43's call light on. CNA 1 stated she asked Resident 43 if she needed assistance and Resident 43 stated she needed to use the restroom. CNA 1 then told Resident 43 she needed another person because she was a two- person assist for transfer when Resident 43 stated she did not need anybody else. CNA 1 stated Resident 43 started to stand and CNA 1 assisted Resident 43, when suddenly Resident 43 stated she was feeling dizzy and her legs were weak. CNA 1 stated she assisted Resident 43 down to the floor while holding Resident 43 by her pants. Once CNA 1 lowered Resident 43 to the floor, CNA 1 noticed the right foot was folded backwards and fixed it (moved the foot). CNA 1 stated she then pulled the emergency call light in the restroom and the charge nurse entered the resident's room. During an interview on 1/31/19 at 1:12 p.m., and concurrent record review, the MDS nurse verified that Section E of the MDS, dated [DATE], for rejection of care was coded incorrect. The MDS nurse stated Resident 43 refused RNA exercises from 9/3/18 to 9/20/18. The MDS nurse stated if Section E question E0800 was coded with refusal of care, the staff would have been prompted to notify the physician and the care plan would have been revised. MDS nurse verified both were not done. During an interview on 1/31/19 at 1:32 p.m., the DON stated the facility did not have a policy for refusal of care. During the interview, a concurrent review of Resident 43's record was conducted with the DON. The DON verified that the care plans were not reviewed and revised for the refusal of RNA. The DON stated when a resident was assessed as two- person assist, it meant the resident required two staff for a transfer or to lift the resident. During an interview on 1/31/19 at 2:36 p.m., the Director of Staff Development (DSD) stated CNAs were trained not to move the resident after a fall because the resident could have been injured. During an interview on 2/1/19 at 7:56 a.m., the Administrator and DON stated there was no policy and procedures (P&P) for refusal of care. They both stated if there was a change in condition (C[NAME]), they use the Change of Condition policy and procedures. A review of the Patient Report, dated 10/21/18, indicated Resident 43's right ankle had a distal tibial and fibular fracture (near the ankle joint). A review of the acute care hospital record, dated 10/22/18, indicated Resident 43 had a mechanical fall with right tibia fibula fracture and had an open reduction internal fixation (ORIF/type of surgical procedure used to repair a serious bone break) on 10/24/18. A review of the facility's Change of Condition policy and procedures (P&P), dated 10/15, indicated to report any condition change to the physician so proper treatment will be implemented. The P&P indicated a significant change meant when a condition requires a revision to the care plan. A review of the facility's Care Plan P&P, dated 11/17/14, indicated the care plan should be maintained and incorporate problem areas, revise when there was a condition change and when the desired outcome are not met. A review of the Fall Prevention and Management Program, dated 12/15, indicated resident behaviors will be considered to better understand resident's activities as they relate to falls and will help identify interventions that as resident specific to decrease falls.

Based on observation, interviews, and record review, the facility failed to protect 2 of 6 residents (Residents 1 and 2) from physical abuse during the 3 p.m. to 11 p.m. (evening) shift. a. The Certified Nursing Assistant (CNA) 1, while providing care to Resident 1, placed a wash cloth inside the resident's mouth and a pillow over her face. b. During a bath, CNA 1 slapped Resident 2's face with a wash cloth. The facility's failure to protect the residents from physical abuse caused psychological harm for Residents 1 and 2. Findings: a. A review of the face sheet indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED].), [MEDICAL CONDITION], hypertension (elevated blood pressure), localized [MEDICAL CONDITION] (swelling), [MEDICAL CONDITION] (confused thinking and reduced awareness of the environment), and [MEDICAL CONDITION] (a type of arthritis that occurs when flexible tissue at the end of bones wears down). A review of the Minimum Data Set (MDS, standardized assessment and care screening tool) dated [DATE], indicated Resident 1 was rarely/never able to understand and was rarely/never understood by others. Resident 1's daily decision making was severely impaired. Resident 1 was totally dependent on staff with transfers, moving between locations, dressing, eating, personal hygiene, and bathing. On [DATE] at 2:50 p.m., an interview was conducted with the Administrator. She stated that on [DATE] CNA 2 brought to her attention abuse allegation from CNA 1 towards Residents 1 and 2. CNA 2 told Administrator that she witnessed CNA 1 place a washcloth inside Resident 1's mouth and put a pillow over her face. The Administrator started an investigation and interviewed additional staff who worked closely with CNA 1 and found that there were more witnesses to the alleged abuse. The investigation led the Administrator to believe the abuse allegations towards Resident 1 to be true and that CNA 1's main purpose of placing a washcloth in Resident 1's mouth and a pillow over her face was to muffle Resident 1's screams. The Administrator stated that CNA 1 was scheduled only at the Villa where Resident 1 and 2 were located. The Administrator found CNA 1's actions toward Resident 1 to be a form of physical abuse and stated that upon CNA 1's termination ([DATE]), CNA 1 stated it wasn't just me. The Administrator