Every finding on record at Mountain View Conv Hosp

Based on observation, interview, and record review, facility failed to follow the Smoking Policy plan for two of five sampled residents (Resident 1 and Resident 2). This failure had the potential for Resident 1 and Resident 2 not receiving appropriate care and smoking safety instructions specific to the residents smoking need.Findings: During a review of Resident 1's Face Sheet (admission Record), the Face Sheet indicated the facility originally admitted Resident 1 on [DATE], with diagnoses including an encounter for orthopedic aftercare following kidney Transplant (is a follow-up medical appointment used to oversee a resident's recovery, functional rehabilitation, and physical adaptation after a surgical procedure to place a healthy kidney from a living or deceased donor into a person with end stage kidney failure ), muscle weakness, and hypertension (high blood pressure).During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated [DATE], the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact.During a review of Resident 2's Face Sheet, the Face Sheet indicated the facility originally admitted the resident on [DATE] with diagnoses including type 2 DM.During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognition was intact. The MDS indicated Resident 2 needed set-up or clean-up assistance with eating, oral hygiene, upper body dressing, and personal hygiene.During a concurrent observation and interview on [DATE] at 10:30 a.m. with Resident 1, Resident 1 was observed in the hallway in a wheelchair holding a cigarette and a match. Resident 1 stated the facility allowed her to keep a match and her cigarettes. Resident 1 stated the facility allowed her to keep cigarettes and match with her and can go outside to smoke by herself at any time. Resident 1 stated that upon admission she was not informed of the facility's policy on smoking.During an interview on [DATE] at 10:30 a.m. with Resident 2, Resident 2 stated he is a smoker and he goes to smoke without supervision. Resident 2 stated he shares cigarettes with another resident who is also a smoker.During an interview, on [DATE] at 3 p.m., with the Assistant Director of Nursing (ADON), the ADON stated the facility failed to have a baseline care plan upon Resident 1's Admission. The ADON stated the facility was not aware that Resident 1 was a smoker. The ADON stated the facility did not follow its Policy of not allowing residents to have a match with them at the facility. The ADON stated the facility failed to follow its policy of not permitting other residents, in the case of Resident 2, to share smoking items with other residents.During a review of the facility policy and procedure titled, Smoking Policy, last reviewed and approved on [DATE], the policy and procedure indicated, Prior to and upon admission, residents are informed of the facility smoking policy, including designated smoking areas. 7. Resident Smoking status is evaluated upon admission. 13. All other forms of lighters, including matches, are prohibited.

Based on observation, interview, and review, the facility failed to ensure the licensed staff develop a baseline care plan addressing the smoking needs for one of three sampled residents (Resident 1). This failure had the potential for Resident 1 not to receive the care and services related to his smoking while under the care of the facility. Findings: During a review of Resident 1's Face Sheet (admission Record), the Face Sheet indicated the facility originally admitted Resident 1 on [DATE], with diagnoses including an encounter for orthopedic aftercare following kidney transplant (is a follow-up medical appointment used to oversee a resident's recovery, functional rehabilitation, and physical adaptation after a surgical procedure to place a healthy kidney from a living or deceased donor into a person with end stage kidney failure), muscle weakness, and hypertension (high blood pressure). During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated [DATE], the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. During a concurrent observation and interview on [DATE] at 10:30 a.m. with Resident 1, Resident 1 was observed in the hallway in a wheelchair holding a cigarette and a match. Resident 1 stated the facility allowed her to keep a match and her cigarettes. Resident 1 stated that upon admission to the facility she was not informed of the facility's policy on smoking. During an interview, on [DATE] at 3 p.m., with the Assistant Director of Nursing (ADON), the ADON stated the facility failed to have a baseline care plan upon Resident 1's admission. The ADON stated the facility was not aware that Resident 1 was a smoker. The ADON stated the facility did not follow its Policy of doing a baseline care plan upon admission to know the need of the resident while in the facility. During a review of the facility policy and procedure titled, Baseline Care Plan, last reviewed and approved on [DATE], the policy and procedure indicated, A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight hours of admission.

Based on observation, interview, and record review, the facility failed to dispose garbage and refuse properly when: a. Two (2) dumpsters (a movable waste container designed to be brought and taken away by special collection vehicle, or to a bin that a specially designed garbage truck lifts) were not completely closed and was propped open by a piece of wood when not actively in use. b. There were gloves, trash, and liquid drippings in the dumpster surroundings. c. The trash can did not have a cover in the dishwashing area. These failures had potential to attract birds, flies, insects, pests and possibly spread infection to 77 of 77 facility residents. Findings: a&b. During a concurrent observation and interview on 3/24/2026 at 2:32 p.m., of the dumpster area, observed 2 dumpsters were not fully closed, propped open by a piece of wood and the floor surroundings had gloves, trash and liquid drippings. The Dietary Supervisor (DS) stated the garbage needed to be always closed but because the dumpster was in a closed area, it's okay. The DS stated there are gaps and spaces where insects and flies could enter in the closed space where the dumpster is located and it's not acceptable to have the dumpster open because flies could get into it. The DS stated flies could spread infection to residents as a potential outcome. During an interview on 3/25/2026 at 9:20 a.m. with the Maintenance Supervisor (MS), the MS stated he cleans the dumpster area once a week or as needed to make sure there was no trash in the surroundings. The MS stated they needed to make sure that the dumpster lid is always closed so it would not attract flies to minimize the use of pesticide in the facility. The MS stated residents could get sick of stomachache when flies transfer bacteria from one place to another. The MS stated staff placed some wood to hold the lid of the dumpster because the trash is heavy and they forget to close it. During a review of the facility's policies and procedures (P&P) titled, Sanitation, dated 9/10/2025, the P&P indicated, 14. Garbage and refuse containers are in good condition, without leaks, and waste is properly contained in dumpsters/compactors with lids (or otherwise covered). 15. Areas used for garbage disposal free from odors and waste fats and maintained to prevent pests. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 5-501.116 Cleaning Receptacles. Proper storage and disposal of garbage and refused are necessary to minimize the development of odors, prevent such waste from becoming an attractant and harborage of breeding places for insects and rodents, and prevent the soiling of food preparation and food service areas. Improperly handled garbage creates nuisance conditions, makes housekeeping difficult, and may be possible source of contamination of food, equipment, and utensils. Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. Proper equipment and supplies must be made available to accomplish thorough and proper cleaning of garbage storage areas and receptacles so that unsanitary conditions can be eliminated. c. During a concurrent observation and interview of the trash can by the handwashing sink with the DS in the dishroom area, observed a trash can without a cover while not actively being used. The DS stated the trash can is used for soiled paper towels. The DS stated all trash cans should be covered to keep flies away from the area. The DS stated flies could contaminate clean dishes and residents could get sick as a potential outcome. During a review of the facility's P&P titled Sanitation, dated 9/10/2025, the P&P indicated, 13. Kitchen wastes that are not disposed of by mechanical means are kept in clean, leakproof, nonabsorbent, tightly closed containers and disposed of daily. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 5-501.113 Covering Receptacles and waste handling units for refuse, recyclables, and returnable shall be kept covered: (A) Inside food establishment if the receptacles and units: (1) Contain food residue and are not in continuous use; or (2) After they are filled; and 174 (B) With tight-fitting lids or doors if kept outside the food establishment.

Based on observation, interview, and record review, the facility failed to provide residents' meals at regular times scheduled in accordance with resident needs, preferences, and requests when lunch was served late on 3/23/2026. This deficient practice had the potential to result in hunger and frustration for 71 of 77 residents getting food from the kitchen. Findings: During an observation on 3/23/2026 at 8:19 a.m. of the meal schedule posted in the hallway, observed a sign posted in the hallway indicating meals are scheduled as follows: - Breakfast 7:00 a.m. - Lunch 12:00 p.m. - Dinner 5:00 p.m. During a concurrent observation and interview on 3/23/2026 at 11:48 a.m. of the trayline (an area where foods were assembled from the steamtable [kitchen appliance that keeps food warm at a safe temperature for serving] to residents' plates) service with the Dietary Aide (DA) 3, observed DA 3 holding the stem of the thermometer when taking the temperature of the food. Registered Dietitian (RD) 1 corrected DA 3 to hold the indicator head instead of the stem to get accurate food temperatures. DA 3 stated the puree green seas peas had a temperature of 130 degrees Fahrenheit ( F - a scale of temperature). During an interview on 3/23/2026 at 11:51 a.m. with RD 1, RD 1 stated they needed to reheat the food because their standard for food temperature is 165 F. RD 1 instructed [NAME] 1 to place the puree green seas peas back in the oven. During an observation on 3/23/2026 at 11:52 a.m. of DA 3 taking puree meat sauce temperature, observed puree meat sauce was at 126 F. [NAME] 1 placed the puree meat sauce back in the oven. During a concurrent observation and interview on 3/23/2026 at 12:22 p.m. of the lunch trayline service with the Dietary Supervisor (DS), observed trayline service started. The DS stated the trayline service was late because the food temperatures could not be met. During an observation on 3/23/2026 at 12:30 p.m. of the trayline service, observed the first cart come out from the kitchen. During an interview on 3/23/2026 at 2:28 p.m. with the DS, the DS stated the lunch time schedule is at 12 noon. The DS stated the lunch meals were late today (3/23/3036). The DS stated it was important to have the meals served on time for the residents to not get too hungry and have the same time between each meal. The DS stated residents could be agitated as a potential outcome when they are hungry. During a review of the facility's policies and procedures (P&P) titled, Meal Service Time, dated 9/10/2025, the P&P indicated, Each resident will receive at least three meals daily and offered a bedtime snack with no more than 14 hours between dinner and breakfast the next day. If a nourishing snack is offered at bedtime, then 16 hours may lapse between dinner and breakfast the next day. This meal span must be approved by residents. Procedure: 1. Meal hours will be established by management with input from the Resident's Council, who must agree to the 16 hours between the substantial evening meal and breakfast het next day provided that a nourishing snack is offered. 2. The following mealtimes have been established. Breakfast: 7 a.m. Lunch: 12 p.m. Dinner: 5 p.m. Snacks: 10 a.m., 2 p.m., 8 p.m. 3. A schedule of mealtimes shall be posted in resident areas and dining rooms. 4. The order of service shall be established and maintained.

Based on interview and record review, the facility failed the facility failed to ensure residents are screened using the Preadmission Screening and Resident Review (PASRR - a federal requirement to help ensure that individuals are not appropriately placed in nursing homes for long-term care) for a mental disorder (MD - a person's mind makes it hard to think, feel, or act normally in daily living) or intellectual disability (ID - a person has trouble learning, understanding, or solving problems like most people their age) prior to admission and that individuals identified with serious mental illness (SMI) and/or ID/developmental disability (DD)/related conditions (RC) receive the care and services in maintaining his/her highest practicable level in the most appropriate setting for three (3) of 3 sampled residents (Resident 4, 10, and 74), by failing to submit a new Level I PASRR for Resident 4 and Resident 10, who had discrepancy in the previous PASRR Level I Screening and failing to submit a new Level I PASRR screening for Resident 3, who was readmitted to the facility with a diagnosis of a serious mental illness/disorder. These deficient practices had the potential to result in inappropriate placement and unidentified specialized services for the residents. Findings: 1. During a review of Resident 4's admission Record (AR - front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility admitted the resident on 2/3/2025 with diagnoses including respiratory failure (a condition that occurs when the lungs cannot remove all of the carbon dioxide [a colorless, odorless gas that the body breathes out] the body produces), tracheostomy (a surgical opening in the neck into the windpipe when a person is unable to breathe thru the nose or mouth), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression [a serious, persistent mood disorder characterized by a constant feeling of hopelessness, loss of interest in activities, and low energy] to elevated periods of emotional highs). During a review of Resident 4's History and Physical (H&P), dated 2/3/2026, the H&P indicated Resident 4 did not have the capacity to understand and make decisions. During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool), dated 2/5/2026, the MDS indicated Resident 4 the resident diagnosis including bipolar disorder and the resident was not taking any antipsychotic (drug used to manage abnormal condition of the mind described as involved a loss of contact with reality) medications. During a review of Resident 4's PASRR Level I Screening, dated 2/3/2025, the PASRR Level I Screening indicated that the resident did not have a serious diagnosed mental disorder, no suspected mental illness, and has not been prescribed psychotropic (medications capable of affecting the mind, emotions, and behavior) medications. During a concurrent interview and record review on 3/25/2026 at 1:17 p.m. with the Subacute Coordinator (SAC), Resident 4's admission Record, MDS, and PASRR Level I Screening, dated 2/3/2025, were reviewed. The SAC stated that the admission Record indicated that Resident 4 had a diagnosis of bipolar disorder during admission on [DATE] and that Resident 4's PASRR Level I Screening indicated the resident did not have a SMI/ID/DD/RC and did not require a Level II Screening. The SAC stated prior to a resident's admission to the facility, the acute hospital was responsible in ensuring the Level I Screening was completed, then the facility's admitting nurse will verify the accuracy of the screening. The SAC further stated if there was a discrepancy, the facility would then resubmit a new Level I Screening reflecting the resident's current diagnosis. The SAC stated that Resident 4's Level I Screening should have been resubmitted by the admitting nurse to reflect that the resident has bipolar disorder. The SAC stated that if there was no new Level 1 Screening submitted, the resident would not be evaluated and would not receive the appropriate treatment and referral as needed. The SAC stated it could result in a delay of care and services Resident 4 needed. 2. During a review of Resident 10's AR, the AR indicated the facility admitted the resident on 6/10/2024 with diagnoses including respiratory failure with hypoxia, type 2 diabetes mellitus with other specified complication (a disorder characterized by difficulty in blood sugar control and poor wound healing), unspecified psychosis not due to a substance or known physiological condition (unusual thoughts or behavior that are not caused by drugs, alcohol, or another illness, and exact type is unknown). During a review of Resident 10's H&P, dated 2/3/2026, the H&P indicated Resident 10 can make needs known but cannot make medical decisions. During a review of Resident 10's MDS, dated [DATE], the MDS indicated Resident 10 usually makes self-understood and can understand others. The resident diagnoses including psychotic disorder and the resident was not taking any antipsychotic medications. During a review of Resident 10's PASRR Level I Screening, dated 6/10/2024, the PASRR Level I Screening indicated that the resident did not have a serious diagnosed mental disorder, no suspected mental illness, and has not been prescribed psychotropic medications. During a concurrent interview and record review on 3/25/2026 at 1:17 p.m. with the SAC, Resident 10's Admission Record and PASRR Level I Screening, dated 6/10/2024, were reviewed. The SAC stated that the admission Record indicated that Resident 10 had a diagnosis of unspecified psychosis during admission on [DATE] and that Resident 10's PASRR Level I Screening indicated the resident did not have serious mental illness, intellectual disability, developmental disability or related conditions and did not require a PASRR Level II Screening. The SAC stated prior to a resident's admission to the facility, the acute hospital was responsible in ensuring the PASRR Level I Screening was completed, then the facility's admitting nurse will verify the accuracy of the screening. The SAC further stated if there was a discrepancy, the facility would then resubmit a new Level I Screening reflecting the resident's current diagnosis. The SAC stated Resident 10's PASRR Level I Screening should have been resubmitted by the admitting nurse to reflect that the resident has unspecified psychosis. The SAC stated that if there was no new PASRR Level I Screening submitted, the resident would not be evaluated, would not receive the appropriate treatment, and referral as needed. The SAC stated it could result in a delay in care and services Resident 10 needed. 3. During a review of Resident 3's AR, the AR indicated that the facility originally admitted the resident 4/28/2025 and readmitted on [DATE] with diagnoses including post-traumatic stress disorder (PTSD – a disorder in which a person has difficulty recovering after experiencing, or witnessing a traumatic event), unspecified psychosis not due to a substance or known physiological condition, other psychoactive substance abuse, dysphagia (difficulty swallowing), acute kidney failure (a sudden, temporary loss of kidney function), and history of colon cancer (diseases caused when normal body cells stop following instructions, grow uncontrollably, and spread into surrounding tissues). During a review of Resident 3's H&P, dated 8/30/2025, indicated the resident has the capacity to understand and make decisions. During a review of Resident 3's MDS, dated [DATE], indicated Resident 3 was able to make needs known and understand others. The MDS further indicated that Resident 3's the resident had moderate cognitive impairment (a profound loss of mental capacity where a person cannot live independently or care for themselves). The MDS indicated the resident requires assistance with mobility, transfer, and dressing, toilet use, and personal hygiene. During a review of Resident 3's Medication Administration Record (MAR - document used by healthcare professionals to track all medications given to a resident), dated 3/26/2026, the MAR indicated an order for Zoloft (also known as sertraline - a medication commonly used to treat depression, anxiety, PTSD) oral tablet 37.5 milligrams (mg – a unit of measure for mass) one time a day for depression and Seroquel (also known as quetiapine, an atypical antipsychotic medication used to treat bipolar disorder, schizophrenia, and major depressive disorder) oral tablet 25 mg give at bedtime for psychosis. During a review of Resident 3's PASRR Level I Screening, dated 4/25/2025, the PASRR Level I Screening indicated that the resident did not have a serious diagnosed mental disorder, no suspected mental illness, and has not been prescribed psychotropic (medications capable of affecting mind, emotions, and behavior) medications. During a concurrent interview and record review on 3/25/2026 at 1:17 p.m. with the SAC, Resident 3's AR, MDS, MAR, and PASRR Level I Screening, dated 2/3/2025, were reviewed. The SAC stated that the AR indicated that Resident 3 had a diagnosis of PTSD, unspecified psychosis not due to a substance or known physiological condition, and other psychoactive substance abuse during readmission on [DATE]. The SAC stated Resident 3 was prescribed Zoloft and Seroquel and Resident 3's PASRR Level I Screening indicated Resident 3 did not have a SMI/ID/DD/RC and did not require a Level II Screening. The SAC stated prior to a resident's admission to the facility, the acute hospital was responsible in obtaining a completion of Level I Screening, followed by the facility's admitting nurse verification of accuracy of the screening. The SAC further stated that if there was a discrepancy, the facility would resubmit a new Level I Screening showing the current diagnosis of the resident. SAC further stated Resident 3's Level I Screening should have been resubmitted by the admitting nurse to reflect that the resident has SMI. SAC stated that if there was no Level I Screening submitted, the resident would not receive appropriate treatment and referral as needed. SAC stated it could result in a delay of care and services needed for Resident 3. During a review of the facility's policy and procedure (P&P) titled, admission Criteria, last reviewed on 9/10/2025, the P&P indicated that the facility admits only residents who's medical and nursing care needs can be met. The P&P further indicated that one of the objectives of the admission criteria is to admit residents who can be cared for adequately by the facility. The P&P further indicated: - Prior to admission, the resident or representative is informed of any service limitations or special characteristics of the facility. - All new admissions and readmissions are screened for MD, ID, or RD per the PASRR process. a. The facility conducts a Level 1 PASRR screen for all potential admissions, regardless of payor source, to determine if the individual meets the criteria for a MD, ID, or RD. b. If the Level 1 screen indicates that the individual may meet the criteria for an MD, ID, or RD, he or she is referred to the state PASRR representative for the Level II evaluation and determination screening process. (1) The admitting nurse notifies the social services department when a resident is identified as having a possible MD, ID, or RD. (2) The social worker is responsible for making referrals to the appropriate state-designated authority. c. Upon completion of the Level II evaluation, the stated PASRR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate.

Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs and preferences by failing to ensure the pad call light (a specialty alerting device that have ultra-sensitive touch surface for residents with limited mobility for nurses or other nursing personnel to assist a resident when in need) or call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) was within reach for five of seven sampled residents (Residents 66, 40, 90, 31, and 37) reviewed under the environment task. This deficient practice had the potential to result in a delay of care and services and possible injury when Residents 66, 40, 90, 31, and 37 were unable to call for staff assistance. Findings: 1. During a review of Resident 66's admission Record (AR - front page of the chart that contains a summary of basic information about the resident), the AR indicated the facility admitted the resident on 6/2/2023 with diagnoses including acute respiratory failure with hypoxia ( a condition that happens when the body did not have enough oxygen in the blood leading to low oxygen levels), tracheostomy (an opening a surgeon makes through the neck and into the trachea [also known as windpipe] to help a patient breathe), and cardiac arrest (a condition when the heart suddenly stops beating and ca no longer pump blood to the brain and other vital organs and can be fatal). During a review of Resident 66's History and Physical (H&P), dated 6/2/2025, the H&P indicated Resident 66 did not have the capacity to understand and make decisions. During a review of Resident 66's Minimum Data Set (MDS - a resident assessment tool), dated 2/27/2026, the MDS indicated Resident 66 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and was not able to understand and make her needs known. The MDS further indicated Resident 66 had impairment of both upper and lower extremities and required total assistance from staff with all activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 66's Order Summary Report, dated as of 3/26/2026, the Order Summary Report indicated an order on 9/5/2023 for insulin regular, inject subcutaneously (under the skin) per sliding scale (dosage of medication is determined by the resident's blood sugar) before meals and at bedtime. During a review of Resident 66's care plan (CP) on risk for falls, initiated on 6/3/2023 and last revised on 9/8/2025, the CP indicated to place call light within reach as one of the interventions to keep the resident free from falls. During an observation on 3/23/2026 at 10:04 a.m. inside Resident 66's room, observed Resident 66 was unable to talk, turned towards the left side facing the doorway and the pad call light was placed on Resident 66's bed on the uppermost right corner and not touching any part of the resident's head. During a concurrent observation and interview on 3/23/2026 at 12:19 p.m. inside Resident 66's room with Licensed Vocational Nurse (LVN) 3, Resident 66 was observed lying in bed, unable to talk, and was turned towards the left side. LVN 3 stated Resident 66 was unable to move both of her upper extremities and that the pad call light was placed on the uppermost right corner of the bed and was away from any part of the resident's head. LVN 3 stated that the staff should ensure that the pad call light was within the residents' reach prior to leaving the room, especially residents who were unable to move both arms and legs, so they can call for assistance. LVN 3 stated that Resident 66's pad call light should have been within reach at least next to the head so the resident can touch it for assistance by moving her head. LVN 3 stated if the call light was not within Resident 66's reach, it would place the resident at risk for a delay in providing the care and services the resident needed. During a concurrent interview and record review on 3/25/2026 at 1:40 p.m. with the Subacute Coordinator (SAC), Resident 66's fall risk assessments and CP were reviewed. The SAC stated that the fall risk assessments indicated that Resident 66 was at a risk for falls and that the CP on risk for falls indicated to place the call light within reach as one of the interventions to keep Resident 66 free from falls. The SAC stated that staff are supposed to ensure that the pad call lights are placed within the residents' reach after providing care and prior to leaving the room. The SAC stated Resident 66's pad call light should have been placed within the resident's reach and not on the uppermost right corner of the bed as the resident was unable to move both upper and lower extremities and it placed Resident 66 at risk for a delay in receiving the care she needed. The SAC stated that if Resident 66's pad call light was placed closer to the head, the resident would be able to touch the pad call light and call for assistance when needed. 2. During a review of Resident 40's AR, the AR indicated the facility admitted the resident on 10/12/2023 with diagnoses including acute respiratory failure, tracheostomy, and cardiac arrest. During a review of Resident 40's H&P, dated 10/12/2025, the H&P indicated Resident 40 did not have the capacity to understand and make decisions. During a review of Resident 66's MDS, dated 1/9/2026, the MDS indicated Resident 40 had severely impaired cognition. The MDS further indicated Resident 40 had impairment of both upper and lower extremities and required total assistance from staff with all ADLs. During a review of Resident 40's fall risk assessments, dated 7/14/2025, 10/9/2025, and 1/9/2026, the fall risk assessments indicated Resident 40 was at a risk for falls. During a review of Resident 40's CP on risk for falls, initiated on 1/4/2024 and last revised on 10/13/2025, the CP indicated to ensure the resident's call light is within reach as one of the interventions to keep the resident free from falls. During an observation on 3/23/2026 at 10:27 a.m., inside Resident 40's room, observed Resident 40 was lying in bed in supine position, unable to talk, and the pad call light was placed on Resident 40's bed on the uppermost right corner and not touching any part of the resident's head. During a concurrent observation and interview on 3/23/2026 at 12:21 p.m., inside Resident 40's room, with LVN 3, Resident 40 was observed lying in bed in supine position, unable to talk, and the pad call light was placed on the uppermost right corner of the bed and away from any part of the resident's head. LVN 3 stated Resident 40 was unable to move both of her upper extremities. LVN 3 stated that the staff should ensure that the pad call light was within the residents' reach prior to leaving the room, especially residents who were unable to move both arms and legs, so they can call for assistance. LVN 3 stated that Resident 40's pad call light should have been within reach at least closer to the head so the resident can touch it for assistance by moving her head. LVN 3 stated if the call light was not within Resident 40's reach, it would place the resident at risk for a delay in providing the care and services the resident needed. During a concurrent interview and record review on 3/25/2026 at 1:40 p.m. with the SAC, Resident 40's fall risk assessments, and CP were reviewed. The SAC stated that the fall risk assessments indicated that Resident 40 was at a risk for falls and that the CP on risk for falls indicated to place call light within reach as one of the interventions to keep Resident 40 free from falls. The SAC stated that staff are supposed to ensure that the pad call lights are placed within the residents' reach after providing care and prior to leaving the room. The SAC stated Resident 40's pad call light should have been placed within the resident's reach and not on the uppermost right corner of the bed as the resident was unable to move both upper and lower extremities and it placed Resident 40 at risk for a delay in receiving the care she needed. The SAC stated that if Resident 40's pad call light was placed closer to the head, the resident would be able to touch the pad call light and call for assistance when needed. 3. During a review of Resident 90's AR, the AR indicated the facility admitted the resident on 2/27/2026, with diagnoses including dementia (a progressive state of decline in mental abilities), muscle weakness, and reduced mobility. During a review of Resident 90's H&P, dated 3/2/2026, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 90's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had moderate cognitive impairment. The MDS indicated the resident was dependent to needing supervision assistance on mobility and ADLs. During a review of Resident 90's Admission/readmission Data Tool (ADT), dated 2/27/2026, the ADT indicated the resident was at risk for falls. During a review of Resident 90's CP Report titled, The resident is at risk for falls with injury related to limited mobility, cardiac medication use, confusion, incontinence, psychoactive drug (is any chemical substance that crosses into the brain and changes how a person feels, thinks, behaves, or perceives the world) use, initiated on 2/27/2026, the CP indicated an intervention of to be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. During a concurrent observation and interview on 3/23/2026 at 10:10 a.m. with Dialysis Technician (DT) 1, inside Resident 90's room, observed Resident 90's call light was on the floor at the left side of the bed. DT 1 stated the call light should always be within the reach of the resident so they can make their needs known or to call for help when needed. DT 1 stated the resident can also fall while reaching for the call light on the floor. During an interview and record review on 3/25/2026, at 1:01 p.m., with the Assistant Director of Nursing (ADON), Resident 90's ADT and CP were reviewed. The ADON stated the call light should always be within the reach of Resident 90. The ADON stated all staff was responsible in ensuring the call light is within reach of all residents so they can call for help when needed. The ADON stated during the observation period, the staff failed to keep the call light within reach. The ADON stated the failure of the staff to keep the call light within reach can lead to a delay in care and the resident can fall while reaching for it on the floor. The DON stated the resident was at risk for falls dated 6/12/2025 on the ADT and also on the Quarter Risk Data Collection tool dated 3/10/2026, still at risk for falls. The ADON stated the care plan for falls was not followed and the policy and procedure (P&P) titled Answering the Call Light, was not followed. 4. During a review of Resident 31's AR, the AR indicated the facility admitted the resident on 6/12/2025, with diagnoses including dementia, muscle weakness, and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (a type of stroke that occurs when an artery supplying blood to the brain becomes blocked). During a review of Resident 31's H&P, dated 6/13/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 31's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had moderate cognitive impairment. The MDS indicated the resident was dependent to needing supervision assistance on mobility and ADLs. During a review of Resident 31's Quarterly Risk Data Collection Tool (QRDCT), dated 3/10/2026, the QRDCT indicated the resident was at risk for falls. During a review of Resident 31's CP Report titled, The resident is at risk for falls with injury related to limited mobility, stroke, dementia, fractures (break in bone), psychoactive drug use, and weakness, last revised on 6/13/2025, the CP indicated an intervention to be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. During a concurrent observation and interview on 3/23/2026, at 11:04 a.m., with Certified Nursing Assistant (CNA) 1, inside Resident 31's room, observed Resident 31's call light was on the floor at the left side of the bed. CNA 1 stated the call light should always be within the reach of the resident so they can make their needs known or to call for help when needed. CNA 1 stated the resident can also fall while reaching for the call light on the floor. During a concurrent interview and record review on 3/25/2026 at 1:01 p.m., with the ADON, Resident 31's QRDCT and CP were reviewed. The ADON stated the call light should always be within the reach of Resident 31. The ADON stated all staff were responsible in ensuring the call light is within reach of all residents do they can call for help when needed. The ADON stated during the observation period, the staff failed to keep the call light within reach. The ADON stated the failure of the staff to keep the call light within reach can lead to a delay in care and the resident can fall while reaching for it on the floor. The DON stated Resident 31 was at risk for falls on the QRDCT dated 3/10/2026. The ADON stated the care plan for falls was not followed and the P&P titled Answering the Call Light, was not followed. 5. During a review of Resident 37's AR, the AR indicated the facility admitted the resident on 8/23/2021, and readmitted on [DATE], with diagnoses including parkinsonism, unspecified (a condition where a person moves slowly, feels stiff, may shake, and has balance problems, but the exact reason is not identified), chronic respiratory failure with hypoxia, and type 2 diabetes mellitus without complications (a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 37's H&P, dated 8/1/2025, the H&P indicated the resident can make needs known but cannot make medical decisions. During a review of Resident 37's MDS, dated [DATE], the MDS indicated the resident had the ability to sometimes make self-understood and sometimes understand others and had severe cognitive impairment (very limited memory, thinking, decision-making and needs help with daily activities).The MDS indicated Resident 37 was independent to need maximal assistance on mobility and ADLs. During an observation on 3/23/2026, at 12:25 p.m., in Resident 37's room, the resident was observed lying in bed watching television. The call light was noted to be on the left side of the bed, resting on the floor. During a concurrent observation and interview on 3/23/2026, at 12:33 p.m., with CNA 4 stated the call light is on the floor and it is not supposed to be there. CNA 4 stated the call light is supposed to be next to resident so the resident can call for anything that may be needed or in case of emergency. CNA 4 stated the resident would not have been able to call for assistance and it is not appropriate for the call light to be on the floor. During an interview on 3/25/2026, at 1:01 p.m., with the Assistant Director of Nursing (ADON), the ADON stated the call light should be within the reach of the resident. All staff are responsible for ensuring the call light is within reach. The ADON stated call lights not within reach can lead to delays in care and the resident can fall while reaching for call light. ADON stated that the Policy & Procedure (P&P) titled, Answering the Call Light was not followed. During a review of the facility's P&P titled, Call Lights, last reviewed on 9/10/2025, the P&P indicated a purpose to ensure timely responses to the resident's requests and needs. The P&P further indicated to ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower, or bathing facility and from the floor. During a review of the facility's recent P&P titled, Answering the Call Light, last reviewed on 9/10/2026, the P&P indicated the purpose of this procedure is to ensure timely response to the resident's requests and needs. General Guidelines 5. Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor. During a review of the facility's recent P&P titled, Safety and Supervision of Residents, last reviewed on 9/10/2025, the P&P indicated our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Policy Interpretation and Implementation Resident Risks and Environmental Hazards 1. Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include the following: c. Falls

Based on interview and record review, the facility failed to inform and provide a written information to all adult residents concerning the right to accept and refuse medical surgical treatment and, at the resident's option, formulate an advance directive (a legal document indicating resident preference on end-of-life treatment decisions) to three of nine sampled residents (Residents 9, 17, and 3) by the Social Services Director (SSD) failing to provide written information to residents on advanced directive formulation reviewed for Advanced Directives. These deficient practices violated the resident's rights and/or representative's right to be fully informed of the option to formulate their advanced directives. Findings: 1. During a review of Resident 9's admission Record (AR), the AR indicated the facility admitted the resident on 10/8/2024, and readmitted the resident on 9/4/2025, with diagnoses including encephalopathy (a broad term for any disease, damage, or malfunction that alters brain function), dysarthria (a motor speech disorder caused by weakness, paralysis, or lack of coordination in the muscles used for speaking), and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one entire side of the body (left or right)) following cerebral infarction (a type of stroke that occurs when an artery supplying blood to the brain becomes blocked). During a review of Resident 9's History and Physical (H&P), dated 9/5/2025, the H&P indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 9's Minimum Data Set (MDS - a resident assessment tool), dated 1/8/2026, the MDS indicated the resident rarely to never had the ability to make self-understood and understand others and had severe cognitive impairment (a profound loss of mental capacity where a person cannot live independently or care for themselves). The MDS indicated the resident had a family and significant other that was actively participating in assessment and goal setting on the resident's health. During a review of Resident 9's Social Service Review (SSR), dated 12/9/2025, the SSR indicated the resident/representative was not provided with advance directive information. During a review of Resident 9's Care Plan (CP) Report titled, Advanced directives, resident has directives as follows per Physician Orders for Life-Sustaining Treatment (POLST - a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life), last revised on 10/15/2025, the CP indicated an intervention to respect resident and family wishes. During a concurrent interview and record review on 3/25/2026 at 9:36 a.m. with Registered Nurse (RN) 1, Resident 9's electronic health record was reviewed for scanned advanced directive acknowledgement form. RN 1 stated they got rid of the physical medical records for residents, everything was scanned and uploaded to point click care (PCC - an electronic healthcare record). RN 1 stated she did not find any advanced directive acknowledgement form uploaded in PCC for Resident 9. During a concurrent interview and record review on 3/25/2026 at 9:39 a.m. with the SSD, Resident 9's SSR, CP, and Miscellaneous documents in PCC were reviewed. The SSD stated there was no scanned advanced healthcare directive acknowledgment form on the Miscellaneous tab in PCC and her documentation in SSR indicated she did not provide a written advanced healthcare directive formulation information to the resident or representative. The SSD stated she misunderstood the question in the SSR and thought the question was asking if the family provided the advance directive information to her. The SSD stated she had not documented if she has given the information to the resident or representative. The SSD stated her failure to provide a written information on the formulation of advance directive to the resident or representative had violated the rights of the resident to formulate an advanced healthcare directive. 2. During a review of Resident 17's AR, the AR indicated the facility admitted the resident on 1/30/2025, with diagnoses of hepatic encephalopathy (the liver is damaged, it cannot remove toxins from the blood, causing toxins to build up and affect the brain, leading to changes in thinking and behavior); chronic obstructive pulmonary disease, unspecified (COPD - a chronic lung disease causing difficulty in breathing); heart failure, unspecified. During a review of Resident 17's H&P, dated 1/30/2026, the H&P indicated the resident was awake, alert, oriented, cooperative, able to follow commands. The H&P indicated the resident has the capacity to understand and make decisions. During a review of Resident 17's MDS, dated [DATE], the MDS indicated Resident 17 was able to make self-understood and able to understand others. The MDS further indicated that Resident 17 had normal cognitive function (can understand, think clearly, and remember things). The MDS indicated the resident is independent with bed mobility, transfer, dressing, toilet use, eating, and personal hygiene. During a review of Resident 17's SSR, dated 2/1/2026, the SSR indicated the resident/representative was not provided with advance directive information. During a concurrent interview and record review on 3/25/2026 at 9:36 a.m. with RN 1, Resident 17's electronic health record was reviewed and scanned advanced directive acknowledgement form. RN 1 stated they do not have physical medical records for residents, everything was scanned and uploaded to PCC. RN 1 stated she did not find any advanced directive acknowledgement form uploaded into PCC for Resident 17. During a concurrent interview and record review on 3/25/2026 at 9:39 a.m., with the SSD Resident 17's SSR and Miscellaneous documents in PCC were reviewed. The SSD stated there was no scanned advanced healthcare directive acknowledgment form on the Miscellaneous tab in PCC and her documentation in the SSR indicated she did not provide written advanced healthcare directive formulation information to the resident or representative. The SSD stated she misunderstood the question in the SSR. The SSD stated she had not documented if she had given the information to the resident or representative. The SSD stated that by not providing written information about formulating an Advanced Directive there was a potential risk for not honoring resident wishes. 3. During a review of Resident 3's AR, the AR indicated that the facility originally admitted the resident on 4/28/2025 and readmitted on [DATE] with diagnoses including post-traumatic stress disorder (PTSD – a disorder in which a person has difficulty recovering after experiencing, or witnessing a traumatic event), unspecified psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) not due to a substance or known physiological condition, other psychoactive (affecting the mind) substance abuse, dysphagia (difficulty swallowing), acute kidney failure (a sudden, temporary loss of kidney function), and history of colon cancer (disease caused when normal body cells stop following instructions, grow uncontrollably, and spread into surrounding tissues). During a review of Resident 3's H&P, dated 8/30/2025, the H&P indicated the resident has the capacity to understand and make decisions. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 was able to make needs known and understand others. The MDS further indicated that Resident 3's the resident had moderate cognitive impairment. The MDS indicated the resident requires assistance with mobility, transfer, and dressing, toilet use, and personal hygiene. During a concurrent interview and record review on 3/25/2026 at 9:36 a.m. with RN 1, Resident 3's electronic health record was reviewed for scanned advance directive acknowledgement form. RN 1 stated they got rid of the physical medical records for residents, everything was scanned and uploaded to PCC. RN 1 stated she did not find any advance directive acknowledgment form uploaded in PCC for Resident 3. During a concurrent interview and record review on 3/25/2026 at 9:39 a.m. with the SSD, Resident 3's SSR, CP, and miscellaneous documents in PCC were reviewed. The SSD stated there was no scanned advance directive healthcare directive formulation information for the resident. The SSD stated she misunderstood the question in the SSR and thought the question was asking if the family provided the advance directive information to her. The SSD stated she had not documented if she has given the information to the resident or representative. The SSD stated her failure to provide a written information on the formulation of advance directive to the resident or representative had violated the rights of the resident to formulate an advanced healthcare directive. During an interview on 3/25/2026 at 1:11 p.m. with the Assistant Director of Nursing (ADON), the ADON stated the Social Worker was responsible for offering advance healthcare directive formulation information to residents. The ADON stated the SSD should have provided and documented yes on the question in the SSR, on 1b letter g, Advance Directive: Resident/representative provided written advanced directive information. The ADON stated an Advanced Directive is intended to honor residents' wishes regarding medical care and living wills. The ADON stated the SSD failed to provide residents information about the formulation of an Advanced Directive and failed to properly document whether the information had been offered. The ADON stated the SSD failed to provide the advanced healthcare directive information to the resident or representative that led to violation of the resident or representative's right to formulate an advance healthcare directive. The ADON stated there is a potential risk that the resident's wishes may not be followed. During a review of the facility's recent policy and procedure (P&P) titled, Advanced Directives, last reviewed on 9/10/2025, the P&P indicated the resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy. Policy Interpretation and Implementation The facility defines the following in accordance with current OBRA definitions and guidelines: Advance Directive- a written instruction, such as a living will or durable power of attorney for health care, recognized by state law (whether statutory or as recognized by the courts of the state), relating to the provisions of health care when an individual is incapacitated (per 489.100) Determining Existence of Advance Directive 1. The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advanced directive if he or she chooses to do so. 2. The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advanced directive if he or she chooses to do so. 3. Written information about the right to accept or refuse medical or surgical treatment, and the right to formulate an advanced directive is provided in a manner that is easily understood by the resident or representative. 4. Written information includes a description of the facility's policies to implement advanced directives as applicable state law.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for three (3) of three sampled residents (Residents 11, 4) by failing to ensure: 1. Resident 11 had a care plan addressing the schizophrenia (a mental illness that is characterized by disturbances in thought) upon admission from another long-term care facility. 2. Resident 4 had a care plan addressing the bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). These deficient practices had the potential for a delay in the delivery of the necessary care and services the residents need. Findings: a. During a review of Resident 11's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility admitted the resident on 8/10/2023, with diagnoses including chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or remove enough carbon dioxide [a colorless, odorless gas that the body breathes out] from the body), tracheostomy (a surgical opening in the neck into the windpipe when a person is unable to breathe thru the nose or mouth), and paranoid schizophrenia. During a review of Resident 11's History and Physical (H&P) dated 8/10/2025, the H&P indicated Resident 11 had the capacity to understand and make decisions. The H&P further indicated that Resident 11 had a diagnosis of schizophrenia. During a review of Resident 11's Minimum Data Set (MDS, a resident assessment tool), dated 2/5/2026, the MDS indicated Resident 11 had diagnosis of schizophrenia and that the resident was not taking any antipsychotic (drug used to manage abnormal condition of the mind described as involved a loss of contact with reality) medications. During a review of Resident 11's care plans (CP), there was no care plan developed and implemented addressing the resident's schizophrenia. During a concurrent interview and review on 3/25/2026 at 4 p.m., with the MDS Coordinator (MDSC), Resident 11's admission Record, H&P, and CP were reviewed. The MDSC stated Resident 11 was admitted from another long-term care facility with a diagnosis of schizophrenia, and the H&P indicated the resident had schizophrenia. The MDSC further stated there was no CP developed and implemented addressing Resident 11's schizophrenia. The MDSC stated baseline CP is initiated within 48 hours of admission and the comprehensive CP are developed and implemented seven (7) after completion of admission MDS assessment or 21 days after admission in the facility. The MDSC stated that the MDS assistant is responsible in making sure that the care plans are developed and implemented and reviewed during the MDS quarterly assessment. The MDSC stated that the importance of CP is that it is the basis for the facility staff involved in the residents' care of how to properly care for them and meet their needs. The MDSC stated that Resident 11's care plan for schizophrenia should have been developed and implemented timely so the staff involved in his care would be aware of his current condition and properly care for Resident 11 to prevent a delay in the care and services the resident needs. During a concurrent interview and record review on 3/25/2026 at 4:15 p.m., with the Subacute Coordinator (SAC), Resident 11's admission Record, H&P, and CP were reviewed. The SAC stated Resident 11 was admitted from another long-term care facility. The SAC stated that Resident 11 was admitted with a diagnosis of schizophrenia, and the H&P indicated the resident has schizophrenia. The SAC stated there was no CP developed and implemented addressing Resident 11's schizophrenia. The SAC stated that the comprehensive CP are developed and implemented 7 after completion of admission MDS assessment or 21 days after admission in the facility. The SAC stated that the MDSC or her assistant are responsible in making sure that the care plans are developed and implemented and reviewed during the MDS quarterly assessment. The SAC stated that the licensed nurses are also responsible in developing and implementing a care plan to address each resident's needs. The SAC stated that the importance of CP is that it is the basis for the facility staff involved in the residents' care of how to properly care for them and meet their needs. The SAC stated that Resident 11's care plan for schizophrenia should have been developed and implemented timely so the staff involved in his care would be aware of his current condition and properly care for Resident 11 to prevent a delay in the care and services the resident needs. b. During a review of Resident 4's admission Record, the admission Record indicated the facility admitted the resident on 2/3/2025, with diagnoses including respiratory failure (a condition that occurs when the lungs cannot remove all of the carbon dioxide [a colorless, odorless gas that the body breathes out] the body produces), tracheostomy (a surgical opening in the neck into the windpipe when a person is unable to breathe thru the nose or mouth), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 4's History and Physical (H&P) dated 2/3/2026, the H&P indicated Resident 4 did not have the capacity to understand and make decisions and had a diagnosis of bipolar disorder. During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4 had the diagnosis of bipolar disorder, and the resident was not taking any antipsychotic medications. During a review of Resident 4's care plans (CP), there was no care plan developed and implemented addressing the resident's bipolar disorder. During a concurrent interview and review on 3/26/2026 at 2:30 p.m., with the MDSC, Resident 4's admission Record, H&P, and CP were reviewed. The MDSC stated Resident 4 was admitted from an acute hospital with a diagnosis of bipolar disorder, and the H&P indicated the resident has bipolar disorder. The MDSC further stated there was no CP developed and implemented addressing Resident 4's bipolar disorder. The MDSC stated baseline CP is initiated within 48 hours of admission and the comprehensive CP are developed and implemented 7 after completion of admission MDS assessment or 21 days after admission in the facility. The MDSC stated that the MDS assistant is responsible in making sure that the care plans are developed and implemented and reviewed during the MDS quarterly assessment. The MDSC stated that the importance of CP is that it is the basis for the facility staff involved in the residents' care of how to properly care for them and meet their needs. The MDSC stated that Resident 4's care plan for bipolar disorder should have been developed and implemented timely so the staff involved in his care would be aware of his current condition and properly care for Resident 4 to prevent a delay in the care and services the resident needs. During a concurrent interview and record review on 3/26/2026 at 2:45 p.m., with the SAC, Resident 4's admission Record, H&P, and CP were reviewed. The SAC stated that Resident 4 was admitted with a diagnosis of bipolar disorder, and the H&P indicated the resident has bipolar disorder. The SAC stated there was no CP developed and implemented addressing Resident 4's bipolar disorder. The SAC stated that the comprehensive CP are developed and implemented 7 after completion of admission MDS assessment or 21 days after admission in the facility. The SAC stated that the MDSC or her assistant are responsible in making sure that the care plans are developed and implemented and reviewed during the MDS quarterly assessment. The SAC stated that the licensed nurses are also responsible in developing and implementing a care plan to address each resident's needs. The SAC stated that the importance of CP is that it is the basis for the facility staff involved in the residents' care of how to properly care for them and meet their needs. The SAC stated that Resident 4's care plan for bipolar disorder should have been developed and implemented timely so the staff involved in his care would be aware of his current condition and properly care for Resident 4 to prevent a delay in the care and services the resident needs. During a review of the facility's policy and procedure (P&P) titled, Care Plans - Comprehensive Person-Centered, last reviewed on 9/10/2026, the P&P indicated a comprehensive, person-centered care plan that includes measurable objective and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The P&P further indicated: - The interdisciplinary team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of the patients) in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive person-centered care plan for each resident. - The comprehensive person-centered care plan is developed within 7 days of completion of the required MDS assessment (Admission, Annual, or Significant Change in Status), and no more than 21 days after admission. - The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. - The comprehensive person-centered care plan: a. Includes measurable objective and timeframes b. Describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (1) Services that would otherwise be provided for the above, but are not provided due to the resident exercising his/her rights, including the right to refuse treatment; (2) Any specialized services to be provided (3) Which professional services are responsible for each element of care. - When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. - Assessment of residents are ongoing, and care plans are revised as information about the residents and the resident's conditions change.