stated she was not aware of CNA 1 abusing other residents (Resident 2) in Villa 1. The Administrator stated Resident 1 had been declining and had not been able to communicate with the staff before her death on [DATE]. On [DATE] at 4:38 p.m., an interview was conducted with CNA 3. She stated Resident 1 would become very agitated, bite, and twist hands. CNA 3 stated that on [DATE], during the evening shift (3 p.m. to 11 p.m.), she and CNA 1 were changing Resident 1's diaper and the resident started screaming and fighting. CNA 3 witnessed CNA 1 put a wash cloth inside Resident 1's mouth and a pillow over her face. CNA 3 stated she believed CNA 1 acted in such a way to reduce the screaming and the germs/splashing from Resident 1's mouth. CNA 3 stated that CNA 1 was not gentle when handling residents and that the residents would cry when they were cared for by CNA 1. On [DATE] at 3:55 p.m., an interview was conducted with CNA 2. She stated that on [DATE] and 17, 2016 she worked with CNA 1. CNA 2 stated that on [DATE] during patient care, Resident 1 was combative. CNA 2 stated she was holding Resident 1 while CNA 1 was cleaning the resident. During this care, Resident 1 was screaming. CNA 2 witnessed CNA 1 put a wash cloth inside Resident 1's mouth and a pillow over her face. CNA 1 told CNA 2 the action was done because of her germs. CNA 2 removed the pillow from Resident 1's face and CNA 1 placed it over the resident's face again. CNA 1 stated that the wash cloth inside Resident 1's mouth and pillow over her face remained until completion of the care, approximately 3 to 5 minutes. Once the care was completed, CNA 2 removed the pillow and washcloth from Resident 1's mouth. CNA 2 reported the incident to the Administrator on [DATE], 10 days after. On [DATE] at 4:15 p.m., the interview with CNA 2 continued. She stated that CNA 1 had an aggressive personality, would call the staff names stupid, and was rough when handling the residents. CNA 2 recalled that on certain occasions (unable to remember specific residents or dates), residents were sitting in their wheelchairs and would attempt to get up, CNA 1 would push them back down and say, don't get up honey. CNA 2 stated this was physical abuse and the pushing had been happening since February, 2016. CNA 2 stated that she was afraid of CNA 1. The pushing incidents were never reported to the administration. A review of the facility's investigation of possible abuse dated [DATE] indicated that the Registered Nurse (RN 1) remembered a time, upon administration of a suppository to Resident 1, Resident 1 yelled. RN 1 stated that CNA 1 put a towel over Resident 1's face. A review of the employee schedule for July, 2016, indicates CNA 1 worked the evening shift on [DATE], 5, and 6. A review of the employee schedule for July, 2016, indicated CNA 1 worked the evening shift on [DATE], and 13. b. A review of Resident 2's face sheet indicated an admission date of [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS, standardized assessment and care screening tool) dated [DATE] indicated, Resident 2 was able to understand and was usually understood by others. Resident 2 required extensive assistance from staff with toilet use and bathing. On [DATE] at 3:24 p.m., Resident 2 was observed sitting in her wheelchair awake, alert, and very talkative with CNA 2. CNA 2 mentioned CNA 1 to Resident 2 and the resident became hesitant to speak and appeared upset and no longer as talkative, stating It's disturbing. On [DATE] at 3:44 p.m., an interview was conducted with CNA 2. She stated that on [DATE], during the evening shift, a scream came from Resident 2's room. CNA 2 stated that CNA 1 was showering Resident 2. When CNA 1 put Resident 2 back on her bed, CNA 2 came to check on the resident. Resident 2 told CNA 2 that CNA 1 was nasty with her and had slapped her on her face with a wash cloth Resident 2 was crying and told CNA 2, I don't know why, I didn't do anything to her. On [DATE] at 2:58 p.m., during an interview CNA 4 stated that stated that around 2 weeks ago ([DATE], or 20 th), Resident 2 told her I'm scared of someone taking care of me. Resident 2 provided a physical description to CNA 4. CNA 4 stated that CNA 1 was the only CNA who provided care to Resident 2 that fit this description. On [DATE] at 3:46 p.m., an interview was attempted with Resident 2. Resident 2 was asked about CNA 1 and stated she remembered being showered by CNA 1 but the image was disturbing. Resident 2 stated, I don't want to talk about it, it's disturbing. On [DATE] at 4:59 p.m., an interview was conducted with Resident 2. Resident 2 was asked if CNA 1 had slapped her on the face with a wash cloth during her bath. Resident 2 shook her head up and down to indicate yes. Resident 2 stated I didn't like her doing that to me, she has a scary personality. I don't know why she (CNA 1) did that, she's a difficult girl and has an aggressive personality. Resident 2 stated that what CNA 1 did to her made her feel bad, Resident 2 stated I don't want it to happen again. A review of the Elder Abuse Prevention policy and procedure dated [DATE] indicated, It is the policy of the facility to prohibit abuse, mistreatment .All employees must ensure residents' well-being and comply with Federal and State regulations. Any employee who engages in physical, verbal, sexual, or mental abuse .will be subject to disciplinary action. A review of the Course Completion History of the Your Legal Duty-Abuse Prevention Video indicated the following staff completed the facility required abuse training on the following dates: CNA 1 on [DATE], CNA 2 on [DATE], CNA 3 on [DATE], CNA 4 on [DATE], CNA 5 on [DATE] and RN 1 on [DATE].