Based on interview, and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards of care for two of two sampled residents (Residents 7 and 90) reviewed for insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq, beneath the skin) insulin administration sites. The deficient practice had the potential for adverse effect (unwanted, unintended result) of the same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Cross reference F760. Findings: 1. During a review of Resident 7's admission Record (AR), the AR indicated the facility admitted the resident on 7/1/2025, and readmitted the resident on 12/31/2025, with diagnoses including type two (2) diabetes mellitus (DM 2, a disorder characterized by difficulty in blood sugar control and poor wound healing) with foot ulcer (an open sore, wound, or crater on the skin of the foot or toe that takes a long time to heal or keeps returning), long term use of insulin, and alcoholic cirrhosis of liver (a severe, late-stage liver disease caused by long-term, heavy alcohol consumption). During a review of Resident 7's History and Physical (H&P), dated 1/2/2026, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 7's Minimum Data Set (MDS, a resident assessment tool), dated 3/20/2026, the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (having a clear, sharp, and functioning mind that allows a person to think, learn, remember, and make decisions effectively). The MDS indicated the resident was on a high-risk drug class hypoglycemic medication (a type of medicine taken by mouth to lower high blood sugar levels in people with type two (2) diabetes). During a review of Resident 7's Order Summary Report (OSR), the OSR indicated an order for: 12/31/2025 Novolog (a type of insulin) FlexPen (a pre-filled, disposable insulin injection pen) Subcutaneous Solution 100 unit per milliliter (unit/ml, in insulin measures the concentration or strength of the medication-essentially, how much active medicine is packed into a specific volume of liquid) (Insulin Aspart). Inject as per sliding scale (a simple, pre-set chart used to determine a rapid-acting insulin dose based on blood sugar levels): if 151 - 200 = 2 units (Give OJ 8 ounces (oz, a unit of weight equal to one sixteenth of a pound or 16 drams or 28.349 grams) If BS is equal or less than 70, and notify MD); 201 - 250 = 3 units; 251 - 300 = 4 units; 301 - 350 = 5 units; 351 - 400 = 6 units, subcutaneously before meals and at bedtime for DM 2 (Notify MD if blood sugar (BS) is equal or greater than 400), subcutaneously before meals and at bedtime for DM (Administer insulin coverage per sliding scale promptly before or after meals, or with food) (Rotate injection sites). 3/12/2026 Insulin Glargine (a type of insulin) Subcutaneous Solution 100 unit/ml (Insulin Glargine). Inject 28 unit subcutaneously one time a day for DM 2 (Hold if BS is less than 100) (Rotate injection sites). During a review of Resident 7's Care Plan (CP) Report titled, The resident is at risk for hyper (high)/hypoglycemia (low blood sugar) related to diabetes mellitus, initiated on 7/10/2025, the CP indicated an intervention to administer insulin per MD order and to rotate site for insulin injections. During a review of Resident 7's Location of Administration Report (LAR) on the use of Insulin from 1/2026 to 3/2026, the LAR indicated insulin: Glargine Subcutaneous Solution 100 unit/ml was given subcutaneously on, 2/23/2026 at 8:24 a.m. on the Abdomen - Left Lower Quadrant (LLQ) 2/24/2026 at 9:07 a.m. on the Abdomen - LLQ 3/4/2026 at 9:44 a.m. on the Abdomen - LLQ 3/5/2026 at 10:16 a.m. on the Abdomen - LLQ Novolog FlexPen Subcutaneous Solution 100 unit/ml was given subcutaneously on, 2/8/2026 at 11:04 a.m. on the Abdomen - Right Upper Quadrant (RUQ) 2/8/2026 at 4:44 p.m. on the Abdomen - RUQ 2/12/2026 at 9:35 p.m. on the Abdomen - LLQ 2/12/2026 at 9:35 p.m. on the Abdomen - LLQ During a concurrent interview and record review on 3/25/2026, at 1:19 p.m., with the Assistant Director of Nursing (ADON), Resident 7's OSR, CP, and LAR were reviewed. The ADON stated not rotating insulin administration sites of administration is a medication error. The ADON stated the staff failed to rotate sites of injection as seen on the LAR. The ADON stated they rotate insulin administration site to prevent skin damage to residents. The ADON stated the frequented sites of administration can develop lipodystrophy and if administered on that site will cause malabsorption of insulin. The ADON stated the residents can suffer from hypo/hyperglycemia. During a review of the facility's recent policy and procedure (P&P) titled, Insulin Administration, last reviewed on 9/10/2025, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes. Steps in the Procedure (Insulin Injections via Syringe) 16. Select an injection. a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility-provided information on the use of glargine-ygfn subcutaneously, copyright 2023, the information indicated to administer Insulin Glargine-ygfn subcutaneously into the abdominal area, thigh, or deltoid, and rotate injection sites within the same region from one injection to the next to reduce risk of lipodystrophy and localized cutaneous amyloidosis. Do not inject into areas of lipodystrophy or localized cutaneous amyloidosis {see Warnings and Precautions (5.2) and Adverse Reactions (6)]. During a review of the facility-provided Highlights of Prescribing Information (HPI) on the use of Humulin N (insulin isophane human) injectable suspension, for subcutaneous use, with initial U.S. approval in 1982, the HPI indicated to rotated injection sites to reduce the risk of lipodystrophy and localized cutaneous amyloidosis. 2. During a review of Resident 90's AR, the AR indicated the facility admitted the resident on 2/27/2026, with diagnoses including type two (2) diabetes mellitus with proliferative diabetic retinopathy (the most advanced stage of diabetic eye disease, where damaged, blocked blood vessels in the retina trigger the growth of new, fragile vessels), and end stage renal disease (ESRD, irreversible kidney failure). During a review of Resident 90's H&P, dated 3/2/2026, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 90's MDS, dated [DATE], the H&P indicated the resident had the ability to make self-understood and understand others and had moderate cognitive impairment (a stage of brain decline between mild forgetfulness and dementia, where memory or thinking problems noticeably interfere with daily life). The MDS indicated the resident was on a high-risk drug class hypoglycemic medication. During a review of Resident 90's OSR, the OSR indicated an order for: 3/2/2026 Insulin Lispro Injection Solution 100 unit/ml (Insulin Lispro). Inject as per sliding scale: if 150 - 200 = 2 units (Give OJ 8 oz. If BS is less than or equal to 70, and notify MD); 201 - 250 = 3 units; 251 - 300 = 4 units; 301 - 350 = 6 units; 351 - 400 = 8 units (Notify MD if BS is equal or greater than 400), subcutaneously before meals and at bedtime for DM2 administer insulin coverage per sliding scale promptly right before or after meals, and with foods) (Rotate injection sites). 3/3/2026 Insulin Glargine-yfgn Subcutaneous Solution 100 unit/ml (Insulin Glargine-yfgn). Inject 15 unit subcutaneously at bedtime for DM2 (Hold if BS is less than 100) (Rotate injection sites). During a review of Resident 90's Care Plan (CP) Report titled, The resident is at risk for hyper/hypoglycemia related to diabetes mellitus, initiated on 3/2/2026, the CP indicated an intervention to administer insulin per order and to rotate site for insulin injections. During a review of Resident 90's Location of Administration Report (LAR) on the use of Insulin from 3/1/2026 to 3/31/2026, the LAR indicated insulin: Lispro Injection Solution 100 unit/ml was administered subcutaneously on, 3/3/2026 at 4:50 p.m. on the Abdomen - LLQ 3/5/2026 at 4:09 p.m. on the Abdomen - LLQ 3/7/2026 at 9:36 p.m. on the Arm - left 3/8/2026 at 11:23 a.m. on the Arm - left During a concurrent interview and record review on 3/25/2026, at 1:19 p.m., with the ADON, Resident 90's OSR, CP, and LAR were reviewed. The ADON stated not rotating insulin administration sites of administration is a medication error. The ADON stated the staff failed to rotate sites of injection as seen on the LAR. The ADON stated they rotate insulin administration site to prevent skin damage to residents. The ADON stated the frequented sites of administration can develop lipodystrophy and if administered on that site will cause malabsorption of insulin. The ADON stated the residents can suffer from hypo/hyperglycemia. During a review of the facility's recent P&P titled, Insulin Administration, last reviewed on 9/10/2025, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes. Steps in the Procedure (Insulin Injections via Syringe) 16. Select an injection. a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility-provided information on the use of glargine-ygfn subcutaneously, copyright 2023, the information indicated to administer Insulin Glargine-ygfn subcutaneously into the abdominal area, thigh, or deltoid, and rotate injection sites within the same region from one injection to the next to reduce risk of lipodystrophy and localized cutaneous amyloidosis. Do not inject into areas of lipodystrophy or localized cutaneous amyloidosis {see Warnings and Precautions (5.2) and Adverse Reactions (6)]. During a review of the facility-provided Instructions for use on Insulin Lispro, Kwikpen injection, for subcutaneous use 3 ml single-patient use pen (100 units per ml), last revised 7/2023, the Information indicated to change (rotate) your injection sites within the area you choose for each dose to reduce your risk of getting lipodystrophy (pits in skin or thickened skin) and localized cutaneous amyloidosis (skin with lumps) at the injection sites.

Based on observation, interview, and record review, the facility failed to: 1. Provide appropriate treatment and services for care of one (1) of three (3) sampled residents (Residents 111) reviewed for urinary tract infection (UTI, a common infection that occurs when bacteria enters and multiplies in the urinary system, which includes the kidneys, bladder, and urethra) by failing to ensure Resident 111's suprapubic catheters (a thin, flexible tube used to drain urine (pee) from the bladder when a person cannot urinate normally) did not have loops on the catheter tubing. The deficient practice had the potential for the resident to develop urinary tract infection. 2. Provide appropriate treatment and services for care of one (1) of three (3) sampled residents (Residents 113) reviewed for UTI by failing to ensure that Resident 113`s urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) tubing did not have a dependent loop while hanging on the side of the bed. The deficient practice had the potential for the urine not to flow freely, which may lead to the development of UTI. 3. Ensure the urinal bottle (a handheld container designed for collecting urine) for one (1) of three (3) sampled residents (Resident 17), was labeled with the name, room number, and the date the bottle was provided. The deficient practice had the potential to place Resident 17 at risk for an infection Findings: a. During a review of Resident 111's admission Record (AR), the AR indicated the facility admitted the resident on 7/16/2025, and readmitted the resident on 3/6/2026, with diagnoses including urinary tract infection (UTI), enterocolitis due to clostridium difficile (a serious infection of the intestines, specifically affecting the lining of the large intestine (colon) and sometimes the small intestine), and methicillin resistant staphylococcus aureus infection (a type of staph bacteria that causes infections resistant to many common antibiotics, making them harder to treat). During a review of Resident 111's History and Physical (H&P), dated 3/8/2026, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 111's Minimum Data Set (MDS, a resident assessment tool), dated 3/12/2026, the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (having a clear, sharp, and functioning mind that allows a person to think, learn, remember, and make decisions effectively). The MDS indicated that the resident had a catheter and urinary ostomy (commonly called a urostomy). During a review of Resident 111's Order Summary Report (OSR), the OSR indicated an order for: 3/8/2026 Suprapubic catheter French size (FR, is a universal measurement system used to determine the outer diameter (thickness) of a catheter tube) #18/10 cubic centimeter (cc, a small unit of volume used to measure how much space a solid, liquid, or gas takes up) to bladder sphincter dyssynergia (BSD, is a breakdown in coordination between the bladder and the urinary sphincter (the muscle that opens/closes to let urine out)) due to diagnosis (DX). Neurogenic Bladder (a loss of bladder control caused by damage to the nerves, spinal cord, or brain) due to history of cerebrovascular accident (CVA, stroke, loss of blood flow to a part of the brain). 3/8/2026 Change suprapubic Catheter FR#18/10 cc and bag if needed (PRN) if leaking, plugged or pulled out, obstruction, excessive sedimentation (the buildup of mineral salts, and crystalline deposits within the catheter tubing) or when the closed system is compromised. 3/7/2026 Suprapubic Care (flush if with sediments, use of leg strap, position urinary bag below bladder level, with dignity bag, drainage bag not touching the floor). Every day shift and as needed. During a review of Resident 111's Care Plan (CP) Report titled, The resident is at risk for infection due to the resident had a suprapubic catheter for obstructive uropathy (a blockage in the urinary tract that prevents urine from flowing freely, causing it to back up and potentially damage one or both kidneys), last revised on 7/29/2025, the CP indicated an intervention to position the catheter bag and tubing below the level of the bladder, check for kinks each shift, and to provide suprapubic care. During a concurrent observation and interview on 3/23/2026 at 10:06 a.m., with Restorative Nursing Assistant (RNA) 1, inside Resident 111's room, observed Resident 111's suprapubic catheter's tubing looped at the side of the bed with urine trapped on them not draining in the collection bag. RNA 1 stated the suprapubic catheter tubing should not have loops to prevent backflow of the urine into the bladder or growth of bacteria on the tubing where the urine settles, to prevent UTI. During a concurrent interview and record review on 3/25/2026, at 1:44 p.m., with the Assistant Director of Nursing (ADON), Resident 111's OSR and CP were reviewed. The ADON stated the licensed nurses should provide catheter care to the resident and ensured the drainage bag was below the waist, with no loops and kink on tubing. The ADON stated the licensed staff failed to ensure that the urinary catheter tubing was free of loops, which could potentially lead to a backflow of urine into the bladder increasing the risk of UTI. The ADON stated the policy and procedure (P&P) titled, Cather Care, Urinary, was not followed. During a review of the facility's recent P&P titled, Cather Care, Urinary, last reviewed on 9/10/2025, the P&P indicated the purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. Maintaining Unobstructed Urine Flow 1. Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks. 3. Position the drainage bag lower than the bladder at all times to prevent urine from flowing back into the urinary bladder. Steps in the Procedure Routine Perineal Hygiene 17. Check drainage tubing and bag to ensure that the catheter is draining properly. b. During a review of Resident 113's admission Record, the admission Record indicated the facility admitted the resident on 2/27/2026, with diagnoses including acute and chronic respiratory failure (a condition that occurs when the lungs cannot remove all of the carbon dioxide [a colorless, odorless gas that the body breathes out] the body produces), tracheostomy (a surgical opening in the neck into the windpipe when a person is unable to breathe thru the nose or mouth), and neuromuscular dysfunction of bladder (lack of bladder control due to a brain, spinal cord or nerve problem). During a review of Resident 113's H&P dated 2/28/2026, the H&P indicated Resident 113 did not have the capacity to understand and make decisions. During a review of Resident 113's MDS dated [DATE], the MDS indicated Resident 113 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and was unable to understand others and make his needs known. The MDS further indicated Resident 113 required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 113 had an indwelling urinary catheter. During a review of Resident 113's Order Summary Report, the Order Summary Report indicated the following physician's order: - 2/27/2026: Foley catheter (FC – also known as urinary catheter) French (Fr – a unit of measurement) 16 per ten (10) milliliters (ml – a unit of measurement) attached to bedside drainage bag due to neurogenic bladder. - 2/27/2026: Change FC Fr 16 per10 ml and bag if leaking, plugged or pulled out, for obstruction, excessive sedimentation or when the closed system is compromised. as needed. - 2/27/2026: FC: may irrigate with 100 ml of normal saline (NS - a saltwater solution) as needed for clogged catheter tube. - 2/27/2026: FC care every shift During an observation on 3/23/2025 at 11:14 a.m., inside Resident 113's room, observed Resident 113 lying in bed. Observed Resident 113's bedside drainage bag hanging on the right side of the bed frame in the middle and the FC tubing had a dependent loop. During a concurrent observation and interview on 3/23/2026 at 12 p.m. inside Resident 113's room with Licensed Vocational Nurse (LVN) 6, LVN 6 stated Resident 113's urinary tubing had a loop preventing the urine from flowing freely into the bag. LVN 6 stated the urinary catheter tubing had urine in the loop with some white sediments. LVN 6 stated staff responsibility when it comes to care of urinary catheter is to ensure the bag is below the bladder, the bag had privacy cover, and there must be no kink or loop in the tubing. LVN 6 stated if there is a kink or loop the urine cannot flow freely and cause development of urine infection. LVN 6 stated Resident 113's urinary catheter tubing should not have a loop so the urine can flow freely and prevent backing up to the bladder which can cause development of UTI. During an interview on 3/25/2926 at 1:40 p.m., with the Subacute Coordinator (SAC), the SAC stated that for urinary catheter care, the staff are supposed to ensure the drainage bag is not touching floor to keep the bag clean, monitor for signs and symptoms of UTI, application of a leg strap to anchor the tubing and prevent accidental pulling, and the urine should be free flowing. The SAC stated the tubing should not be coiled or have a dependent loop because it prevents the urine to flow freely and can back flow. The DON stated Resident 113's urinary catheter tubing should not have been coiled or kinked as it had the potential for the urine not to flow freely and flow back into the bladder which could lead to development or UTI. During a review of the facility's policy and procedure (P&P) titled, Catheter Care, Urinary, last reviewed on 9/10/2025, the P&P indicated that the purpose of the procedure is to prevent urinary catheter-associated complications, including urinary tract infections. The P&P further indicated that to maintain unobstructed urine flow, check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks and to position the drainage bag lower than the bladder at all times to prevent urine from flowing back into the urinary bladder. c. During a review of Resident 17's admission Record (AR), the AR indicated the facility admitted the resident on 1/30/2025, with diagnoses of hepatic encephalopathy (the liver is damaged, it cannot remove toxins from the blood, causing them to build up and affect the brain, leading to changes in thinking and behavior); chronic obstructive pulmonary disease, unspecified ( COPD- a chronic lung disease causing difficulty in breathing); heart failure, unspecified (when the heart is weak and cannot pump blood around the body properly). During a review of Resident 17's H&P, dated 1/30/26, the H&P indicated the resident was awake, alert, oriented, cooperative, able to follow commands. The H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 17's MDS, dated [DATE], the MDS indicated Resident 17 was able to make self- understood and able to understand others. The MDS further indicated that Resident 17 had normal cognitive function (can understand, think clearly, and remember things). The MDS indicated the resident was independent to staff with bed mobility, transfer, dressing, toilet use, eating, and personal hygiene. During a concurrent observation and interview on 3/23/2026, at 12:35 p.m., with Certified Nurse Assistant (CNA) 4, CNA 4 stated the urinal for Resident 17 did not have room number or the resident's name, initials, and date. CNA 4 stated that by the urinal not having a name, it can be confused with other resident's urinal, and the residents can also get an infection. CNA 4 stated that he (CNA 4) will change the urinal and write room number, initials, and date when it was changed. During an interview on 3/25/2026, at 1:35 p.m., with the Assistant Director of Nursing (ADON), ADON stated urinals should be labeled with the residents' initial and date it was provided to the residents for infection prevention purposes. The ADON stated the Admitting the Resident: Role of the Nursing Assistant, policy was not followed. During a review of the facility's recent policy and procedure (P&P) titled, Admitting the Resident: Role of the Nursing Assistant revised on 9/2013, the P&P indicated write resident's name on appropriate articles (i.e., water pitcher, cup, urinal, denture cup, etc.).

Based on interview, and record review, the facility failed to ensure residents were free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which are not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for two of three sampled residents (Residents 7 and 90) reviewed for insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq, beneath the skin) insulin administration sites. The deficient practices had the potential for adverse effect (unwanted, unintended result) of the same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Cross reference F658. Findings: 1. During a review of Resident 7's admission Record (AR), the AR indicated the facility admitted the resident on 7/1/2025, and readmitted the resident on 12/31/2025, with diagnoses including type two (2) diabetes mellitus (DM 2, a disorder characterized by difficulty in blood sugar control and poor wound healing) with foot ulcer (an open, slow-healing sore or crater-like wound on the skin of the foot), long term use of insulin, and alcoholic cirrhosis of liver (the final, severe stage of long-term liver damage caused by excessive alcohol consumption). During a review of Resident 7's History and Physical (H&P), dated 1/2/2026, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 7's Minimum Data Set (MDS, a resident assessment tool), dated 3/20/2026, the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (having a clear, sharp, and functioning mind that allows a person to think, learn, remember, and make decisions effectively). The MDS indicated the resident was on a high-risk drug class hypoglycemic medication (a type of medicine used to lower high blood sugar levels in people with diabetes, specifically two (2) diabetes). During a review of Resident 7's Order Summary Report (OSR), the OSR indicated an order for: 12/31/2025 Novolog (a type of insulin) FlexPen (a pre-filled, disposable insulin injection pen) Subcutaneous Solution 100 unit per milliliters (unit/ml, a measure of concentration, defining how many units of insulin medication are dissolved in one milliliter (mL) of liquid) (Insulin Aspart). Inject as per sliding scale (a simple, pre-set chart used to determine a rapid-acting insulin dose based on blood sugar levels): if 151 - 200 = 2 units (Give OJ 8 ounces (oz., a unit of weight equal to one sixteenth of a pound or 16 drams or 28.349 grams) If blood sugar (BS) is equal or less than 70, and notify MD); 201 - 250 = 3 units; 251 - 300 = 4 units; 301 - 350 = 5 units; 351 - 400 = 6 units, subcutaneously before meals and at bedtime for DM 2 (Notify MD if BS is equal or greater than 400), subcutaneously before meals and at bedtime for DM (Administer insulin coverage per sliding scale promptly before or after meals, or with food) (Rotate injection sites). 3/12/2026 Insulin Glargine (a type of insulin) Subcutaneous Solution 100 unit/ml (Insulin Glargine). Inject 28 unit subcutaneously one time a day for DM 2 (Hold if BS is less than 100) (Rotate injection sites). During a review of Resident 7's Care Plan (CP) Report titled, The resident is at risk for hyper (high)/hypoglycemia (low blood sugar) related to diabetes mellitus, initiated on 7/10/2025, the CP indicated an intervention to administer insulin per order and to rotate site for insulin injections. During a review of Resident 7's Location of Administration Report (LAR) on the use of Insulin from 1/2026 to 3/2026, the LAR indicated insulin: Glargine Subcutaneous Solution 100 unit/ml was given subcutaneously on, 2/23/2026 at 8:24 a.m. on the Abdomen - Left Lower Quadrant (LLQ) 2/24/2026 at 9:07 a.m. on the Abdomen - LLQ 3/4/2026 at 9:44 a.m. on the Abdomen - LLQ 3/5/2026 at 10:16 a.m. on the Abdomen - LLQ NovoLog FlexPen Subcutaneous Solution 100 unit/ml was given subcutaneously on, 2/8/2026 at 11:04 a.m. on the Abdomen - Right Upper Quadrant (RUQ) 2/8/2026 at 4:44 p.m. on the Abdomen - RUQ 2/12/2026 at 9:35 p.m. on the Abdomen - LLQ 2/12/2026 at 9:35 p.m. on the Abdomen - LLQ During a concurrent interview and record review on 3/25/2026, at 1:19 p.m., with the Assistant Director of Nursing (ADON), Resident 7's OSR, CP, and LAR were reviewed. The ADON stated not rotating insulin administration sites of administration is a medication error. The ADON stated the staff failed to rotate sites of injection as seen on the LAR. The ADON stated they rotate insulin administration site to prevent skin damage to residents. The ADON stated the frequented sites of administration can develop lipodystrophy and if administered on that site will cause malabsorption of insulin. The ADON stated the residents can suffer from hypo/hyperglycemia. During a review of the facility's recent policy and procedure (P&P) titled, Adverse Consequences and Medication Errors, last reviewed on 9/10/2025, the P&P indicated the interdisciplinary team monitors medication usage in order to prevent and detect medication-related problems such as adverse drug reactions (ADRs) and side effects. Policy Interpretation and Implementation Medication Errors 1. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. During a review of the facility's recent P&P titled, Insulin Administration, last reviewed on 9/10/2025, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes. Steps in the Procedure (Insulin Injections via Syringe) 16. Select an injection. a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility-provided information on the use of glargine-ygfn subcutaneously, copyright 2023, the information indicated to administer Insulin Glargine-ygfn subcutaneously into the abdominal area, thigh, or deltoid, and rotate injection sites within the same region from one injection to the next to reduce risk of lipodystrophy and localized cutaneous amyloidosis. Do not inject into areas of lipodystrophy or localized cutaneous amyloidosis [see Warnings and Precautions (5.2) and Adverse Reactions (6)]. During a review of the facility-provided Highlights of Prescribing Information (HPI) on the use of Humulin N (insulin isophane human) injectable suspension, for subcutaneous use, with initial U.S. approval in 1982, the HPI indicated to rotate injection sites to reduce the risk of lipodystrophy and localized cutaneous amyloidosis. 2. During a review of Resident 90's AR, the AR indicated the facility admitted the resident on 2/27/2026, with diagnoses including type two (2) diabetes mellitus with proliferative diabetic retinopathy (the most advanced stage of diabetic eye disease, where high blood sugar causes damage so severe that the eye grows new, fragile blood vessels), and end stage renal disease (ESRD, irreversible kidney failure). During a review of Resident 90's H&P, dated 3/2/2026, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 90's MDS, dated [DATE], the H&P indicated the resident had the ability to make self-understood and understand others and had moderate cognitive impairment (a stage of mental decline, often between mild impairment and dementia, where memory, thinking, and reasoning problems are noticeable to others and interfere with daily tasks). The MDS indicated the resident was on a high-risk drug class hypoglycemic medication. During a review of Resident 90's OSR, the OSR indicated an order for: 3/2/2026 Insulin Lispro Injection Solution 100 unit/ml (Insulin Lispro). Inject as per sliding scale: if 150 - 200 = 2 units (Give OJ 8 oz. If BS is less than or equal to 70, and notify); 201 - 250 = 3 units; 251 - 300 = 4 units; 301 - 350 = 6 units; 351 - 400 = 8 units (Notify MD if BS is equal or greater than 400), subcutaneously before meals and at bedtime for DM2 administer insulin coverage per sliding scale promptly right before or after meals, and with foods) (Rotate injection sites). 3/3/2026 Insulin Glargine-yfgn Subcutaneous Solution 100 unit/ml (Insulin Glargine-yfgn). Inject 15 unit subcutaneously at bedtime for DM 2 (Hold if BS is less than 100) (Rotate injection sites). During a review of Resident 90's Care Plan (CP) Report titled, The resident is at risk for hyper/hypoglycemia related to diabetes mellitus, initiated on 3/2/2026, the CP indicated an intervention to administer insulin per order and to rotate site for insulin injections. During a review of Resident 90's Location of Administration Report (LAR) on the use of Insulin from 3/1/2026 to 3/31/2026, the LAR indicated insulin: Lispro Injection Solution 100 unit/ml was administered subcutaneously on, 3/3/2026 at 4:50 p.m. on the Abdomen - LLQ 3/5/2026 at 4:09 p.m. on the Abdomen - LLQ 3/7/2026 at 9:36 p.m. on the Arm - left 3/8/2026 at 11:23 a.m. on the Arm - left During a concurrent interview and record review on 3/25/2026, at 1:19 p.m., with the ADON, Resident 90's OSR, CP, and LAR were reviewed. The ADON stated not rotating insulin administration sites of administration is a medication error. The ADON stated the staff failed to rotate sites of injection as seen on the LAR. The ADON stated they rotate insulin administration site to prevent skin damage to residents. The ADON stated the frequented sites of administration can develop lipodystrophy and if administered on that site will cause malabsorption of insulin. The ADON stated the residents can suffer from hypo/hyperglycemia. During a review of the facility's recent P&P titled, Adverse Consequences and Medication Errors, last reviewed on 9/10/2025, the P&P indicated the interdisciplinary team monitors medication usage in order to prevent and detect medication-related problems such as adverse drug reactions (ADRs) and side effects. Policy Interpretation and Implementation Medication Errors 1. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. During a review of the facility's recent P&P titled, Insulin Administration, last reviewed on 9/10/2025, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes. Steps in the Procedure (Insulin Injections via Syringe) 16. Select an injection. a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility-provided information on the use of glargine-ygfn subcutaneously, copyright 2023, the information indicated to administer Insulin Glargine-ygfn subcutaneously into the abdominal area, thigh, or deltoid, and rotate injection sites within the same region from one injection to the next to reduce risk of lipodystrophy and localized cutaneous amyloidosis. Do not inject into areas of lipodystrophy or localized cutaneous amyloidosis [see Warnings and Precautions (5.2) and Adverse Reactions (6)]. During a review of the facility-provided Instructions for use on Insulin Lispro, Kwikpen injection, for subcutaneous use 3 ml single-patient use pen (100 units per ml), last revised 7/2023, the Information indicated to change (rotate) your injection sites within the area you choose for each dose to reduce your risk of getting lipodystrophy (pits in skin or thickened skin) and localized cutaneous amyloidosis (skin with lumps) at the injection sites.

Based on observation, interview, and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills when:1.Cook 1 was unable to verbalize final minimum internal temperature of foods when cooking and did not check if the blender was completely dry before preparing puree foods. 2. Dietary Aide 1 (DA 1) did not submerge the blender appropriately in the sanitizer. 3. Dietary Aide 2 (DA 2) was unable to use the right test strips when checking for chlorine concentration. These failures had potential to result in harmful bacterial growth and cross-contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food and drinks that are contaminated with germs or chemicals) in 71 of 77 medically compromised residents who received food from the kitchen. Findings: 1. During an observation on 3/23/2026 at 11:13 a.m., of [NAME] 1 cooking seas green peas, observed [NAME] 1 did not take the temperature of the seas green peas. Observed [NAME] 1 took portions of the vegetables and placed them in the blender. During an interview on 3/24/2026 at 9:03 a.m., with [NAME] 1 with the use of a Spanish interpreter and the Dietary Supervisor (DS), [NAME] 1 stated that she checks the food temperature two times, one during cooking and another one before starting trayline (an area where foods were assembled form the steamtable [kitchen appliance that keeps food warm at a safe temperature for serving] to resident's plates). [NAME] 1 stated she knows when food already cooks when the food temperature reaches 165 degrees Fahrenheit ( F, a scale of temperature). [NAME] 1 stated she checked the temperature of the vegetables while she was cooking it, and it was 75 F as minimum temperature of cooking vegetables. [NAME] 1 stated the next time she checked the vegetables temperature was before the start of the trayline. The DS stated they do not record cooking temperature of foods. During an interview on 3/24/2026 at 10:01 a.m., with [NAME] 1 and [NAME] 2 (Cook 2 as an interpreter), [NAME] 1 stated she misspoke earlier about the temperature of the vegetables, and it was supposed to be 165 F instead of 75 F. [NAME] 1 stated she started cooking the vegetables at 11 a.m. then she checked it to see with her eyes if it was cooked and okay. [NAME] 1 stated she knew that the vegetables were cooked by looking at it, and she did not use a thermometer. [NAME] 1 stated she did not check the temperature of the vegetables, and they checked the temperature of it before the start of trayline. During an interview on 3/25/2026 at 9:52 a.m., with Registered Dietitian 1 (RD 1), RD 1 stated they record the food temperatures before trayline starts but not after cooking but the practice was for the cooks to take the temperature of the food during cooking. RD 1 stated the food needed to reach minimum temperatures to kill any bacteria in the food and it was not appropriate to eyeball it without taking the temperature of the food. RD 1 stated residents could have food borne illness as a potential outcome when food did not reach its minimal internal temperatures. During a review of the facility's P&P titled, Food Service Temperature Control, dated 9/10/2025, the P&P indicated, The preparation of food will be done following the food safety practices outlines in the most current FDA Food Code. Minimum temperature for fruit, vegetables that will be hot-held for service is 135 F for 15 seconds. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-401.13 Plant Food Cooking for Hot Holding. Plant foods that are cooked for hot holding shall be cooked to a temperature of 135 F) During an observation on 3/23/2026 at 11:20 a.m., of DA 1's dishwashing process using the two-compartment sink, observed DA 1 washed the blender and did not completely dry it. Observed [NAME] 1 used the blender to puree meat sauce and there was still liquid dripping from the blender. During an observation on 3/23/2026 at 11:22 a.m., of the food preparation by [NAME] 1, observed [NAME] 1 took the meat sauce from the regular meat sauce in the oven and started pureeing the food using the blender. During an interview on 3/23/2026 at 12:40 p.m., with the DS, the DS stated it was important to air dry kitchen utensils to make sure there is no sanitizer left to prevent chemical contamination. The DS stated chemical contamination could poison the residents. During an interview on 3/23/2026 at 12:54 p.m., with Registered Dietitian 2 (RD 2), RD 2 stated air drying is the cleanest way to dry the dishes, and they could not use towels because particles from the towel could get in the equipment. During an interview on 3/23/2026 at 12:56 p.m. with RD 1 stated staff needed to allow kitchen equipment to air dry completely to allow the sanitizer to dry to prevent chemical contamination. RD 1 stated residents could get gastrointestinal upset depending on the transfer of chemicals to food. RD 1 stated chemical contamination could spoil the food and get residents' sick. During a concurrent interview and record review on 3/23/2026 at 1:59 p.m. with the DS, the facility Safety Data Sheet titled, Sani-10%, dated 9/30/2015, the document indicated, Maybe harmful when swallowed. The DS stated quaternary ammonium compound (QUAT, a chemical used to kill bacteria, germ and viruses) sanitizer is harmful when swallowed and may cause gastrointestinal irritation with nausea, vomiting and diarrhea according to the safety data sheet (SDS,) for QUAT sanitizer. During an interview on 3/24/2026 at 9:39 a.m. with [NAME] 1, [NAME] 1 stated she prepared the puree foods yesterday and used the blender. [NAME] 1 stated they only have one blender, and the dishwasher washed it in between use. [NAME] 1 stated she used the blender three times yesterday for the vegetables, meat and pasta and did not cook anything in between preparing these food items. [NAME] 1 stated the second compartment sink has sanitizer in it and after sanitizing the blender, it had to be air dried on the countertop. [NAME] 1 stated that the blender is dry when there is no water dripping and if there is still visible water dripping, it could contaminate the food, and residents could get sick of upset stomach and stomach pain. [NAME] 1 stated she did not check if the blender was dry before using it yesterday. During a review of the facility's P&P titled, Sanitization, dated 9/10/2025, the P&P indicated, (7) Food preparation equipment and utensils that are manually washed are allowed to air dry whenever practical. Drying food preparation equipment and utensils with a towel or cloth may increase risk for cross-contamination. During a review of the facility's P&P titled, Two Compartment Sink Method, dated 9/10/2025, the P&P indicated, Place sanitized dishes on drain board to air dry. During a review of the facility's posted instructions on the wall titled, Compartment Sink Cleaning Procedures, dated 9/10/2025, the P&P indicated, 5. Place on clean surface, allow to air dry. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-901.11 Equipment and Utensils, air-drying required. After cleaning and sanitizing equipment and utensils: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface sanitizing solutions), before contact with food and; (B) May not be cloth dried except that utensils that have been air-dried may be polished with cloths that are maintained clean and dry. During a review of the facility's job description (JD) titled Cook, signed and dated 7/30/2025 by [NAME] 1, the JD indicated, Essential Duties and Responsibilities included: adhering to sanitation and food safety guidelines during meal preparation and clean up. During a review of the facility's competency checklist titled, Food and Nutrition: Competency Checklist-Food Service Worker, dated 8/15/2025, the checklist indicated [NAME] 1 is competent when demonstrating correct sanitation and equipment and utensils and monitor and log time/temperature of food. The checklist did not indicate [NAME] 1 was competent with internal minimum temperature of food when cooking. 2. During an observation on 3/23/2026 at 11:27 a.m., observed [NAME] 1 placed the soiled blender in the two-compartment sink and DA 1 washed it. Observed DA 1 used the soap in the green bucket and then placed it in the second compartment for 26 seconds. DA 1 removed the blender from the second compartment then placed it in the small drying area next to the second compartment sink. During an observation on 3/23/2026 at 11:29 a.m., observed DA 1 took the blender from the drying area and gave it to [NAME] 1. Observed [NAME] 1 put the spaghetti noodles in the blender and there was still liquid dripping from the blender. During an interview on 3/23/2026 at 11:31 a.m., with DA 1, DA 1 stated the second compartment has sanitizer and it is used to sanitize the dishes. During an observation on 3/23/2026 at 11:34 a.m., of the puree food preparation, observed [NAME] 1 finished preparing puree spaghetti and placed the blender in the two-compartment sink. During an interview on 3/23/2026 at 12:34 p.m., with the DS, the DS stated they have one blender and one food processor and the process of washing in the two-compartment sink was to wash and rinse in the first compartment then sanitize on the second compartment. The DS stated the blender must stay in the sanitizer completely submerging for one minute and air dry. The DS stated if there were water dripping from the blender then it's not completely air dried. The DS stated it was important to submerge the blender for one minute so that the sanitizer 100 percent work and kill bacteria. The DS stated if the blender was not submerged for one minute, it would not kill bacteria. During an interview on 3/23/2026 at 12:46 p.m., with RD 2, RD 2 stated the process of dishwashing in the two-compartment sink is to wash, rinse, sanitize and air-dry. RD 2 stated the second compartment has QUAT sanitizer and water and the sanitizer disinfects the dishes. RD 2 stated the dishes or kitchen equipment had to be submerged in the sanitizer for 1 minute to prevent bacterial growth and residents could get sick of foodborne illness due to contamination. During an interview on 3/23/2026 at 2:24 p.m., with the DS, the DS stated she asked DA 1 about dishwashing and DA 1 thought he submerged the blender for one minute and he usually air-dried it before using however, [NAME] 1 needed to use the blender so DA 1 rushed it. During a review of the facility's P&P titled, Two Compartment Sink, dated 9/10/2025, the P&P indicated, 6. Submerse the clean dishes in the sanitizing solution of the compartment #3 according to chemical vendor's time requirements. During a review of the facility's posted instructions on the wall titled, Compartment Sink Cleaning Procedures, dated 9/10/2025, the P&P indicated, 3. Place items in sanitizing solution for 1 minute. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitation- Temperature, pH, Concentration, and Hardness. A chemical sanitizer used in a sanitizing solution for a manual or mechanical operation at contact times specified under 4-703.11 (C) shall meet criteria specified under 7-204.11 Sanitizers, criteria shall be used in accordance with the EPA-registered label use instructions, and shall be used as follows: (C) A quaternary ammonium compound solution shall (1) Have a minimum temperature of 24 C (75 F), (2) Have a concentration as specified under 7-204.11 and as indicated by the manufacturer's use directions included in the labeling. During an observation on 3/23/2026 at 11:37 a.m. of DA 1 washing the dishes in the two-compartment sink, observed DA 1 washed the blender in the first compartment then used the soap from the green bucket then place the blender to the second compartment sink without submerging it completely in the sanitizing solution. During an observation on 3/23/2026 at 11:42 a.m., of DA 1 washing kitchen utensils in the two-compartment sink, observed DA 1 removed the blender from the second compartment with sanitizer. Observed DA 1 handed the blender to [NAME] 1 and there was still water dripping from it. During an interview on 3/23/2026 at 12:40 p.m. with the DS, the DS stated the blender had to be completely submerge in the sanitizing solution to ensure it goes inside the blender to kill bacteria. The DS stated residents could get sick of foodborne illness if it was not sanitized correctly. During a concurrent interview and record review on 3/23/2026 at 2:08 p.m. with the DS, the facility P&P titled Two Compartment Sink, dated 9/10/2025 was reviewed. The P&P indicated, Submerse the clean dishes in the sanitizing solution. The DS stated, the clean dishes and kitchen utensils are submersed in the sanitizing solution of compartment number 3 according to the chemical vendor's time requirements then place the sanitize dishes on the drain board to air dry. During a review of the facility's JD, titled, Dietary Aide, dated 7/24/2013, the JD indicated, Duties and responsibilities included, perform dishwashing/cleaning procedures. Assure that utensils, etc., are readily available for next meal. Prepare food, etc., in accordance with sanitary regulations as well as without established policies and procedures. During a review of the facility's competency checklist titled, Food and Nutrition: Competency Checklist-Food Service Worker, signed and dated on 7/31/2025 by DA 1, the checklist indicated, DA 1 was competent in utilizing 2 or 3 compartments sink correctly but did not indicate he was competent in air drying of utensils. 3. During a concurrent observation and interview on 3/24/2026 at 2:02 p.m., of the dishwashing process demonstration with DA 2, DA 2 stated he wash, rinse, sanitize and air-dry dishes. DA 2 stated he checks the temperature of the dish machine, and it should be at 140 F and above and if it's below it, he reports it to the supervisor. DA 2 stated he did not know what type of dish machine they use and stated he used a test strip to check the sanitizer concentration. Observed DA 2 got the test strip for QUAT sanitizer and stated the test strip turned yellow when dipped into the chlorine and it was not an acceptable concentration for the chlorine. Observed DA 2 dipped the test strip for QUAT sanitizer and agitated it. DA 2 stated the test strips were not reading an acceptable chlorine concentration, and he uses this test strip when checking the chlorine concentration. The DS stated DA 2 was using the wrong test strips and handed the correct test strips to DA 2. The DS stated it was important to use the correct test strips to ensure that they get the correct concentration of the sanitizer. The DS stated the chlorine needed to be at the right concentration to sanitize and kill bacteria from the dishes. The DS stated residents could get sick of cross contamination as a potential outcome. During a review of the facility's P&P titled Chemical Sanitation, dated 9/10/2025, the P&P indicated, The appropriate temperature, pH concentration and water hardness will be used when chemical sanitation requires techniques are used as in storing wet wiping cloths, cleaning food preparation surfaces and manual and mechanical (chemical machine) ware washing. Sanitizers shall be used in accordance with the EPA-approved manufacturer's label use instructions. During a review of the facility's manufacturer's guidelines, Chlorine Test Paper, the guidelines indicated, The chlorine test paper measures total available chlorine from 0-200 parts per million (ppm, a unit of measurement expressing dilute concentrarion) and give results just seconds. During a review of Food Code 2022, the Food Code 2022 indicated, 4-501.116 Warewashing Equipment, Determining Chemical Sanitizer Concentration. Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device. During a review of the facility's JD titled, Dietary Aide, signed and dated by DA 2 on 7/27/2021, the JD indicated, essential duties and responsibilities of DA 2 included adhering to sanitation and food safety guidelines during meal preparation and clean up and dishwashing and cleaning of utensils. During a review of the facility's competency checklist titled, Food and Nutrition: Competency Checklist-Food Service Worker, dated 7/31/2025, the checklist indicated DA 2 was competent in stating proper sanitizer solution range and correctly prepares sanitizer solution and test concentration. The checklist did not indicate DA 2 was competent in using the correct test strip in testing chlorine concentration.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Thawed ground beef was placed back in the freezer and was at 31 degrees Fahrenheit ( F, a scale of temperature). 2. Walk-in refrigerator's gasket (a rubber placed between two solid and flat surfaces to create a tight leak-proof seal) was torn, it had dust and dirt buildup. 3. Two (2) dented (a hallow, dip, or depression on a surface, caused by blow, impact or pressure) cans were stored with non-dented cans. 4. [NAME] 1 did not take the temperature of the vegetables during cooking using a food thermometer. (Cross Reference Ftag 802) 5. Dietary Aide 1 (DA 1) did not wash kitchen equipment correctly in the three-compartment sink when: a. DA 1 did not completely air dry the blender before [NAME] 1 used the blender in preparing puree foods. (Cross-Reference Ftag 802) b. DA 1 did not submerge the blender in the quaternary (QUAT, a common chemical cleaner used to kill germs, bacteria and viruses) sanitizer for one (1) minute per sanitizer manufacturer's guidelines. (Cross-reference Ftag 802) c. DA 1 did not submerge the blender completely in the sanitizer. 6. Kitchen staff did not perform handwashing, going to dirty and then the clean area when: a. DA 1 did not wash his hands when washing dishes in the two-compartment sink then putting away clean dishes. b. Dietary Aide 2 (DA 2) washed his hands for five (5) seconds and used a blue towel when drying his hands. DA 2 turned off the faucet using his hands after handwashing. 7. [NAME] 1 directly toasted the tortilla on the stove without sanitizing it prior to use. 8. Kitchen equipment and utensils were not free from dirt, dust and food debris. a. Wall air conditioning in the preparation area had dust and dirt buildup. b. Residents' refrigerator in Station 1 had dirt debris. 9. Sugar-free watermelon drink had a best buy date of 3/23/2026 and was not discarded on 3/24/2026. 10. DA 2 used the wrong test strips when checking chlorine concentration of the dish machine. 11. Residents' refrigerator had visible dirt in Station 1 and nursing staff did not address the out-of-range temperatures of the residents' refrigerator. 12. There was no thermometer in the residents' freezer in Station 3 where egg waffles were stored. 13. An unlabeled bottle of Powerade (is a sports drink that is designed to help the body rehydrate and replenish essential minerals lost through sweat during exercise) was stored in the residents' refrigerator inside the Medication Storage Room in Station 1. Powerade bottle had no name, room number, and the date it was received. These failures had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 71 of 77 medically compromised residents who received food from the kitchen. Findings: 1. During an observation on 3/23/2026 at 8:33 a.m. of the meat freezer, observed ground beef was soft to touch. During a concurrent observation and interview on 3/23/2026 at 8:40 a.m., of the meat freezer with the Dietary Supervisor (DS), observed the DS touched the ground meat. The DS stated the ground meat was not frozen because it was soft to touch. The DS stated the ground beef was received last Sunday and it was thawed but it should not be returned to the freezer as the bacteria could start growing during the thawing process and it should not be refrozen to prevent foodborne illnesses. The DS stated [NAME] 1 prepared the ground beef this morning and cut the ground beef and got what she needed. The DS stated [NAME] 1 needed to place the thawed ground beef in the refrigerator and not in the freezer. During a review of the facility's P&P titled, Thawing, dated 9/10/2025, the P&P indicated, Once thawed raw food will not be re-frozen, unless it is thoroughly cooked. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-501.11 Frozen Food. Stored Frozen Food shall be maintained frozen. Freezing prevents microbial growth in foods but usually does not destroy all microorganisms. Improper thawing provides an opportunity for surviving bacteria to grow to harmful numbers and/or produce toxins. If the food is then refrozen, significant numbers of bacteria and/or all preformed toxins are preserved. 2. During an observation on 3/23/2026 at 8:52 a.m. of the walk-in refrigerator observed the refrigerator gasket was torn on the bottom portion and there was dust and dirt accumulation. During an interview on 3/23/2026 at 8:54 a.m. with the DS, the DS stated the walk-in refrigerator is cleaned once a week but there was no assigned day to clean it. The DS stated the last time the walk-in refrigerator was cleaned was last weekend, but the gasket has dirt accumulation, and it should be because the dirt could go to the food causing bacterial growth and cross contamination of food. The DS stated residents could have foodborne illnesses as a potential outcome. During an interview on 3/23/2026 at 8:56 a.m. with the DS, the DS stated the walk-in refrigerator gasket was torn and it should not be torn to prevent hot air from coming in because if the air comes in the walk-in refrigerator, it could spoil the food. The DS stated spoiled food could get the residents sick of foodborne illness. The DS stated she told the maintenance staff to replace it long time ago but forgot to follow-up. During a review of the facility's P&P titled, Sanitization dated 9/10/2025, the P&P indicated, The food service is maintained in a clean and sanitary manner. (1) All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects. (2) All utensils, counters, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosion, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners are kept in good repair. During a review of the facility's P&P titled, Refrigerator and Freezers, dated 9/10/2025, the P&P indicated, 10. Supervisors inspect refrigerators and freezer monthly for gasket condition, fan condition, presence of rust, excess condensation, and any other damage or maintenance needs. Necessary repairs are initiated immediately. Maintenance schedules per manufacturer guidelines are scheduled and followed. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated,4-602.13 Nonfood-Contact Surfaces. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. 3. During a concurrent observation and interview on 3/23/2026 at 9:11 a.m. of the dry storage area with the DS, found 2 dented cans were stored with non-dented cans. The DS stated dented cans needed to be separated from non-dented cans to prevent using them because there could be air going in the dented cans in which bacteria could grow. The DS stated residents could get foodborne illness when they consume food from dented cans. During a review of the facility's P&P titled, Recommended Food Storage Practices-Dry dated 9/10/2025, the P&P indicated Leaking, dented, or rusty cans should be disposed of promptly to prevent contamination. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-101.11 Safe Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under 3-601.12, honestly presented. 3-201.11 Compliance with Food Law. A primary line of defense ensuring that food meets the requirements of 3-101.11 is to obtain food from approved sources, the implications of which are discussed below. However, it is also critical to monitor food products to ensure that, after harvesting, processing, they do not fail victim to conditions that endanger their safety, make them adulterated, or compromise their honest presentation. The regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard. 4. During an observation on 3/23/2026 at 11:13 a.m., of [NAME] 1 cooking seas green peas, observed [NAME] 1 did not take the temperature of the seas green peas. Observed [NAME] 1 took portions of the vegetables and placed them in the blender. During an interview on 3/24/2026 at 9:03 a.m., with [NAME] 1 and the DS, [NAME] 1 stated that she checks the food temperature two times, one during cooking and another one before starting trayline (an area where foods were assembled form the steamtable [kitchen appliance that keeps food warm at a safe temperature for serving] to resident's plates). [NAME] 1 stated food is already cooked when the food temperature reaches 165 degrees F. [NAME] 1 stated she checked the temperature of the vegetables while she was cooking it, and it was 75 degrees F. [NAME] 1 stated the next time she checked the vegetables temperature was before the start of the trayline. The DS stated they do not record cooking temperature of foods. During an interview on 3/24/2026 at 9:20 a.m. with the DS, the DS stated that it was not in their policy to record temperatures of foods during cooking. During an interview on 3/24/2026 at 10:01 a.m., with [NAME] 1 and [NAME] 2 (Cook 2 as an interpreter), [NAME] 1 stated she misspoke earlier about the temperature of the vegetables, and it was supposed to be 165 degrees F instead of 75 degrees F. [NAME] 1 stated she started cooking the vegetables at 11 a.m. then she checked it to see with her eyes if it was cooked and okay. [NAME] 1 stated she knew that the vegetables were cooked by looking at it, and she did not use a thermometer. [NAME] 1 stated she did not check the temperature of the vegetables, and they checked the temperature of it before the start of trayline. During an interview on 3/25/2026 at 9:52 a.m., with Registered Dietitian 1 (RD 1), RD 1 stated they record the food temperatures before trayline starts but not after cooking but the practice was for the cooks to take the temperature of the food during cooking. RD 1 stated the food needed to reach minimum temperatures to kill any bacteria in the food and it was not appropriate to eyeball it without taking the temperature of the food. The RD stated residents could have food borne illness as a potential outcome when food did not reach its minimal internal temperatures. During a review of the facility's P&P titled, Food Service Temperature Control, dated 9/10/2025, the P&P indicated, The preparation of food will be done following the food safety practices outlines in the most current FDA Food Code. Minimum temperature for fruit, vegetables that will be hot-held for service is 135 degrees F for 15 seconds. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-401.13 Plant Food Cooking for Hot Holding. Plant foods that are cooked for hot holding shall be cooked to a temperature of 135 degrees F. 5. a. During an observation on 3/23/2026 at 11:20 a.m., of DA 1's dishwashing process using the two-compartment sink, observed DA 1 washed the blender and did not completely dry it. Observed [NAME] 1 used the blender to puree meat sauce and there was still liquid dripping from the blender. During an observation on 3/23/2026 at 11:22 a.m., of the food preparation by [NAME] 1, observed [NAME] 1 took the meat sauce from the regular meat sauce in the oven and started pureeing the food using the blender. During an interview on 3/23/2026 at 12:40 p.m., with the DS, the DS stated it was important to air dry kitchen utensils to make sure there is no sanitizer left to prevent chemical contamination. The DS stated chemical contamination could poison the residents. During an interview on 3/23/2026 at 12:54 p.m., with Registered Dietitian 2 (RD 2), RD 2 stated air drying is the cleanest way to dry the dishes, and they could not use towels because particles from the towel could get in the equipment. During an interview on 3/23/2026 at 12:56 p.m. with Registered Dietitian 1 (RD), RD 1 stated staff needed to allow kitchen equipment to air dry completely to allow the sanitizer to dry to prevent chemical contamination. RD 1 stated residents could get gastrointestinal upset depending on the transfer of chemicals to food. RD 1 stated chemical contamination could spoil the food and get residents sick. During a concurrent interview and record review on 3/23/2026 at 1:59 p.m. with the DS, the facility Safety Data Sheet titled, Sani-10%, dated 9/30/2015, the document indicated, Maybe harmful when swallowed. The DS stated QUAT sanitizer is harmful when swallowed and may cause gastrointestinal irritation with nausea, vomiting and diarrhea according to the safety data sheet (SDS) for QUAT sanitizer. During an interview on 3/24/2026 at 9:39 a.m. with [NAME] 1, [NAME] 1 stated she prepared the puree foods yesterday and used the blender. [NAME] 1 stated they only have one blender, and the dishwasher washed it in between use. [NAME] 1 stated she used the blender three times yesterday for the vegetables, meat and pasta and did not cook anything in between preparing these food items. [NAME] 1 stated the second compartment sink has sanitizer on it and after sanitizing the blender, it had to be air dried on the countertop. [NAME] 1 stated that the blender is dry when there is no water dripping and if there is still visible water dripping, it could contaminate the food, and residents could get sick of upset stomach and stomach pain. [NAME] 1 stated she did not check if the blender was dry before using it yesterday. During a review of the facility's P&P titled, Sanitization, dated 9/10/2025, the P&P indicated, (7) Food preparation equipment and utensils that are manually washed are allowed to air dry whenever practical. Drying food preparation equipment and utensils with a towel or cloth may increase risk for cross-contamination. During a review of the facility's P&P titled, Two Compartment Sink Method, dated 9/10/2025, the P&P indicated, Place sanitized dishes on drain board to air dry. During a review of the facility's posted instructions on the wall titled, Compartment Sink Cleaning Procedures, dated 9/10/2025, the P&P indicated, 5. Place on clean surface, allow to air dry. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-901.11 Equipment and Utensils, air-drying required. After cleaning and sanitizing equipment and utensils: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface sanitizing solutions), before contact with food and; (B) May not be cloth dried except that utensils that have been air-dried may be polished with cloths that are maintained clean and dry. b. During an observation on 3/23/2026 at 11:27 a.m., observed [NAME] 1 placed the soiled blender in the two-compartment sink and DA 1 washed it. Observed DA 1 used the soap in the green bucket and then placed it in the second compartment for 26 seconds. DA 1 removed the blender from the second compartment then placed it in the small drying area next to the second compartment sink. During an observation on 3/23/2026 at 11:29 a.m., observed DA 1 took the blender from the drying area and gave it to [NAME] 1. Observed [NAME] 1 put the spaghetti noodles in the blender and there was still liquid dripping from the blender. During an interview on 3/23/2026 at 11:31 a.m., with DA 1, DA 1 stated the second compartment has sanitizer and it is used to sanitize the dishes. During an observation on 3/23/2026 at 11:34 a.m., of the puree food preparation, observed [NAME] 1 finished preparing puree spaghetti and placed the blender in the two-compartment sink. During an interview on 3/23/2026 at 12:34 p.m., with the DS, the DS stated they have one blender and one food processor and the process of washing in the two-compartment sink was to wash and rinse in the first compartment then sanitize on the second compartment. The DS stated the blender must stay in the sanitizer completely submerging for one minute and air dry. The DS stated if there were water dripping from the blender then it's not completely air dried. The DS stated it was important to submerge the blender for one minute so that the sanitizer will 100 percent work and kill the bacteria. The DS stated if the blender was not submerged for one minute, it would not kill bacteria. During an interview on 3/23/2026 at 12:46 p.m., with RD 2, RD 2 stated the process of dishwashing in the two-compartment sink is to wash, rinse, sanitize and air-dry. RD 2 stated the second compartment has QUAT sanitizer and water and the sanitizer disinfects the dishes. RD 2 stated the dishes or kitchen equipment had to be submerged in the sanitizer for 1 minute to prevent bacterial growth and residents could get sick of foodborne illness due to contamination. During an interview on 3/23/2026 at 2:24 p.m., with the DS, the DS stated she asked DA 1 about dishwashing and DA 1 thought he submerged the blender for one minute and he usually air-dried it before using, however, [NAME] 1 needed to use the blender so DA 1 rushed it. During a review of the facility's P&P titled, Two Compartment Sink, dated 9/10/2025, the P&P indicated, 6. Submerse the clean dishes in the sanitizing solution of the compartment #3 according to chemical vendor's time requirements. During a review of the facility's posted instructions on the wall titled, Compartment Sink Cleaning Procedures, dated 9/10/2025, the P&P indicated, 3. Place items in sanitizing solution for 1 minute. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitation- Temperature, pH, Concentration, and Hardness. A chemical sanitizer used in a sanitizing solution for a manual or mechanical operation at contact times specified under 4-703.11 (C) shall meet criteria specified under 7-204.11 Sanitizers, criteria shall be used in accordance with the EPA-registered label use instructions, and shall be used as follows: (C) A quaternary ammonium compound solution shall (1) Have a minimum temperature of 24 degrees C (75 degrees F), (2) Have a concentration as specified under 7-204.11 and as indicated by the manufacturer's use directions included in the labeling. c. During an observation on 3/23/2026 at 11:37 a.m. of DA 1 washing the dishes in the two-compartment sink, observed DA 1 washed the blender in the first compartment then used the soap from the green bucket then place the blender to the second compartment sink without submerging it completely in the sanitizing solution. During an observation on 3/23/2026 at 11:42 a.m., of DA 1 washing kitchen utensils in the two-compartment sink, observed DA 1 removed the blender from the second compartment with sanitizer. Observed DA 1 handed the blender to [NAME] 1 and there was still water dripping from it. During an interview on 3/23/2026 at 12:40 p.m. with the DS, the DS stated the blender had to be completely submerge in the sanitizing solution to ensure it goes inside the blender to kill bacteria. The DS stated residents could get sick of foodborne illness if it was not sanitized correctly. During a concurrent interview and record review on 3/23/2026 at 2:08 p.m. with the DS, the facility P&P titled Two Compartment Sink, dated 9/10/2025 was reviewed. The P&P indicated, Submerse the clean dishes in the sanitizing solution. The DS stated, the clean dishes and kitchen utensils are submersed in the sanitizing solution of compartment number 3 according to the chemical vendor's time requirements then place the sanitize dishes on the drain board to air dry. 6. a. During an observation on 3/23/2026 at 11:46 a.m., of DA 1 washing kitchen utensils and equipment in the two-compartment sink, observed DA 1 washed the kitchen equipment then put away the clean dishes without washing his hands. During an observation on 3/23/2026 at 11:55 a.m., of DA 1 washing kitchen utensils and equipment in the two-compartment sink, observed DA 1 did not wash his hands after washing kitchen utensils and before putting away clean dishes. During an interview on 3/23/2026 at 1 p.m., with the DS, the DS stated the dishwasher should wash their hands after washing kitchen equipment and before putting the sanitized kitchen equipment away as it could be dirty again and bacteria could grow causing the residents to get sick of foodborne illness. During a review of the facility's P&P titled Handwashing, dated 9/10/2025, the P&P indicated, Employee will wash his or hands frequently to eliminate visible dirt and reduce bacterial load. Procedure when to wash hands: (i)After working with or cleaning dirty equipment or utensils (k) Anytime hands are soiled. (l) Between gloves changes (q) Between any dirty to clean task. During a review of the facility's P&P titled, Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices, dated 9/10/2025, the P&P indicated, Handwashing/hand hygiene (g) During food preparation, as often as necessary to remove soil and contamination and to prevent cross-contamination when changing task and or (h) After engaging in other activities that contaminate the hands. b. During an observation on 3/24/2026 at 1:43 p.m., of the dishwashing process, observed DA 2 performed handwashing by wetting his hand with water and soap then touched the faucet knob then wiped his hands with a blue towel. Observed DA 2 threw the blue towel on top of the tile by the window after wiping his hands. During an observation on 3/24/2026 at 1:47 p.m., of the dishwashing process, observed DA 2 wash his hands and use the soap for five (5) seconds then wiped his hands with a blue towel. During an interview on 3/24/2026 at 2:02 p.m., with the DS, the DS stated DA 2 was using a blue towel to dry his hands and did a quick handwashing. The DS stated handwashing should be 20 to 30 seconds or not less than 20 seconds to make sure they are washing their hands thoroughly. The DS stated handwashing is important to protect the residents from getting bacteria and prevent cross-contamination of their food. The DS stated kitchen staff should not be using a blue towel and should be using disposable towel because it was not sanitary. During an interview on 3/24/2026 at 2:18 p.m., with DA 2, DA 2 stated he washes his hands for 10 to 15 seconds and thought he washed his hands for 10 seconds by counting 1, 2, 3, 4, 5. DA 2 stated it was important to wash hands in a specific time to prevent cross-contamination. DA 2 stated he also used the blue towel because it was inconvenient for him to go around and get the disposable towel. DA 2 stated it was important to use the disposable towel to prevent cross-contamination. DA 2 stated he used the blue towel to dry his hands and stated he threw the other blue towel near the window. During a review of the facility's P&P titled Handwashing, dated 9/10/2025, the P&P indicated, How to wash: a. Place hands under warm, running water, wetting wrists and forearms. b. Apply soap to hands and rub them together vigorously for at least 10-15 seconds. c. Scrub wrists, forearms, and both sides of the hands. d. Clean fingers, fingertips, and under nails by rubbing one hand against the other. Be sure to clean under the fingernails with a nail brush e. Rinse the washed areas thoroughly with warm, running water f. Dry hands with paper towel. g. Use paper towel to turn off the faucet. Do not sure bare hands. h. Discard paper towel. i. Total handwashing time should be no less than 20 seconds. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLESP and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; P (B) After using the toilet room; P (C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in ¶ 2-403.11(B); P (D) Except as specified in ¶ 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using TOBACCO PRODUCTS, eating, or drinking; P (E) After handling soiled EQUIPMENT or UTENSILS; P (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; P (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; P (H) Before donning gloves to initiate a task that involves working with FOOD; P and (I) After engaging in other activities that contaminate the hands. 7. During an observation on 3/23/2026 at 12:05 p.m., of [NAME] 1 toasting the tortilla, observed [NAME] 1 toasted the tortillas directly on the stove. During an interview on 3/23/2026 at 9:30 a.m., with [NAME] 1 and the DS, [NAME] 1 stated she placed the tortilla directly on the stove because the resident wants it crunchy. The DS stated they sanitize the stove after every shift. The DS stated it was acceptable for [NAME] 1 to cook the tortilla directly to the stove because heat kills bacteria however they clean the stove to prevent dirt buildup and burning. The DS stated spill could happen in between cooking and bacteria could grow causing cross contamination to food. The DS stated toasting the tortilla directly on the stove would not be acceptable because the stove is not clean and the tortilla could be contaminated. The DS stated [NAME] 1 has been doing it for a month for a resident and she did not talk to the resident about it. During a review of the facility's P&P titled, Food Preparation and Service, dated 9/10/2025, the P&P indicated, Food and nutrition service employees prepare and serve food in a manner that complies with safe food handling practices. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-307.11 Miscellaneous Sources of Contamination. Food shall be protected from contamination that may result from a factor or source not specified under subparts 3-391 – 3-306. 8. a. During an observation on 3/24/2026 at 11:36 a.m., of the wall air conditioning (AC) unit by the preparation area, observed dust buildup on the vent. During an interview on 3/24/2026 at 12:02 a.m., with the DS stated the AC filter has sticky dust buildup and it needed to be clean as it could blow dust in the food during preparation of food causing cross contamination. The DS stated kitchen staff should clean the filter every single shift. During a review of the facility's P&P titled Sanitization, dated 9/10/2025, the P&P indicated, The Food service area is maintained in a clean and sanitary manner. b. During a concurrent observation and interview on 3/25/2026 at 8:33 a.m. of the residents' refrigerator with Registered Nurse 1 (RN 1) in Station 1, observed dirt debris in the refrigerator. RN 1 stated nursing staff maintains the resident's refrigerator and cleans it when there is visible dirt. RN 1 stated there is visible dirt in the resident's refrigerator and the staff should have cleaned it. RN 1 stated she was not sure about the facility's policy regarding food from outside source, but it was important to ensure cleanliness of the resident's refrigerator for infection control for contamination of food that belongs to the residents. During a review of the facility's P&P titled, Refrigerator and Freezer, dated 9/10/2025, the P&P indicated, Refrigerator and Freezers are kept clean, free of debris, and disinfected with sanitizing solution on a scheduled basis and more often than necessary. During a review of Food Code 2022, the Food Code 2022 indicated, 4-601.11 (E) Except when dry cleaning methods are used as specified under 4-603.11, surfaces of utensils and equipment contacting food that is not time/temperature control for safety food shall be cleaned: (1) At anytime when contamination may have occurred; (2) At least every 24 hours for iced tea dispensers and consumer self-service utensils such as tongs, scoops, or ladles; (3) Before restocking consumer self-service equipment and utensils such as condiment dispensers and display containers; and (4) In equipment such as ice bins and beverage dispensing nozzles and enclosed components of equipment such as ice makers, cooking oil storage tanks and distribution lines, beverage and syrup dispensing lines or tubes, coffee bean grinders, and water vending equipment: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specification, at a frequency necessary to preclude accumulation of soil or mold. 9. During an observation on 3/24/2026 at 11:37 a.m., of the juice containers, observed sugar free watermelon with a best buy date of 3/23/2026 and were not discarded. During an interview on 3/24/2026 at 12:05 p.m., with the DS, the DS stated they date food items with open date and use by date, and they needed to consume the food item by the use by date or throw it away because they do not want the food to be bad and get spoiled. The DS stated residents could get sick upon consuming spoiled food. The DS stated the sugar free watermelon has a best buy date of 3/23/2026 and it should have been thrown away yesterday because it was no longer good. During a review of the facility's P&P titled, Recommended Food Storage Practices, dated 9/10/2025, the P&P indicated, Check expiration date of milk, prepared salads and other dated foods. Discard outdated product daily. During a review of Food Code 2022, the Food Code 2022 indicated, 3-501.17 Commercially processed food, open and hold cold, (B) except specified in (E) – (G) of this section, refrigerated, ready-to-eat time/temperature control for food safety food prepared and packed by a food processing plant shall be clearly [NAME]

Based on interview and record review, the facility failed to ensure the binding arbitration agreement (a resident waives the right to pursue legal action against the nursing home in court, and instead agrees to have any future disputes handled by a private arbitrator [an independent person or body officially appointed to settle a dispute]) indicated the resident or anyone else (e.g., resident's representative) were allowed to communicate with federal, state, or local officials such as federal and state surveyors, other federal or state health department employees and representative of the Office of the State Long Term Care Ombudsman (a resident advocate) for three of three sampled residents (Residents 33, 75, and 93) reviewed for Arbitration Facility Task. The deficient practice had the potential for residents to be unaware of their rights pertaining to Arbitration Agreement. Findings: 1. During a review of Resident 33's admission Record (AR), the AR indicated the facility admitted the resident on 3/18/2025, with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety disorder (a mental health condition characterized by excessive, persistent, and uncontrollable fear or worry that interferes with daily life). During a review of Resident 33's History and Physical (H&P), dated 3/19/2025, the H&P indicated the resident could make needs known but cannot make medical decisions. During a review of Resident 33's Minimum Data Set (MDS - a resident assessment tool), dated 3/17/2026, the MDS indicated the resident had the ability to make self-understood and understand others and had impaired cognition (a decline in mental abilities where a person has trouble with thinking, memory, concentration, judgment, or learning new things). The MDS indicated the resident had a family member who participated in the assessment and goal setting of resident's healthcare management. During a review of Resident 33's Resident-Facility Arbitration Agreement (AA), electronically signed by Resident 33 on 4/1/2025, the AA did not indicate the resident were allowed to communicate with federal, state, or local officials such as federal and state surveyors, other federal or state health department employees and representative of the Office of the State Long Term Care Ombudsman. During a concurrent interview and record review on 3/26/2026 at 9:46 a.m. with the Admissions Coordinator (AC), Resident 33's AA was reviewed. he AC stated nothing on the AA mentions about allowing the resident or anyone else (e.g., resident's representative) to communicate with federal, state, or local officials such as federal and state surveyors, other federal or state health department employees and representative of the Office of the State Long Term Care Ombudsman. The AC stated she will call their legal department and ask if the AA Form they have was the latest. During a concurrent interview and record review on 3/26/2026 at 11 a.m. with the AC and the Administrator (ADM), Resident 33's AA was reviewed. Both the AC and ADM stated the verbiage of allowing residents or anyone else from communicating with federal, state, or local officials, including but not limited to, federal and state surveyors, other federal or state health department employees, and representative of the Office of the State Long-Term Care Ombudsman was not on their Arbitration Agreement and they agreed it should be included in the agreement so the residents know they can or are allowed to communicate to the entities mentioned. 2. During a review of Resident 75's AR, the AR indicated the facility admitted the resident on 3/31/2025, and readmitted the resident on 10/13/2025, with diagnoses including depression (a serious, common mood disorder causing persistent sadness, loss of interest, and exhaustion, lasting at least two weeks) and systolic heart failure (a chronic condition where the heart's main pumping chamber (left ventricle) becomes weak, enlarged, or damaged). During a review of Resident 75's H&P, dated 10/15/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 75's MDS, dated [DATE], the MDS indicated the resident had intact cognition (having a clear, sharp, and functioning mind that allows a person to think, learn, remember, and make decisions effectively). During a review of Resident 75's AA, electronically signed by Resident 75 on 4/1/2025, the AA did not indicate the resident were allowed to communicate with federal, state, or local officials such as federal and state surveyors, other federal or state health department employees and representative of the Office of the State Long Term Care Ombudsman. During a concurrent interview and record review on 3/26/2026, at 9:46 a.m., with the AC, Resident 75's AA was reviewed. The AC stated nothing on the AA mention about allowing the resident or anyone else (e.g., resident's representative) to communicate with federal, state, or local officials such as federal and state surveyors, other federal or state health department employees and representative of the Office of the State Long Term Care Ombudsman. The AC stated she will call their legal department and ask if the AA Form they have was the latest. During a concurrent interview and record review on 3/26/2026 at 11 a.m. with the AC and the ADM, Resident 75's AA was reviewed. Both the AC and ADM stated the verbiage of allowing residents or anyone else from communicating with federal, state, or local officials, including but not limited to, federal and state surveyors, other federal or state health department employees, and representative of the Office of the State Long-Term Care Ombudsman was not on their Arbitration Agreement and they agreed it should be included in the agreement so the residents know they can or are allowed to communicate to the entities mentioned. 3. During a review of Resident 93's AR, the AR indicated the facility admitted the resident on 6/10/2024, and readmitted the resident on 2/27/2026, with diagnoses including acute embolism ('plug' or 'stopper' or a clot that blocks blood flow) and thrombosis (the formation of a blood clot (called a thrombus) inside a blood vessel (a vein or an artery) that restricts or completely blocks the normal flow of blood) of deep veins in the lower extremity, bilateral and diverticulitis (a digestive condition that occurs when small, bulging pouches (diverticula) in the lining of the large intestine (colon) become inflamed or infected) of intestine. During a review of Resident 93's H&P, dated 10/18/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 93's AA, electronically signed by Resident 93 on 3/10/2026, the AA did not indicate the resident were allowed to communicate with federal, state, or local officials such as federal and state surveyors, other federal or state health department employees and representative of the Office of the State Long Term Care Ombudsman. During a concurrent interview and record review on 3/26/2026 at 9:46 a.m. with the AC, Resident 93's AA was reviewed. The AC stated nothing on the AA mention about allowing the resident or anyone else (e.g., resident's representative) to communicate with federal, state, or local officials such as federal and state surveyors, other federal or state health department employees and representative of the Office of the State Long Term Care Ombudsman. The AC stated she will call their legal department and ask if the AA Form they have was the latest. During a concurrent interview and record review on 3/26/2026 at 11 a.m. with the AC and the ADM, Resident 93's AA was reviewed. Both the AC and ADM stated the verbiage of allowing residents or anyone else from communicating with federal, state, or local officials, including but not limited to, federal and state surveyors, other federal or state health department employees, and representative of the Office of the State Long-Term Care Ombudsman was not on their Arbitration Agreement and they agreed it should be included in the agreement so the residents know they can or are allowed to communicate to the entities mentioned. During a review of the facility's recent policy and procedure (P&P) titled, Arbitration, last revised on 9/10/2025, the P&P indicated under Policy Interpretation and Implementation, the agreement may not contain language that prohibits or discourages communications with federal, state, or local officials, including federal, state, or local officials, including federal and state surveyors, other federal or state health department employees, and representatives of the Office of the State Long Term Care Ombudsperson.

Based on interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to ensure: 1. Certified Nurse Assistant (CNA) 3 washed hands after removing gloves from changing Resident 26's diaper and proceeded to leave the room, observed during infection control tasks. 2. Linen carts for resident's personal clothing were not covered with a loosely woven/permeable (having pores or openings that permit liquids or gases to pass through) material to protect the linens inside the cart, observed during infection control tasks. 3. The water in the facility was above 108 degrees Fahrenheit (F - a unit of measurement for temperature) based on the Centers for Disease Control Prevention (CDC - federal government agency that works to protect public health) Toolkit: Developing a Legionella (a bacteria found naturally in water and soil) Water Management Program that the facility is observing during infection control tasks. 4. Licensed Vocational Nurse (LVN) 4 properly disinfected (cleanse of bacteria that may cause disease) the glucometer (blood glucose meter - device that measures the amount of glucose [sugar] in the blood of someone with diabetes mellitus (DM II - a disorder characterized by difficulty in blood sugar control and poor wound healing) prior to placing the used glucometer in Medication Cart 4 (MC 4) for one (1) of three (3) sampled residents (Resident 66) observed during the medication administration task. These deficient practices had a potential to spread infections and illnesses among residents. Findings: 1. During a review of Resident 26's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility admitted the resident on 3/11/2026 with diagnoses including fracture of head and neck of right femur (broken thigh bone), DM, hypothyroidism (thyroid gland not making enough thyroid hormones to meet body needs), anxiety (a mental health disorder characterized by feelings of worry or fear that interfere one's daily activities), hypertension (high blood pressure) and history of falling. During a review of Resident 26's History and Physical (H&P), dated 3/13/2026, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 26's Minimum Data Set (MDS - a resident assessment tool), dated 3/16/2026, the MDS indicated that Resident 26's cognitive skills for daily decision making is moderately impaired (decisions poor; cues/supervision required). The MDS indicated Resident 26 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completed activity) with oral, toileting and personal hygiene. The MDS also indicated that Resident 26 is dependent on staff (helper does all of the effort) in putting on/taking off shoes. During a concurrent observation and interview on 3/23/2026 at 9:57 a.m., with CNA 3, inside Room A, with Resident 26 and Resident 53, CNA 3 changed Resident 26 adult brief and removed her gown and gloves without performing proper hand hygiene after removal. CNA 3 stated she should have used a hand sanitizer or washed her hands after removing her gloves after providing care to Resident 26. CNA 3 stated that without performing hand hygiene after giving care to a resident, cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) can occur especially when there are two residents in one room. During an interview on 3/25/2026 at 2:10 p.m. with Registered Nurse (RN) 1, RN 1 stated that handwashing is important especially between resident care as it is a safe practice to prevent cross-contamination and spread infection. During an interview on 3/25/2026 at 2:24 PM with the Assistant Director of Nursing (ADON), the ADON stated that the appropriate length of time for handwashing should be at least 20 seconds. The ADON stated after giving care to each resident, proper hand hygiene must be observed. The ADON stated if hands are not visibly soiled, alcohol-based hand sanitizer can be used. The ADON stated if hands are visibly soiled, hand washing with soap and water must be performed to prevent cross-contamination. 2. During a concurrent observation and interview on 3/24/2026 at 1:19 p.m. with Laundry Personnel (LP) 1, in the laundry area, observed linen carts with different covering materials. LP 1 stated that he is responsible for doing the laundry linens. LP 1 stated that the linen carts are covered with green non-woven covers while the residents' personal clothing are covered with blue-colored woven/permeable cover to protect the clothing inside the cart and stated that it has always been that way. During an interview on 3/25/2026 at 9:45 a.m. with the Maintenance Supervisor (MS), the MS stated that the cart for the residents' personal clothing has always used blue-colored permeable cover. The MS stated that with the mesh covering, cross-contamination can occur. During a concurrent observation and interview on 3/25/2026 2:35 p.m. with the ADON, inside the laundry area, the ADON stated the maintenance department is responsible for maintaining clean linen carts. The ADON stated that the covers for residents' personal clothing were not totally protected from environmental contamination because air and water can seep through the covers. The ADON further stated that a non-permeable cover should be used to minimize transmission and cross-contamination. 3. During a review of the facility provided Daily Water Temperature Log for the months of January 2026 through March 2026, indicated the following: - On 1/13/2026, in rooms [ROOM NUMBERS], the water temperature was 107 degrees F. - On 1/14/2026, in rooms [ROOM NUMBERS], the water temperature was 108 degrees F. - On 1/22/2026, in rooms [ROOM NUMBERS], the water temperature was 107 degrees F. - On 2/11/2026, in rooms [ROOM NUMBERS], the water temperature was 108 degrees F. - On 2/19/2026, in rooms [ROOM NUMBERS], the water temperature was 107 degrees F. - On 3/5/2026, in rooms [ROOM NUMBERS], the water temperature was 106 degrees F. - On 3/12/2026, in rooms [ROOM NUMBERS], the water temperature was 108 degrees F. - On 3/16/2026, in rooms [ROOM NUMBERS], the water temperature was 108 degrees F. During a concurrent interview and record review on 3/26/2026 at 11:16 a.m. With the MS and the Infection Preventionist (IP), the IP stated that the MS is responsible for the water management program with the involvement of the IP, Administrator, Director of Nursing (DON), and Medical Director. The IP stated that the facility is following the CDC Toolkit: Developing a Legionella Water Management Program. The MS stated that they are doing water temperature control to prevent the growth of water-borne bacteria and should not be less than 106 degrees F and not more than 120 degrees F. The MS and the IP stated that per CDC Toolkit guidelines, the water temperature fluctuations: provide conditions where Legionella grows best (77 degrees F – 108 degrees F); Legionella can still grow outside this range. The MS stated that bacteria can grow if water temperature goes within those ranges. The MS further stated that they do water check temperatures on different locations within the facility and that the facility only uses temperature control, not chemical treatments. During an interview on 3/26/2026 at 1 p.m. with the DON, the DON stated that when water temperature falls within the range where bacteria grow best, there is a risk for bacteria going into the facility's water system that could potentially cause illness among residents. 4. During a review of Resident 66's admission Record, the admission Record indicated the facility admitted the resident on 6/2/2023 with diagnoses including acute respiratory failure with hypoxia ( a condition that happens when the body did not have enough oxygen in the blood leading to low oxygen levels), tracheostomy (an opening a surgeon makes through the neck and into the trachea [also known as windpipe] to help a patient breathe), and cardiac arrest (a condition when the heart suddenly stops beating and ca no longer pump blood to the brain and other vital organs and can be fatal). During a review of Resident 66's H&P, dated 6/2/2025, the H&P indicated Resident 66 did not have the capacity to understand and make decisions. During a review of Resident 66's MDS, dated [DATE], the MDS indicated Resident 66 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and was not able to understand and make her needs known. The MDS further indicated Resident 66 had impairment of both upper and lower extremities and required total assistance from staff with all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 66's Order Summary Report, dated 3/26/2026, the Order Summary Report indicated a physician's order for insulin lispro, inject subcutaneously (under the skin) per sliding scale (dosage of medication is determined by the resident's blood sugar) every six (6) hours for DM II, dated 9/30/2024. During a medication pass observation on 3/25/2025 at 12 p.m. with LVN 4, at MC 4, LVN 4 stated she would check Resident 66's blood sugar. Observed an enhanced barrier precaution (EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO - microorganisms, mainly bacteria, that are resistant to one or more classes of antibiotics] that uses targeted gown and glove use during high contact resident care activities) was posted at Resident 66's door. Observed LVN 4 remove a glucometer from MC 4 and disinfected with alcohol swab from the front to the back in 1 sweeping motion, disinfected the bedside table with Disinfectant Wipe (DW) 1, gathered all the equipment and placed the glucometer on the resident's bedside table, used a disposable lancet (sharp needle that's used to prick the skin to draw a small amount of blood) on the resident's finger, placed a test strip in the glucometer, and angled the glucometer at the resident's finger to test the blood. After the test was completed LVN 4 then removed and disposed of the used test strip, walked back to MC 4 after administration of the insulin. Observed LVN 4 used an alcohol pad to clean the glucometer with one sweeping motion on the middle part from front to back. LVN 4 stated they were told to clean the glucometers using alcohol pad in 1 sweeping motion in the middle from front to back. LVN 4 stated each medication cart has DW 1 and is used for disinfecting any resident care equipment before and after use. LVN 4 disinfecting the glucometer in 1 sweeping motion in the middle from front to back did not disinfect the glucometer properly as Resident 66 as well as other residents in the unit is on EBP due to indwelling devices such as tracheostomy and is at risk for developing MDROs. LVN 4 stated not disinfecting the glucometer can cause cross contamination and placed Resident 66 and other residents at risk for acquiring infection due to not disinfecting the glucometer properly During an interview on 3/25/2026 at 12:40 p.m. with the Subacute Coordinator (SAC), the SAC stated each medication cart has a canister of DW 1 and the licensed nurses are supposed to use the DW 1 when disinfecting any resident care equipment such as the glucometer and should be wiped all over paying close attention to where the test strip was inserted not just on one 1 area of the glucometer. The SAC stated all residents in the subacute unit all have tracheostomy and were all at risk for acquiring infection if any shared resident care equipment was not disinfected properly. The SAC stated that LVN 4 should have properly disinfected the glucometer after use on Resident 66 by wiping the unit with DW 1 all over the sides, front, and back as it placed Resident 66 and other residents for acquiring infection. During a review of the facility's Policy and Procedure (P&P) titled, Handwashing/Hand Hygiene last revised in October 2023, the P&P indicated the facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Hand hygiene is indicated: - Immediately before touching a resident; - After contact with blood, body fluids, or contaminated surfaces; - After touching a resident; - After touching the resident's environment; - Before moving from work on a soiled body site to a clean body site on the same resident; and - Immediately after glove removal. Use an alcohol-based hand rub containing at least 60% alcohol for most clinical situations. Wash hands with soap and water: - When hands are visibly soiled; and Single-use disposable gloves must be used: - Before aseptic procedures. - When anticipating contact with blood or body fluids; and - When in contact with a resident, or the equipment or environment of a resident, who is on contact precautions. The use of gloves does not replace hand washing/hand hygiene. During a review of the facility's P&P titled, Department (Environment Services) Laundry and Linen, last revised on December 2025, the P&P indicated that the purpose of this procedure is to provide a process for safe and aseptic handling, washing, and storage of linen. - Clean linen will remain hygienically clean (free of pathogens [tiny organisms that cause disease] in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination, such as covering clean linen carts. During a review of the facility's P&P titled, Legionella Surveillance and Detection, last revised December 2022, the P&P indicated, Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella. Legionnaire's disease is included as part of our infection surveillance activities. Policy Interpretation and Implementation - Legionella can grow in parts of building water systems that are continually wet (e.g., pipes, faucets, water storage tanks, decorative fountains), and certain devices can spread contaminated water droplets via aerosolization. During a review of the facility P&P titled, Policies and Practices - Infection Control, last reviewed 9/10/2025, the P&P indicated the facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. The P&P further indicate that the objectives the infection control policies and practices are to prevent, detect, investigate, and control infections in the facility, and provide guidelines for the safe cleaning and reprocessing or reusable resident-care equipment. During a review of the facility P&P titled, Obtaining a Fingerstick Glucose Level, last reviewed on 9/10/2025, the P&P indicated always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses. The P&P further indicated to clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice.

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the food services department when there were five (5) flies (a type of insect) observed in the dishroom. This failure had the potential to result in 71 of 77 residents, who received food from the kitchen, to acquire food borne illnesses (illness caused by consuming contaminated foods or beverages) by consuming potentially contaminated food. Findings: During a concurrent observation and interview on 3/24/2026 at 1:41 p.m., of the dishwashing area with the Dietary Supervisor (DS), observed 5 flies flying and landing from dirty dishes, to trash, then to the clean dishes. The DS stated there were flies flying around the dishwashing area, but she did not know why as the pest control company just came in this morning. During an interview on 3/24/2026 at 1:53 p.m. with the DS, the DS stated flies were landing on the clean dishes and the area needed to be fly free to keep the clean dishes away from the flies. The DS stated flies could spread diseases and bacteria to the residents as a potential outcome. During a review of facility's policies and procedures (P&P) titled, Pest Control, dated 9/10/2025, the P&P indicated, Our facility shall maintain an effective pest control program. (1) This facility maintains an on-going pest control program to ensure that the building.

Based on interview and record review, the facility failed to honor the resident's right to be informed in advance by the physician or other practitioner or professional, of the risks and benefits of proposed care, treatment, and treatment alternative or option for one of one sampled resident (Resident 73) reviewed for informed consents (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) by failing to complete Resident 73's informed consent on the use of bolsters and matched the physician's order. This deficient practice violated the resident's/resident representative's right to make an informed decision regarding the use of the bolsters. Findings: During a review of Resident 73's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility originally admitted the resident on 9/14/2018 and readmitted in the facility on 9/15/2025 with diagnoses including chronic respiratory failure (a long-term condition that happens when your lungs cannot get enough oxygen into the blood), tracheostomy (an opening a surgeon makes through the neck and into the trachea [also known as windpipe] to help a resident breathe), and quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury). During a review of Resident 73's History and Physical (H&P), dated 9/23/2025, the H&P indicated Resident 73 did not have the capacity to understand and make decisions. During a review of Resident 73's Minimum Data Set (MDS - a resident assessment tool), dated 2/18/2026, the MDS indicated Resident 73 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and was not able to understand and make his needs known. The MDS further indicated Resident 73 had impairment of both upper and lower extremities and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 73's Order Summary Report, dated as of 3/26/2026, the Order Summary Report indicated a physician's order for bilateral bolster on bed for comfort, positioning and safety dated 9/23/2025. During a review of Resident 73's informed consent form, dated 9/23/2025, the informed consent indicated that a phone consent was obtained by the physician from the party responsible. The informed consent indicated that the facility verified an informed consent was obtained for the use of bolsters but did not indicate the reason for the use of the device. During a review of Resident 73's fall risk assessments dated 8/20/2025, 11/28/2025, and 2/18/2026, the fall risk assessments indicated Resident 73 was at a risk for falls. During a review of Resident 77's care plan (CP) on risk for falls, initiated on 9/15/2018 and last revised on 3/6/2026, the CP indicated the use of bilateral bolster in bed for comfort, positioning, and safety as one of the interventions to minimize falls or injury. During an observation on 3/23/2026 at 11:33 a.m. inside Resident 73's room, observed Resident 73 lying in bed with triangular shaped bolsters on both sides of the bed and strapped around the bed frame. During a concurrent observation and interview on 3/25/2026 at 9:30 a.m. inside Resident 73's room with the Subacute Coordinator (SAC), the SAC stated that the bilateral bolsters were strapped on the bedframe and are used for resident safety and positioning. During a concurrent interview and record review on 3/25/2026 at 1:54 p.m. the SAC, Resident 73's physician's order, informed consent, fall risk assessments, and CP were reviewed. The SAC stated Resident 73 had a physician's order for bilateral bolsters in bed for comfort, positioning, and safety. The SAC stated the fall risk assessments indicated Resident 73 was at a risk for falls, and the CP indicated the use of bolsters as one of the interventions to minimize resident falls/injury. The SAC stated that the informed consent did not indicate the reason for the use of bilateral bolsters in bed. The SAC stated when obtaining informed consent from the resident and/or responsible party, the informed consent should be complete to indicate the device/restraint to be used and the reason for the use of the device/restraint. The SAC stated that Resident 73's informed consent should have been complete to indicate the reason for the use of the bilateral bolsters to give the resident and/resident representative the opportunity to accept or decline the use of the device for Resident 73's safety and minimize falls or injury. The SAC stated that the policy on Use of Restraints to include the specific reason for the restraint was not followed. During a review of the facility's policy and procedure (P&P) titled, Use of Restraints, last reviewed on 9/10/2025, the P&P indicated that restraints shall only bed used upon the written order of the a physician and after obtaining a consent from the resident and/or representative and should include the specific reason for the restraint as it relates to the resident's medical symptom, how the restraint will be used to benefit the resident's medical symptom, and the type of restraint, and period of time for the use of the restraint.

Based on observation, interview, and record review, the facility failed to honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and support for daily living safely for one of seven sampled residents (Resident 84) reviewed under environment facility task by failing to ensure Resident 84 did not have a dilapidated (in very bad condition because of age or lack of care) bedside drawer on the resident's room. The deficient practice had violated the resident's right to a safe, clean, comfortable, and homelike environment that can potentially lead to the resident`s depression and not feeling welcomed. Findings: During a review of Resident 84's admission Record (AR), the AR indicated the facility admitted the resident on 11/25/2025, with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (a mental health condition characterized by excessive, persistent, and uncontrollable fear or worry that interferes with daily life), and age-related physical debility (the gradual loss of strength, energy, and physical function that happens with older age, making a person more vulnerable to health issues and less able to handle daily activities). During a review of Resident 84's History and Physical (H&P), dated 11/26/2025, the H&P indicated the resident had impaired mental status, and did not follow commands. The H&P indicated the resident did not have the capacity to understand and make decisions. During a concurrent observation and interview on 3/23/2026, at 10:26 a.m., with the Director of Nursing (DON), inside Resident 84's room, observed Resident 84's bedside drawer dilapidated, with multiple tapes on to keep the furniture intact. Resident 84's drawer was not properly maintained, when pulled out, could fall apart into pieces. The DON stated the drawer had multiple tapes to keep the drawer intact and when you pull the drawer it could fall off and hurt the resident. The DON stated the dilapidated drawer was not promoting a homelike environment to the resident. During an interview on 3/25/2026, at 1:48 p.m., with the Assistant Director of Nursing (ADON), the ADON stated it was not appropriate to have broken furniture on Resident 84's environment because it does not promote a homelike environment. The ADON stated the policy and procedure (P&P) titled Homelike Environment, was not followed. The ADON also stated the broken furniture can make the resident feel unwelcomed and depressed. During a review of the facility's recent P&P titled, Homelike Environment, last reviewed on 9/10/2025, the P&P indicated residents are provided with a safe, clean, comfortable environment and encouraged to use their personal belongings to the extent possible. Policy Interpretation and Implementation 1. Staff provides person-centered care that emphasizes the resident's comfort, independence and personal needs and preferences. 2. The facility staff and management maximize, to the extent possible, the characteristics of the facility reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary, and orderly environment. d. personalized furniture and room arrangements.

Based on interview, and record review, the facility failed to report an allegation of staff to resident abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) immediately, but no later than two (2) hours after the allegation was made to the State Survey Agency (CDPH, California Department of Public Health), the Ombudsman (a resident advocate), and local law enforcement (LLE) in accordance with federal and state law for one (1) of one (1) sampled resident (Resident 20) reviewed under the abuse care area. This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect residents from harm from abuse. Findings: During a review of Resident 20's admission Record (AR), the AR indicated the facility admitted the resident on 4/16/2025, with diagnoses including diabetes mellitus (DM 2-a disorder characterized by difficulty in blood sugar control and poor wound healing), legal blindness (a term that defines severe limitation with vision where someone can see at 20 feet when a normal person can see at 200 feet), and adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity) During a review of Resident 20's Minimum Data Set (MDS - resident assessment tool) dated 1/16/2026, the MDS indicated that Resident 20 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and was able to understand others and sometimes was able to make her needs known. The MDS further indicated that Resident 20 required setup or clean-up assistance with eating, supervision or touching assistance with oral hygiene and roll left and right; partial or moderate assistance with upper body dressing and sit to lying; total assistance with bathing; substantial/maximal assistance from staff with all other activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 20's History and Physical (H&P), dated 4/17/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 20's eINTERACT Change in Condition Evaluation form dated 3/17/2026 at 9:45 a.m. completed by Registered Nurse (RN) 2, the eINTERACT Change in Condition Evaluation form indicated that Resident 20 reported an allegation of being abused by a staff member. The eINTERACT Change in Condition Evaluation form indicated that the physician was notified with new order for psychologist/psychiatrist consultation and that the nurse practitioner came and assessed Resident 20. During an interview on 3/25/2026 at 7:45 a.m. with Certified Nursing Assistant (CNA) 6, CNA 6 stated that on 3/17/2026 at approximately 4:30 a.m. while CNA 6 was cleaning Resident 20, Resident 20 accused CNA 6 of hitting the resident during activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) care. CNA 6 stated she continued cleaning Resident 20 and the resident continued to scream accusing CNA 6 of hitting Resident 20. CNA 6 stated CNA 5 offered to assist CNA 6 while providing ADL care to Resident 20, but CNA 6 stated she (CNA 6) was almost finished cleaning the resident. CNA 6 stated Resident 20 continued to be upset, and repeating CNA 6 hit her. CNA 6 stated she (CNA 6) continued with her work and went to provide ADL care to another resident. CNA 6 stated that when Resident 20 accused her of hitting her, it should be considered an allegation of abuse. CNA 6 stated she (CNA 6) did not report the incident to the charge nurse because she (CNA 6) did not hit Resident 20. CNA 6 stated she (CNA 6) should have reported the allegation to the charge nurse immediately, or within two (2) hours, regardless of whether it was true, to ensure resident's safety. During an interview on 3/25/2026 at 10:10 a.m. with Licensed Vocational Nurse (LVN) 8, LVN 8 stated that she (LVN 8) was notified by CNA 5 at approximately 5 a.m. on 3/17/2026 to speak with Resident 20 as the resident was extremely upset with CNA 6. LVN 8 stated that upon arrival to Resident 20's room, the resident seemed upset and stated that she (Resident 20) was hit by a CNA. LVN 8 stated she (LVN 8) did not ask Resident 20 to identify the CNA. LVN 8 stated that she (LVN 8) just checked Resident 20 for any injuries and there were no injuries, so she (LVN 8) continued with her medication administration. LVN 8 stated all staff are mandated reporters for any allegation of abuse and that such allegations should be reported to the Administrator (Adm) or Director of Nursing (DON). LVN 8 stated that the licensed nurses are supposed to remove the CNA being accused from the assignment and/or reassign to other residents away from the alleged victim. LVN 8 stated that any allegations of abuse should be reported to CDPH, the Ombudsman and LLE agency within two hours. LVN 8 stated she (LVN 8) should have notified the Adm/DON, CDPH, Ombudsman, and LLE immediately or within two hours. LVN 8 stated that she (LVN 8) should have removed CNA 6 from the assignment and reassigned her to ensure the resident`s safety, as continuing the assignment could cause the resident to become more upset and feel unsafe. During an interview on 3/25/2025 at 10:39 a.m. with the Director of Staff Development (DSD), the DSD stated that she (DSD) was made aware by the Adm of Resident 20's allegation that she (Resident 20) was hit by CNA 6 which happened on 3/17/2026 at approximately 4:30 a.m. The DSD stated that she (DSD) spoke with CNA 5, who stated that while providing care to Resident 20's roommate (Resident 55), he (CNA 5) overheard that Resident 20 upset and cursing, telling CNA 6, who was providing care, not to hit her in the face. The DSD stated CNA 5 denied witnessing the alleged abuse. The DSD stated LVN 8 said that she (LVN 8) went to check on Resident 20 and the resident seemed upset and stated that she (Resident 20) was hit by a staff member but did not identify. The DSD stated that LVN 8 stated she (LVN 8) talked to Resident 20, calmed the resident down, and continued on administering medications to other residents. The DSD stated that CNA 6 said Resident 20 was upset with her for being late in providing care and was cursing at CNA 6 telling her something about the face in Spanish. The DSD stated CNA 6 further stated she (CNA 6) continued providing care to Resident 20 and left the room once finished and did not report to LVN 8. The DSD stated that all staff are mandatory reporters and any allegation of abuse should be reported to the Adm immediately and to the CDPH, Ombudsman, and LLE within two hours to keep the residents safe from further abuse per facility policy on abuse. The DSD stated that any staff accused of any type of abuse should be immediately removed from the assignment, removed from work schedule pending final investigation of the allegation. The DSD stated that CNA 6 should have reported Resident 20`s allegation to LVN 8 and Adm. The DSD stated that LVN 8 should have reported Resident 20`s allegation of abuse to the Adm, completed the report best of her ability and faxed the report to CDPH and Ombudsman, and called the LLE. The DSD stated that the policy to report any types of abuse within two hours was not followed which placed Resident 20 and other resident at risk for further abuse. During an interview on 3/25/2026 at 1:31 p.m. with CNA 5, CNA 5 stated that on 3/17/2026 at approximately 5 a.m., after cleaning Resident 55, he (CNA 5) saw Resident 20 upset and crying and stated in Spanish that CNA 6 was very rough with her. CNA 5 further stated that after speaking with Resident 20, he (CNA 5) went to LVN 8 and told her to speak with the resident as the resident was saying CNA 6 was rough with her. CNA 5 stated that they received in-services in the past on reporting allegations of abuse to the Adm, who is the facility's abuse coordinator, immediately. This allows the facility to report the allegation to CDPH, the Ombudsman, and LLE within two hours of the allegation to prevent further potential abuse to residents. During an interview on 3/26/2026 at 7:56 a.m. with the Assistant Director of Nursing (ADON), the ADON stated that on 3/17/2026 at approximately 9:30 a.m. he (ADON) was made aware by the licensed nurse assigned to Resident 20 that the resident's roommate (Resident 55) claimed that CNA 6 hit Resident 20 while providing ADL care earlier in the morning. The ADON stated that Resident 55 said that she (Resident 55) did witness the alleged abuse, but she (Resident 55) heard slapping sound while Resident 20 was receiving ADL care. The ADON stated that Resident 20 said that she (Resident 22) was hit on the face by CNA 6. The ADON stated that an investigation was immediately started, and it was confirmed with CNA 5, CNA 6, and LVN 8 that the allegation of abuse happened between 4:30 a.m. and 5 a.m. The ADON stated that the Adm was immediately notified, and CDPH, Ombudsman, and LLE were called, and the report was faxed within two hours. The ADON stated all staff are mandated reporters and that any allegations of abuse regardless of if it is true or not has to be reported to the Adm immediately and to CDPH, the Ombudsman, and LLE within two hours of the allegation. the ADON stated that LVN 8 should have removed CNA 6 from her current assignment and reassigned to ensure that Resident 20 was safe from further abuse. The ADON stated that CNA 5, CNA 6, and LVN 8 should have reported the allegation of abuse to the Adm immediately per facility policy so it can reported to the CDPH, Ombudsman, and LLE within two hours to keep Resident 20 and other residents safe and free from abuse at all times. During an interview on 3/26/2026 at 12:54 p.m. with the Administrator (Adm), the Adm stated that on 3/17/2026 at 9:15 a.m., she (Adm) was made aware by the ADON that Resident 20 claimed that she (Resident 20) was hit on the face by CNA 6 while providing care to her early in the morning. The Adm that during interview with Resident 20, the resident stated that she (Resident 20) was covering her face and CNA 6 removed the cover. The Adm stated during an interview with CNA 6, CNA 6 stated that she (CNA 6) did not report to LVN 8. The Adm stated that CNA 5 stated that he (CNA 5) reported to LVN 8 at approximately 5 a.m. after providing care to Resident 20's roommate and seeing Resident 20 upset but did not report to the Adm. The Adm stated that LVN 8 said that CNA 5 reported to her that CNA 6 was rough with Resident 20 during care and she (LVN 8) just checked Resident 20 if there was pain, or for any signs of injury then continued with her medication administration and did not report to the Adm. The Adm stated that all staff are mandated reporters and must report any allegation of abuse immediately to the Adm as the facility is required to report to CDPH, Ombudsman, and LLE within two hours of when the allegation was made per facility policy and state/federal regulations. The Adm stated that CNA 5, CNA 6, and LVN 8 should have reported to her (Adm) the allegation of abuse immediately to be reported within two hours to CDPH, Ombudsman, and LLE for resident safety and protect Resident 20 and other resident at risk for further abuse. The Adm stated that CNA 6 should have been removed from providing care to Resident 20, as the resident may become upset, stressed, and psychologically affected upon seeing CNA 6 again. During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, last reviewed on 9/10/2025, the P&P indicated that all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. The P&P further indicated: - If resident abuse, neglect, exploitation, misappropriation or resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. - The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility b. The local/state ombudsman c. The resident's representative d. Adult protective services (where state law provides jurisdiction in long-term care) e. Law enforcement officials f. The resident's attending physician g. The facility medical director - Immediately is defined as: a. Within two (2) hours of an allegation involving abuse or result in serious bodily injury; or b. Within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. - Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents. - Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. - If the investigation reveals that the allegation(s) of abuse are unfounded, the employee(s) may be reinstated to his/her /their former position with back pay.

Based on interview and record review, the facility failed to follow its policy and procedure (P&P) regarding transfers and discharge by failing to ensure that necessary medical information was communicated to the receiving long term care facility for one (1) of three (3) sampled residents (Resident 118) during a review of closed records. This deficient practice placed Resident 118 at risk for a delay in the continuity of care and receiving the services and treatment the resident needed. Findings: During a review of Resident 118's admission Record, the admission Record indicated the facility admitted the resident on 1/8/2026 with diagnoses including dementia (a progressive state of decline in mental abilities), difficulty in walking, and heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 118's History and Physical (H&P), dated 1/9/2026, the H&P indicated the Resident 118 had the capacity to understand and make decisions. During a review of Resident 118's Minimum Data Set (MDS - a resident assessment tool), dated 1/13/2026, the MDS indicated Resident 118 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and was able to understand others and make his needs known. The MDS further indicated Resident 118 required setup or clean-up assistance with eating; supervision or touching assistance with oral hygiene; partial/moderate assistance with upper body dressing and personal hygiene; substantial/maximal assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 118's Order Summary Report, dated as of 3/26/2026, the Order Summary Report indicated a physician's order dated 1/13/2026 to discharge Resident 118 to Skille Nursing Facility (SNF) 1. During a review of Resident 118's Social Services Notes, dated 1/12/2026, the Social Services Notes indicated that the Social Services Director (SSD) received a message from the resident representative with a request to transfer Resident 118 to SNF 1 where the resident used to reside. During a review of Resident 118's Discharge Summary Note, dated 1/14/2026, the Discharge Summary Note indicated the resident was discharged to SNF 1 per family request. The Discharge Summary Note further indicated the physician was notified of the discharge. The Discharge Summary Note did not indicate a verbal report was provided to the SNF 1 prior to Resident 118's transfer. During a review of Resident 118's Discharge Instruction Form/Recapitulation of Stay, dated 1/14/2026, the Discharge Instruction Form/Recapitulation of Stay did not indicate the name of the next provider, the provider type, and that e verbal report was provided to SNF 1. During a concurrent interview and record review on 3/25/2026 at 1:03 p.m. with Registered Nurse (RN) 2, Resident 118's physician's order, Social Services Notes, Discharge Summary Notes, and Discharge Instruction Form/Recapitulation of Stay were reviewed. RN 2 stated that Resident 118 had a physician's order to discharge the resident to SNF 1, dated 1/13/2026, and that the Discharge Summary Notes, and Discharge Instruction Form/Recapitulation of Stay did not indicate that a verbal report was provided to SNF 1 and did not indicate the name of the next provider and provider type. RN 2 stated that the process for discharging residents to another long-term care facility is the licensed nurse will complete the Discharge Instruction Form/Recapitulation of Stay to include the name of the next provider and provider type and document that a report was provided to the receiving facility. RN 2 stated that upon discharge, the Discharge Instruction Form/Recapitulation of Stay and a list of the medications the resident will be discharged with will be sent with the resident. RN 2 stated that the discharging nurse has to call the receiving facility for a report for continuity of care and for the receiving facility to be aware of the resident's current status and document in the resident's medical record. RN 2 stated that she was the one who discharged Resident 118 and she did not document that she called SNF 1 for a report on the resident. RN 2 stated that she should have documented that she called SNF 1 for a report prior to Resident 118 discharge to ensure that SNF 1 was aware of the resident current functional status and current plan of care. RN 2 stated if the report was not documented, it placed Resident 118 for a delay in receiving the care and services he needed. During an interview on 3/26/2026 1 p.m. with the Assistant Director of Nursing (ADON), the ADON stated that when discharging residents, the discharging nurse has to call the receiving facility or hospital for a report to ensure the receiving facility was aware of the resident's current status including level of functioning, any isolation status, and the medications and document in the resident's medical record. The ADON stated that the Discharge Instruction Form/Recapitulation of Stay will be completed by the discharging nurse to include the next provider and provider type. The ADON stated that RN 2 should have documented that she called SNF 1 for a report to ensure SNF 1 was aware of the resident's current tatus for continuity of care and prevent delay in the delivery of care and services Resident 118 needed. During a review of the facility's P&P titled, Discharging the Resident, last reviewed on 9/10/2025, the P&P indicated that if the resident is being discharged to a hospital or another facility, ensure that a transfer summary is completed and telephone report is call to the receiving facility. The P&P further indicated that the date and time the discharge was made should be recorded in the resident's medical record.

Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 1) was free from sexual abuse inflicted by Registered Nurse 1 (RN 1). On 5/20/2023 starting at 10:33 p.m., Resident 1, who was unable to communicate needs, was totally dependent on staff for care, and was unable to make decisions or consent to sexual activities, was recorded by a hidden, motion-activated video camera placed by Family Member 1 (FM 1) in front of the foot part of the bed, when RN 1 came to Resident 1's left side of the bed. RN 1 was observed lifting Resident 1's blanket covering the left foot, grasped his genital from his scrub pants (medical uniform with drawstring and/or elastic waists), and proceeded to rub his genital on the resident's left foot. As a result, Resident 1 was subjected to a non-consensual (without permission) sexual abuse by RN 1 while under the care of the facility. Based on the reasonable person concept (hypothetical [suggested], average person's reaction to the actual circumstances of alleged illegal activities) due to Resident 1's severely impaired cognition (mental action or process of acquiring knowledge and understanding), an individual subjected to sexual abuse has lifetime physical pain and psychological (mental or emotional) effects including feelings of hopelessness, helplessness, and humiliation. On 9/12/2023 at 4:26 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility's failure to prevent the sexual abuse (42 CFR S483.12) to Resident 1. On 9/13/2023 at 7:50 p.m., the ADM provided an acceptable IJ Removal Plan (a detailed plan to address the IJ findings). On 9/14/2023 at 10:31 a.m., while onsite and after verifying the facility's full implementation of the IJ removal plan through observations, interviews, and record reviews, the SSA accepted the IJ removal plan and removed the IJ situation in the presence of the ADM and the DON. The acceptable IJ Removal Plan included the following summarized actions: 1. On 9/12/2023, the DON conducted assessment for signs of sexual abuse (such as facial grimacing, pain, and change in facial expression) to all 15 residents in the Subacute Unit (SA, is a unit within the facility where residents with level of skilled nursing care needs more intensive than the care provided to the majority of residents in the facility), where Resident 1 lived prior to her discharge home on 6/12/2023, and who were totally dependent on staff for care, with no capacity to make decisions, and unable to communicate. No other residents were affected by the deficient practice. 2. On 9/12/2023, the Director of Staff Development (DSD) provided a re-education to nursing staff on 9/12/2023 regarding prevention and management of any types of abuse including identifying signs and symptoms of abuse on non-verbal (unable to speak) residents. 3. On 9/13/2023, the facility reported RN 1 to the Board of Registered Nursing (BRN). 4. On 9/13/2023, the facility termed (released from his job duties by his employer) RN 1. 5. On 9/13/2023, Licensed Vocational Nurses (LVNs) and RNs checked all other residents in the remaining units within the facility and those residents in the SA Unit who were not totally dependent with ADLs and with capacity to make decisions for any abuse. No other residents were affected. 6. On 9/13/2023, the facility developed a sexual screening assessment tool to be utilized for any resident who has been identified to be with suspicions of, or allegation of sexual abuse. These assessments would be discussed during their daily stand-up meetings for further review and interventions. The findings would be investigated by the ADM. 7. On 9/13/2023, the DSD initiated employee file reviews on all staff to be completed by 9/15/2023 validating background checks, licenses or certificates, and abuse prevention training upon hire. 8. On 9/13/2023, the facility developed a process for the interdisciplinary team (IDT- a group of healthcare professional from different discipline who participate in the care of the residents) and the Medical Director to conduct abuse investigation review to include internal guidelines specifying local law enforcement follow-up and timeline needed for the development of the final investigation conclusion. 9. On 9/13/2023, the facility developed a process for the Department Managers (from medical records, social services, activities / recreation, dietary, rehabilitation, and maintenance), the DSD, and the Infection Preventionist (IP) to conduct resident care room rounds daily and when assigned as Manager of the Day to identify any abuse. 10. On 9/13/2023, the facility developed a process for the ADM and/or designee to conduct random observation rounds weekly and as needed to validate compliance on abuse prevention and management. Any findings will be discussed during daily stand-up meetings for further recommendations and interventions. 11. On 9/13/2023, the facility developed a process for the ADM and/or designee to discuss any pattern of findings related to alleged abuse investigation and conclusions with emphasis on law enforcement outcomes of investigation with the Medical Director and the Quality Assurance and Assessment (QAA - broad and systematic process of determining whether the services provided meet facility standards to prevent quality failures) committee that consist of the ADM, the DON, the Medical Director, the SSD, the Medical Records Director, and the Activity Director monthly for three months and/or until the deficient practice is resolved. Findings: A review of Resident 1's Admission Record (face sheet) indicated the facility admitted the resident on 4/1/2023 with diagnoses including anoxic brain damage (occurs when there is a complete loss of oxygen flowing to the brain, often as a result of reduced blood flow), diabetes mellitus (uncontrolled elevated blood sugar), acute respiratory failure (occurs when the lungs cannot release enough oxygen into the blood which prevents the organs from properly functioning), tracheostomy (a surgical procedure which consists of making an opening in the neck in order to place a tube into the windpipe to allow air to enter into the lungs), and history of sudden cardiac arrest (when the heart stops beating). A review of Resident 1's History and Physical (H&P) exam dated 4/3/2023 indicated the resident was unable to make own decisions. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 4/5/2023, indicated the resident was cognitively impaired, was unable to communicate, was totally dependent to staff for care including moving in bed, transfers, dressing, and personal hygiene. Resident 1 was dependent on a gastrostomy tube (GT, a tube surgically inserted into the stomach through the abdominal wall to administer food and medications) for feeding. A review of Resident 1's Change in Condition (COC) Evaluation dated 5/26/2023 documented by RN 4, indicated Resident 1 was involved in an alleged sexual abuse from RN 1. The notes indicated police officers came to the facility and informed RN 4 they had evidence of an alleged abuse. A police officer spoke to RN 1 and took him to the police station. A review of Resident 1's nursing Progress Notes, dated 5/26/2023 and timed at 8:43 p.m., indicated that per RN 4, police officers came to the facility at 6:55 p.m. asking for Resident 1's room and asking if the resident's family were present. At 7 p.m., RN 1 came to the Nursing Station and a police officer questioned him (RN 1) while another police officer requested for RN 1's backpack. RN 1 left the facility with the police officers. A review of Resident 1's nursing Progress Notes dated 5/26/2023 and timed at 10:15 p.m., indicated the DON with RN 4 spoke to FM 1 who then informed them the sexual abuse occurred on 5/20/2023. A review of Resident 1's nursing Progress Notes, dated 5/26/2023 and timed at 9:19 p.m., indicated RN 4 performed body assessment to Resident 1 and noted no obvious injury. RN 4 notified Resident 1's physician who ordered to transfer Resident 1 to General Acute Care Hospital 1 (GACH 1) for further evaluation due to alleged sexual abuse, but FM 1 refused the transfer and Resident 1 remained at the facility. During an interview, on 9/9/2023 at 12 p.m., FM 1 stated he had a video and a police report that RN 1 sexually abused Resident 1 on 5/20/2023 between 9:30 p.m. and midnight. FM 1 stated that it was not until 5/26/2023 when he saw the video and called the police. FM 1 stated he asked, and RN 4 confirmed RN 1 was working that evening (5/26/2023) during 7 p.m. to 7 a.m. shift., and RN 1 was arrested that same night. FM 1 stated RN 1 was currently out on bail (an amount of money a person, who has been arrested pays to a law court to be freed while waiting for a trial). FM 1 stated Resident 1 would tense up by opening her eyes, moving her mouth, and by having facial twitching (sudden movement) when hearing an unknown male voice. FM 1 stated Resident 1 would relax once reassured by the family's presence. FM 1 stated Resident 1 was discharged to home on 6/12/2023. The Evaluator requested FM 1 for the video evidence for review and FM 1 stated he would provide it later. On 9/11/2023 at 10:27 a.m., FM 1 emailed the Evaluator two video recordings dated 5/20/2023 and a police report dated 5/26/2023. On 9/11/2023 at 10:34 a.m., during a telephone interview, RN 1 stated he was aware of the video recording and had seen them, but he could not comment because the case was under investigation. RN 1 stated he had not been back to work, and his RN license had a court order for practice limitation restricting him from providing direct contact with residents or patients. On 9/11/2023 at 12 noon, during an observation of the first video footage dated 5/20/2023 starting at 10:33 p.m. and lasting 43 seconds (secs) long, indicated the following: At 5 secs - RN 1 approached and stood by Resident 1's left side facing the resident's left foot. RN 1 untied the string of his scrub pants and allowed the lower part of his scrub top to cover the string portion of his scrub pants. At 10 secs - RN 1 lifted the blanket covering the left foot and begun observing the resident's left foot by opening the left foot heel protector (offloads pressure from the bony prominence of the heel). At 21 secs - RN 1 moved closer to Resident 1's left side of the bed with his thighs touching the bed and his genitals touching the resident's left foot heel protector. At 27 secs - While looking at the door side of Resident 1's room, RN 1 used his left hand to move the lower part of his scrub top upwards and then placed it back down to cover the string portion of his scrub pants. At 31 secs - RN 1 stepped back from Resident 1's bed. At 38 secs - RN 1 covered Resident 1's left foot and walked away from the resident's left side of the bed. On 9/11/2023 at 12 noon, during an observation of the second video footage, dated 5/20/2023 starting at 10:34 p.m. and lasting 22 secs long, indicated the following: At 2 secs - RN 1 approached Resident 1's left side of the bed while putting a glove on his right hand. RN 1 stood by the resident's left foot area of the bed. At 5 secs - RN 1 untied the string of his scrub pants and allowed the lower part of his scrub top to cover the front of his scrub pants covering his genitals. At 10 secs - RN 1 removed the blanket covering Resident 1's left foot and rested the blanket on the resident exposing the lateral side (outer left side) of the heel protector. At 11 secs - RN 1 moved his thighs closer touching the resident's left side of the bed. At 13 secs - RN 1 moved his genitals closer to touch the resident's left heel protector. At 14 secs - RN 1 lifted the lower part of his scrub top using his left hand and moved closer to Resident 1's left foot. With his left hand, RN 1 grasped his genital while facing the resident's left foot. RN 1's genital was touching the resident's left heel protector. RN 1's blanket covered the inner part of the left heel protector. The lateral side (away from the center) of the left heel protector and RN 1's left hand were left uncovered. At 16 secs - While RN 1's left hand was doing a grasping motion of his genital, RN 1 moved his left hand with five up and down continuous motions towards Resident 1's left foot. At 22 secs - The video stopped with RN 1 still standing on Resident 1's left side. A review of Resident 1's Los Angeles Police Department Investigative Report (LAPD-IR) dated 5/26/2023, indicated the report was about a lewd act (intentionally exposing one's private area/s to someone with the intent to abuse, humiliate, degrade, or to gratify one's sexual desire) by a caretaker. The report indicated Resident 1 was the victim and the suspect was RN 1. The suspect used the victim's foot to stroke or rub his own genitals to get sexual arousal and gratification. The report further indicated the victim was incapacitated (disabled, helpless, and powerless) and the suspect was the victim's nurse. The LAPD-IR indicated that on 5/26/2023 at approximately 3:30 p.m., two police officers received a radio call to handle an elder abuse investigation. The LAPD-IR indicated two police officers responded and FM 1 informed them he noticed Resident 1 would grimace (to distort one's face in an expression usually of pain, disgust, or disapproval) every time she would hear a certain male voice later identified as RN 1. The LAPD-IR indicated FM 1 had suspicion that Resident 1 was not receiving the proper care in the facility, and so he placed a cellphone that would start recording when motion was detected in the room. The LAPD-IR indicated FM 1 provided the video recorded on 5/20/2023 between the times of 9:30 p.m. to 11:48 p.m. and the video did not capture the entire incident. On 9/11/2023 at 3:53 p.m., during an interview, the DON stated FM 1 only informed them about RN 1 sexually abusing Resident 1 and did not provide details or the video footage. The DON stated RN 1 did not return to work since 5/26/2023 and she or the ADM did not call RN 1 after the incident, and they were not aware if RN 1 remained arrested. The DON stated the facility was not aware of the status of the investigation and did not follow-up with the detectives. During an interview, on 9/12/2023 at 6:55 a.m., the ADM stated the facility's Abuse policy and procedures indicated all residents have the right to be free from abuse. During an interview, on 9/12/2023 at 10:28 a.m., the ADM stated on 5/27/2023, Detective 1 (D1) called her (the ADM), and she (the ADM) requested to view the video evidence but was denied because the investigation was ongoing. The ADM stated D1 informed her the case would be assigned to D2 and D3. The ADM stated on 5/30/2023, D2 and D3 visited the facility and requested to speak to the staff who worked on 5/20/2023 and they arranged 6/6/2023 for the detectives to call the facility so all staff could be present during the phone call. The ADM stated D2 and D3 informed her that they will reach out to the ADM once the investigation was done. The ADM stated she did not ask the detectives on how she will receive the police report and she did not clarify on what was the next step to do. The ADM stated they did not report RN 1 to the Board of Registered Nursing because they do not have enough evidence. A review of the facility's Promise to Comply with Anti-Harassment Policy signed and dated by RN 1 on 1/11/2023 indicated, As an employee, I acknowledge that I have read my employer's policy against harassment. I promise that I will fully comply with all aspects of that policy I agree that I will not engage in any conduct that would constitute unlawful harassment of another individual. I also agree to comply with my obligations under the policy to report any sexual harassment immediately to my supervisors. A review of the facility's Abuse Policy Acknowledgement Form signed and dated by RN 1 on 1/11/2023 indicated, I understand that as an employee of a long-term facility I have a legal responsibility to help assure that all residents in the facility are protected and kept safe from harm, further, that I shall report a known or reasonable suspicion of abuse immediately . A review of the facility's policy and procedure titled, Abuse and Neglect-Clinical Protocol, dated 3/2018 and reviewed on 11/16/2022, indicated, Abuse is defined as the willful infliction (with intention to cause) of injury, unreasonable confinement, intimidation or punishment with resulting harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychological well-being. Instances of abuse to all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled using technology. Sexual abuse is defined as non-consensual (without permission) sexual contact of any type with a resident. A review of the facility's policy and procedure titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated 4/2021 and reviewed on 11/16/2022 indicated, Residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment (physical punishment), involuntary seclusion (isolated or confined to a specific area), verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the residents' symptoms. Protect residents from abuse, neglect, exploitation, or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff.

Based on interview and record review, the facility failed to provide cardiopulmonary resuscitation (CPR - refers to any medical intervention used to restore circulatory [the system that moves blood throughout the body] and/or respiratory [breathing in and out] function that has stopped) to one of four sampled residents (Resident 4). Resident 4 ' s Advance Directive (a legally and ethically binding document used by people to state that their medical and end-of-life treatment decisions will be made by someone on their behalf when they become severely ill) Acknowledgment form, signed on [DATE], which was the most current and updated document, indicated Resident 4 was a full code (if a person ' s heart stopped beating or they stopped breathing, all resuscitation procedures will be provided to keep them alive). As a result, on [DATE] at 11:45 p.m., Certified Nursing Assistant 1 (CNA 1) saw Resident 4 sitting down in her wheelchair in her room unresponsive, called Licensed Vocational Nurse 1 (LVN 1), and did not provide CPR to Resident 4. On [DATE] at 12 a.m., Physician 1 pronounced Resident 4 dead. On [DATE] at 5:55 p.m., the State Survey Agency (SSA) identified an Immediate Jeopardy (IJ - a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death of a resident) situation under 42CFR §483.24(a)(3) Personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Regional Director of Operations and Director of Nursing (DON) were notified of the IJ situation from the facility ' s failure to ensure Resident 4 was provided basic life support (refers to maintaining an airway and breathing and the circulation and it comprises initial assessment, airway maintenance, expired air ventilation [rescue breathing; mouth-to-mouth ventilation] and chest compression), including CPR. On [DATE] at 1:52 p.m., the IJ situation was removed in the presence of the Administrator and DON, while onsite, and after verifying through observation, interview, and record review the implementation of the facility ' s submitted and accepted IJ Removal Plan. The IJ removal plan included the following summarized actions: - On [DATE], Clinical Resource, DON, and Medical Records conducted an audit and review using the Advance Directive/POLST Audit Tool on all 88 residents in-house and 2 residents on bed holds with Advance Directive Acknowledgment Forms, Advance Directives, Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . One other resident was found to be affected, which was identified and corrected immediately. - On [DATE], Clinical Resource in-serviced DON, Assistant DON (ADON), and Medical Records and the DON in-serviced licensed nurses to ensure that there is no conflicting information between the Advance Directive Acknowledgment Form, Advance Directive, POLST, and MD orders. - On [DATE], DON in-serviced licensed nurses to provide Basic Life Support including CPR on residents who are on full code status including residents that have not completed an Advance Directive Acknowledgment Form or POLST. - Medical Records/Designee will audit Advance Directive Acknowledgment Form, Advance Directive, POLST, and MD orders for all new admissions and all residents twice a month for 90 days using the Advance Directive/POLST Audit Tool. - The Interdisciplinary Treatment Team will be held upon admission, quarterly, annually, and as needed to discuss resident's Advance Directive Acknowledgment Form/POLST. - The DON and ADON will ensure that all orders for Code Status are accurately entered into the residents ' electronic health record, which will give a visual cue to staff. The orders will be completed by [DATE]. The licensed staff will be in-serviced on how to accurately enter the order into the electronic health record and identify the visual cue starting on [DATE] and completion of the in-service will be on [DATE]. Cross-reference F684. Findings: A review of Resident 4 ' s Admission Record indicated the facility originally admitted the resident on [DATE] and was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 4 ' s POLST, dated [DATE], indicated the following: 1. Do not attempt resuscitations. Allow natural death. 2. Comfort-focused treatment - primary goal of maximizing comfort. 3. No artificial means of nutrition, including feeding tubes (medical device used to provide nutrition to people who cannot obtain nutrition by mouth). The POLST indicated, POLST does not replace the Advance Directive. When available, review the Advance Directive and POLST form to ensure consistency, and update forms appropriately to resolve any conflicts A patient with capacity can, at any time, request alternative treatment or revoke a POLST by any means that indicates intent to revoke. It is recommended that revocation be documented by drawing a line through Sections A through D (A-instruction about CPR, B-Medical Interventions, C-Artificially Administered Nutrition, and D-Information and Signatures), writing VOID in large letters, and signing and dating this line. A review Resident 4 ' s physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 4 ' s Advance Directive Acknowledgment form, signed by Resident 4 on [DATE] and signed by both Social Services Director 2 (SSD 2) and Physician 1 on [DATE], indicated the Preferred Intensity of Care Authorization / Decisions are the following: - Yes to cardio-pulmonary resuscitation; - Yes to hospitalization ; - Yes to intravenous fluids (IV fluids - fluids delivered to the body through a small tube inserted into a vein); - No to tube feeding; - No to medication restriction; - No to treatment restriction; - No to palliative care (comfort care with or without curative intent); - No to hospice care (comfort care without curative intent); and - CPR for 15 minutes only. A review of Resident 4 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated [DATE], indicated resident had the ability to make self understood and understand others. The MDS indicated Resident 4 required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs) with bed mobility, transfer, walk in room, walk in corridor, dressing, toilet use, personal hygiene, and bathing; used a wheelchair (a chair with wheels used when walking is difficult or impossible due to illness or injury) and a walker (a device that gives additional support to maintain balance while walking). A review of Resident 4 ' s physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 4 ' s Progress Notes, dated [DATE] at 4:43 p.m., indicated Resident 4 left for surgery on [DATE] at 4:10 a.m. to GACH 1. A review of Resident 4 ' s Progress Notes, dated [DATE] at 5:45 pm, indicated Registered Nurse 2 (RN 2) documented that at the facility Resident 2 was noted to be very sleepy and lethargic (slow or sleepy), unable to keep eyes open, and not able to answer questions appropriately. RN 2 notified Physician 1 with new order to transfer Resident 4 to GACH 2 and RN 2 called 911. A review of Resident 4 ' s physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] transferred to GACH 2. A review of Resident 4 ' s Progress Notes, dated [DATE] at 12:53 a.m., indicated LVN 1 documented that CNA 1 found Resident 4 in her room unresponsive on [DATE] at 11:45 p.m. with absent radial pulse (pulse taken from the wrist) and apical pulse (heartbeat heard in the left center of your chest, just below the nipple)). The Progress Notes indicated on [DATE] at 12 a.m., Resident 4 was pronounced dead. During a record review on [DATE] at 9:55 a.m., together with ADON, Resident 4 ' s chart (a three-ring binder used to hold resident ' s paper medical records which can be found in the nurses station) was observed with POLST, signed by Resident 4 on [DATE], was on top of the Advance Directive Acknowledgment form, signed by Resident 4 on [DATE]. During a concurrent interview and record review of the POLST and Advance Directive Acknowledgment form, the ADON stated that she believed that LVN 1 who took care of Resident 4 on [DATE] followed the POLST, dated [DATE], that indicated DNR because it was what the LVN 1 first saw. The ADON stated that because there were two documents indicating two different things, these confused the nurse. The ADON stated that if it were her, she would have followed the most recent document which was the Advance Directive Acknowledgment form indicating Resident 4 was a full code. The ADON stated that because Resident 4 was a full code, and was found unresponsive on [DATE] at 11:45 p.m., LVN 1 should have started CPR while another nurse called 911. During an interview on [DATE] at 12:06 p.m., Physician 1 stated Resident 4 was his patient. Physician 1 stated he cannot remember the specific times when the documents were made or signed, but what he knew was that people can change their minds. Physician 1 stated if he was looking at the two documents (POLST and Advance Directive Acknowledgment form), he would go for the most recent one (Advance Directive Acknowledgment form). During an interview on [DATE] at 1:15 pm, the DON stated she would have followed the POLST signed by Resident 4 on [DATE] because it was in Resident 4 ' s chart and the Advance Directive Acknowledgment signed by Resident 4 on [DATE] was in the old chart (chart that was kept by the medical records department). During a concurrent record review, Resident 4 ' s POLST was on top of the Advance Directive Acknowledgment form on both the old chart and Resident 4 ' s current chart. The DON stated Resident 4 ' s POLST indicated DNR, but Resident 4 ' s Advance Directive Acknowledgment indicated full code. The DON stated that with two conflicting documents, the facility should have done an interdisciplinary (resident or resident representative, DON, social worker, physician) meeting with the resident to clarify Resident 4 ' s wishes. The DON stated the conflicting documents confused staff and lead to Resident 4 ' s wishes not determined. The DON stated that based on Resident 4 ' s Advance Directive Acknowledgment form signed on [DATE], resident wanted CPR for fifteen minutes which meant chest compressions and breaths for 15 minutes, to receive intravenous fluids which meant that Resident 4 wanted fluids that go through the vein, no treatment restriction, no medication restriction, no palliative care, no hospice care, and wanted hospitalization if the facility found Resident 4 in distress. During an interview on [DATE] at 2:22 p.m., and concurrent record review of the Advance Directive Acknowledgment and POLST, SSD 1 stated the Advance Directive Acknowledgment and POLST go together as part of resident admission packet and were created together at the same time and should have matching information. SSD 1 stated she was not employed yet at the time Resident 4 created the Advance Directive Acknowledgment that Resident 4 signed on [DATE]. SSD 1 further stated that once residents created and signed the Advance Directive Acknowledgment and POLST, the forms would be flagged (in a three-ring binder, only the middle and bottom holes of the paper are filed so that a portion of the paper is showing or sticking out of the binder) for the physician to sign. SSD 1 stated that it should have been a team effort of the social services, nursing, and medical records departments to ensure that these forms were accurate and signed by the resident and physician. SSD 1 stated there was an absence of a POLST that should have complemented Resident 4 ' s Advance Directive Acknowledgment that Resident 4 signed on [DATE]. SSD 1 stated that it was important that the Advance Directive Acknowledgment and POSLT had matching information, but because Resident 4 ' s chart did not have matching information in the Advance Directive Acknowledgment and the POLST, it created conflicting information which led to not respecting Resident 4 ' s wishes and death. During a telephone interview on [DATE] at 2:39 p.m., LVN 1 stated that on [DATE] between 9:30 p.m. to 9:45 p.m., LVN 1 saw Resident 4 was seated in a wheelchair next to Resident 4 ' s bed watching television. LVN 1 stated that on [DATE] between 10:35 p.m. to 10:50 p.m., CNA 1 told LVN 1 to check Resident 4. LVN 1 stated that CNA 1 and LVN 1 went to check Resident 4 and saw Resident 4 in a sitting position with upper body leaning forward and was not responding after calling Resident 4 ' s name and patting Resident 4 ' s shoulders. LVN 1 stated he then left the room to get blood pressure machine and pulse oximeter machine (a device used to measure oxygen saturation) and told another staff to call 911. LVN 1 stated he went back to Resident 4 ' s room and checked Resident 4 ' s blood pressure and oxygen saturation. LVN 1 stated Resident 4 had no carotid pulse (pulse felt on a person ' s neck), no blood pressure, and no oxygen saturation. LVN 1 stated that LVN 1 and CNA 1 then transferred Resident 4 to Resident 4 ' s bed. LVN 1 stated that RN 1 came into the room and checked Resident 4 ' s pulses and did not feel any pulses. LVN 1 stated LVN 1 called and informed Physician 1 of Resident 4 ' s condition and Physician 1 pronounced Resident 4 dead on [DATE] at 12 a.m. LVN 1 stated that when the paramedics arrived, LVN 1 informed the paramedics that Resident 4 was pronounced dead by Physician 1. LVN 1 stated that LVN 1 did not check Resident 4 ' s POLST and assumed Resident 4 was DNR. LVN 1 stated that staff did not do CPR. LVN 1 stated that if CPR was not done it meant that staff did not try to revive Resident 4. During an interview on [DATE] at 4:15 p.m., and concurrent record review of the POLST (dated on [DATE]) and Advance Directive Acknowledgment form (signed on [DATE]), Medical Records Director (MRD) stated staff could have crossed out the old POLST. MRD stated there was no documented evidence there was a correction made for the inconsistencies of the POLST and Advance Directive Acknowledgment. During an interview on [DATE] at 8:12 a.m., and concurrent record review of the POLST (dated on [DATE]) and Advance Directive Acknowledgment form (signed on [DATE]), RN 2 stated whoever did the Advance Directive Acknowledgment form did not create an updated POLST. RN 2 stated medical records staff should have audited (physically checking records to ensure accuracy) the chart and if the discrepancy was found, should have clarified the conflicting information with Resident 4. During an interview on [DATE] at 12:02 p.m., the DON stated Resident 4 got COVID-19 last [DATE] and Resident 4 was asking to be sent to GACH 1. The DON stated the facility transferred Resident 4 to GACH 1 on [DATE] but discharged against medical advice and was readmitted back at the facility on [DATE]. The DON stated this readmission was a missed opportunity to clarify with Resident 4 her code status whether resident was DNR or full code. A review of facility ' s current policy and procedure, dated ,d+[DATE], titled, Advance Directives, indicated, Advance directives will be respected in accordance with state law and facility policy . 1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so . 8. If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives . 10. The plan of care for each resident will be consistent with his or her documented treatment preferences and/ or advance directive .11. A resident will not be treated against his or her own wishes . 18. The interdisciplinary team will review annually with the resident his or her advance directives to ensure that such directives are still the wishes of the resident. Such reviews will be made during the annual assessment process and recorded on the resident assessment instrument (MDS) . 20. The director of nursing services or designee will notify the attending physician of advance directives so that appropriate orders can be documented in the resident ' s medical record and plan of care. A review of facility ' s current P&P, dated ,d+[DATE], titled, Emergency Procedure - Cardiopulmonary Resuscitation, indicated, 1. If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: a. Instruct a staff member to activate the emergency response system code (code) and call 911; b. Instruct a staff member to retrieve the automatic external defibrillator (AED - sends an electric shock to the heart to stop an extremely rapid, irregular heartbeat, and restore the normal heart rhythm); c. Verify or instruct a staff member to verify the DNR or code status of the individual; d. Initiate the basic life support (BLS) sequence of events. 2. The BLS sequence of events is referred to as C-A-B (chest compressions, airway, breathing). A review of facility ' s current P&P titled, Do Not Resuscitate Order, dated ,d+[DATE], indicated, 1. Do not resuscitate orders must be signed by the resident ' s attending physician on the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. A Do Not Resuscitate (DNR) order from must be completed and signed by the attending physician and resident (or resident ' s legal surrogate, as permitted by state law) and placed in front of the resident ' s medical record . 3. In addition to the advance directive and DNR order form, state-specific forms may be used to specify whether to administer CPR in case of a medical emergency. State-specific forms include a. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 5. Do not resuscitate (DNR) orders will remain in effect until the resident (or legal surrogate) provides the facility with a signed and dated request to end DNR order . 6. The interdisciplinary care planning team will review advance directives with the resident during quarterly care planning sessions to determine if the resident wishes to make changes in such directives .

Based on observation, interview, and record review, the facility failed to ensure one of eight sampled residents (Resident 1), who was dependent on staff for all activities of daily living (ADLs, such as dressing, personal hygiene, and incontinent care), was in persistent vegetative status (showing no signs of awareness related to [CONDITION(S)]), and was dependent on a ventilator (a mechanical breathing machine to provide oxygen [a chemical element found in the air as a colorless odorless tasteless gas that is necessary for life) to the body when the person is unable to breath on his/her own), was free from neglect (the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress). On [DATE], Family Member 1 (FM 1) noticed the area surrounding the [CONDITION(S)] (a surgical hole [stoma] created at the front of the neck so a tube can be inserted into the windpipe to assist in breathing; the tube is connected to the ventilator), had maggots infestation (fly larvae soft bodied , worm-like immature form of an insect that feed on the host ' s dead or living tissue and liquid body substances; myiasis is the infection of a fly larva in human tissue). As a result, Resident 1 was placed at great risk of breathing complications including infection, FM 1 was disconcerted and upset to find the multiple maggots that had not been identified by the staff. Based on the reasonable person concept, due to Resident 1 ' s severely impaired cognition and medical condition, an individual subjected to neglect, may have psychological effects including feelings of hopelessness, helplessness and humiliation. On [DATE] at 5:10 p.m., the State Survey Agency (SSA) identified an Immediate Jeopardy (a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) under 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation. The Administrator (ADM) and the Director of Nursing (DON) were notified of the IJ from the failure to ensure Resident 1 was free from neglect. On [DATE] at 4:45 p.m., the IJ was removed, while onsite, after verifying the implementation of the IJ Removal Plan which included the licensed nurses assessing Resident 1 and all other 18 residents with [CONDITION(S)] tubes to rule out any maggot infestation and any other sign of neglect; the Maintenance Department inspected environmental surroundings of residents ' rooms for fly infestation; and the pest control company was contacted for additional services for the external building to help prevent flies from entering the building. Cross Reference with F695, F880, and F925. Findings: On [DATE], an unannounced visit was conducted to investigate a complaint and a facility-reported incident (FRI) about presence of maggots in Resident 1 ' s [CONDITION(S)] (around the stoma site). On [DATE] at 1:05 p.m., during entrance conference, the ADM stated the in-house census (population count) in the Sub-Acute (a lower level of care setting from a General Acute Care Hospital [GACH]) unit was nineteen (19) residents. On [DATE] at 1:09 p.m., during observation and concurrent interview with the Infection Control nurse (IP), IP observed and confirmed the presence of a live fly resting on the window curtains of the conference room. A review of Resident 1 ' s Admission Record indicated the facility admitted the resident on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident 1 ' s Care Plan for the resident having a [CONDITION(S)], last revised on [DATE] and current, included in the interventions changing the [CONDITION(S)] dressing every shift and as needed for soiling (when dirty) and observing the (stoma) site every shift and document findings. A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated [DATE] indicated the resident was unable to communicate and required total care from staff for all ADLs. A review of Resident 1 ' s Care Plan for Activities of Daily Living Function, last revised on [DATE], included in the interventions anticipating and meet the resident ' s needs daily, and conducting skin inspection (including stoma site) every shift and as needed, observing for redness, open areas, scratches, cuts, bruises, and report changes to the nurse. A review of Resident 1 ' s Change in Condition Evaluation, dated [DATE] at 1:45 p.m., indicated the resident had small white bugs noted around [CONDITION(S)]. On [DATE] at 1:24 p.m., during an interview, Respiratory Therapist (a health care discipline specializing in the promotion of optimum cardiopulmonary function) 1 (RT 1) stated the RTs in the Sub-Acute unit assessed the residents ' respiratory status, oxygen saturation (amount of oxygen measured in the blood), changing and checking [CONDITION(S)] and securing the ties (to hold the tube in place) and checking the ventilators setting and proper functioning. RT 1 stated calling off for [DATE] and notifying the DON 24 hours prior to the scheduled shift (7 a.m. to 7 p.m. shift) but no replacement was provided to the unit. RT 1 stated it was very important to have RTs around the clock due to the residents having [CONDITION(S)] and ventilators. RT 1 indicated neglect was a form of abuse and not providing the residents with RT services was an example of neglect. During the interview, a fly was observed in the conference room which was confirmed by RT 1. On [DATE] at 1:57 p.m., during an interview, Registered Nurse 1 (RN 1) stated assessing Resident 1 ' s [CONDITION(S)] on [DATE] after 1:20 p.m. RN 1 stated, I have never encountered anything like that before. RN 1 indicated the gauze (a loosely woven, almost translucent fabric that is used to bandage wounds) was clean on the outside. RN 1 stated, When we opened up the gauze, it looked like fly larvae or maggots. RN 1 stated the licensed nurses were assigned to do the [CONDITION(S)] care for that morning as there was no RT on duty. RN 1 said Resident 1 did not receive [CONDITION(S)] care for the shift prior to FM 1 identifying the maggots. RN 1 stated, this was sad, really horrible. RN 1 then stated, It is true, the maggots, it is what I saw. I never want to see that again. On [DATE] at 2:50 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated on [DATE], Resident 1 ' s [CONDITION(S)] had maggots around the stoma, and they were alive and moving. LVN 1 confirmed that there was no RT in the morning and the [CONDITION(S)] care was not provided to Resident 1 until after FM 1 saw the maggots on [DATE] around 1:30 pm. On [DATE] at 2:15 p.m., during a telephone interview, the facility ' s contracted pest control company Service Manager 1 (SM 1), stated flies land on food sources where they can leave their eggs, which then become larvae (maggots). SM 1 stated that for the eggs to develop into maggots, it could be from twenty-four (24) hours to a week. On [DATE] at 3:52 p.m., during an observation of Resident 1 in the presence of LVN 1, Resident 1 ' s [CONDITION(S)] and surrounding skin was observed to be reddened in color. On [DATE] at 4:43 p.m., a live fly was observed at the lobby doors beside the ADM ' s office. The DON present at the lobby confirmed the sighting of the live fly. On [DATE] at 4:52 p.m., during an interview, the Director of Nursing (DON) stated that for the [CONDITION(S)], the dressing used is a T-drain (a gauze with a T-slit to provide a snug fit around tubes) and is not taped down onto the resident ' s skin. The DON stated the licensed nurses do not open (remove) the wound dressing if it does not look soiled from the outside. DON stated having maggots in the [CONDITION(S)] can lead to infection because flies transmit bacteria. On [DATE] at 7:24 p.m., during interview, the DON stated the Sub-Acute unit licensed nurses and the RTs chart on the form titled, Daily Sub-Acute Charting. During concurrent review with the DON, the Daily Sub-Acute Charting had no documentation of the stoma status on: - [DATE], timed at 12:01 a.m., and at 10:33 a.m. - [DATE], timed at 1:58 a.m. and at 10:44 a.m. - [DATE], timed at 10:57 p.m. The DON stated 24 to 48 hours is what was understood on the developmental stages from fly eggs to becoming maggots. The DON stated licensed nurses and RT were to document their assessment every shift. A review of an undated document provided to the facility by the pest control company titled, House Fly Larvae, indicated, House fly populations can be harmful to human health: they carry multiple pathogens (microorganisms that cause or can cause diseases) and have been linked to the spread of a number of diseases . House fly eggs look like small grains of rice. Eggs hatch within 24 hours, and house fly larvae emerge. House fly larvae, or maggots, appear similar to pale worms. A review of a facility ' s policy and procedures titled, Activities of Daily Living (ADL), Supporting, last revised ,d+[DATE] and current indicated, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. A review of the facility ' s policy and procedures titled, [CONDITION(S)] Care last revised ,d+[DATE] and current, indicated procedure guidelines to inspect skin and stoma (surgical opening) site for signs or symptoms of infection, leakage, subcutaneous crepitus (air pockets under the skin) or dislodged tube. The policy also states, Document the procedure, condition of the site, and the resident ' s response. A review of the facility ' s policy and procedures titled, Abuse Prevention Program last revised ,d+[DATE] indicated the policy statement, Our residents have the right to be free from abuse, neglect, misappropriation of property and exploitation (action of treating someone unfairly in-order to benefit from their work). A record review of an undated job description titled, Licensed Vocational Nurse indicated the position summary, The purpose of your job position is to provide each resident with routine daily nursing care in accordance with current federal, state, and local standards that govern the facility, and as directed by your supervisors. The job description also indicated that essential duties and responsibilities include, Dressing wounds and Accurate and detailed charting of resident ' s progress notes. A review of the facility ' s policy and procedures titled, Safety and Supervision of Residents last revised ,d+[DATE] and current stated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The policy also indicated that when accident hazards are identified, the Quality Assurance and Performance Improvement (QAPI)/safety committee shall evaluate and analyze the cause(s) of the hazards and develop strategies to mitigate (to lessen severity) or remove the hazards to the extent possible.

Based on observation, interview, and record review, the facility failed to ensure one of eight sampled residents (Resident 1), who was dependent on staff for all activities of daily living (ADLs, such as dressing, personal hygiene, and incontinent care), was in persistent vegetative status (showing no signs of awareness related to [CONDITION(S)]), and was dependent on a ventilator (a mechanical breathing machine to provide oxygen [a chemical element found in the air as a colorless odorless tasteless gas that is necessary for life) to the body when the person is unable to breath on his/her own), was free from neglect (the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress). On [DATE], Family Member 1 (FM 1) noticed the area surrounding the [CONDITION(S)] (a surgical hole [stoma] created at the front of the neck so a tube can be inserted into the windpipe to assist in breathing; the tube is connected to the ventilator), had maggots infestation (fly larvae soft bodied , worm-like immature form of an insect that feed on the host ' s dead or living tissue and liquid body substances; myiasis is the infection of a fly larva in human tissue). As a result, Resident 1 was placed at great risk of breathing complications including spread of the larva into the windpipe. On [DATE] at 5:10 p.m., the State Survey Agency (SSA) identified an Immediate Jeopardy (a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) under 42CFR §483.80 Infection Control. The Administrator (ADM) and the Director of Nursing (DON) were notified of the IJ from the failure to ensure Resident 1 was free from infection to the stoma site caused by flies. On [DATE] at 4:45 p.m., the IJ was removed, while onsite, after verifying the implementation of the IJ Removal Plan which included the licensed nurses assessing Resident 1 and all other 17 residents with [CONDITION(S)] tubes to rule out any maggot infestation and any other sign of neglect; the Maintenance Department inspected environmental surroundings of residents ' rooms for fly infestation; and the pest control company was contacted for additional services for the external building to help prevent flies from entering the building. Cross Reference with F600, F695, and F925. Findings: On [DATE] at 1:05 p.m., during entrance conference, the ADM stated the in-house census (population count) in the Sub-Acute (a lower level of care setting from a General Acute Care Hospital [GACH]) unit was nineteen (19) residents. On [DATE] at 1:09 p.m., during observation and concurrent interview with the Infection Control nurse (IP), IP observed and confirmed the presence of a live fly resting on the window curtains of the conference room. A review of Resident 1 ' s Admission Record indicated the facility admitted the resident on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1 ' s current Care Plan for [CONDITION(S)], last revised on [DATE], included in the interventions changing the [CONDITION(S)] dressing every shift and as needed for soiling (when dirty) and observing the (stoma) site every shift and document findings. A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated [DATE] indicated the resident was unable to communicate and required total care from staff for all ADLs. A review of Resident 1 ' s Care Plan for Activities of Daily Living Function last revised on [DATE], included in the interventions anticipating and meet the resident ' s needs daily, and conducting skin inspection every shift and as needed, observing for redness, open areas, scratches, cuts, bruises, and report changes to the nurse. A review of Resident 1 ' s Change in Condition Evaluation, dated [DATE] at 1:45 p.m., indicated the resident had small white bugs noted around [CONDITION(S)]. On [DATE] at 1:24 p.m., during an interview, Respiratory Therapist (a health care discipline specializing in the promotion of optimum cardiopulmonary function) 1 (RT 1) stated the RTs in the Sub-Acute unit assessed the residents ' respiratory status, oxygen saturation (amount of oxygen measured in the blood), changing and checking [CONDITION(S)] and securing the ties (to hold the tube in place) and checking the ventilators setting and proper functioning. RT 1 stated calling off for [DATE] and notifying the DON 24 hours prior to the scheduled shift but no replacement was provided to the unit. RT 1 stated it was very important to have RTs around the clock due to the residents having [CONDITION(S)] and ventilators. RT 1 indicated neglect was a form of abuse and not providing the residents with RT services was an example of neglect. During the interview, a fly was observed in the conference room which was confirmed by RT 1. On [DATE] at 1:57 p.m., during an interview, Registered Nurse 1 (RN 1) stated assessing Resident 1 ' s [CONDITION(S)] on [DATE] after 1:20 p.m. RN 1 stated, I have never encountered anything like that before. RN 1 indicated the gauze (a loosely woven, almost translucent fabric that is used to bandage wounds) was clean on the outside. RN 1 stated, When we opened up the gauze, it looked like fly larvae or maggots. RN 1 stated the licensed nurses were assigned to do the [CONDITION(S)] care for that morning as there was no RT on duty. RN 1 said Resident 1 did not receive [CONDITION(S)] care for the shift prior to identifying the maggots. RN 1 stated, this was sad, really horrible. RN 1 then stated, It is true, the maggots, it is what I saw. I never want to see that again. On [DATE] at 2:50 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated on [DATE], Resident 1 ' s [CONDITION(S)] had maggots around the stoma, and they were alive and moving. LVN 1 confirmed that there was no RT in the morning and the [CONDITION(S)] care was not provided to Resident 1 until after FM 1 saw the maggots. On [DATE] at 2:15 p.m., during a telephone interview, the facility ' s contracted pest control company Service Manager 1 (SM 1), stated flies land on food sources where they can leave their eggs, which then become larvae (maggots). SM 1 stated that for the eggs to develop into maggots, it could be from twenty-four (24) hours to a week. On [DATE] at 3:52 p.m., during an observation of Resident 1 in the presence of LVN 1, Resident 1 ' s [CONDITION(S)] and surrounding skin was observed to be reddened in color. On [DATE] at 4:43 p.m., a live fly was observed at the lobby doors beside the ADM ' s office. The DON present at the lobby confirmed the sighting of the live fly. On [DATE] at 4:52 p.m., during an interview, the DON stated for the [CONDITION(S)], the dressing used is a T-drain (a gauze with a T-slit to provide a snug fit around tubes) and is not taped down onto the resident ' s skin. The DON stated staff do not open (remove) the wound dressing if it does not look soiled from the outside. DON stated having maggots in the [CONDITION(S)] can lead to infection because flies transmit bacteria. On [DATE] at 2:49 p.m., during interview and record review with Infection Prevention Nurse (IP), IP stated flies can cause infection. The IP stated there were goats in the neighboring building and flies rested on the goats ' droppings. IP stated Resident 1 ' s [CONDITION(S)] care plan included observing the site every shift and any findings should be documented. Concurrent record review with IP of Resident 1 ' s Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Concurrent record review on Resident 1 ' s MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . IP was informed that on [DATE] at 3:52 p.m., Resident 1 ' s [CONDITION(S)] was observed with reddened skin. IP was unable to answer why the documentation was different from the observation but stated that the assessments should be consistent with what is being seen on Resident 1. On [DATE] at 5:52 p.m., while exiting the facility, a live fly was observed at the glass exit doors. The observation was made in the presence of the Activity Director (AD). The AD confirmed the sighting of the fly. On [DATE] at 7:24 p.m., during interview, the DON stated the Sub-Acute unit licensed nurses and the RTs chart on the form titled, Daily Sub-Acute Charting. During concurrent review with the DON, the Daily Sub-Acute Charting had no documentation of the stoma status on: - [DATE], timed at 12:01 a.m., and at 10:33 a.m. - [DATE], timed at 1:58 a.m. and at 10:44 a.m. - [DATE], timed at 10:57 p.m. The DON stated 24 to 48 hours is what was understood on the developmental stages from fly eggs to becoming maggots. The DON stated staff were to document their assessment every shift. A review of the facility ' s current policy and procedure titled, Departmental (Respiratory Therapy) - Prevention of Infection, revised on ,d+[DATE], indicated, The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff The following information should be recorded in the resident ' s medical record: . 4. All assessment data obtained during the treatment. A review of an undated document provided to the facility by the pest control company titled, House Fly Larvae, indicated, House fly populations can be harmful to human health: they carry multiple pathogens (microorganisms that cause or can cause diseases) and have been linked to the spread of a number of diseases . House fly eggs look like small grains of rice. Eggs hatch within 24 hours, and house fly larvae emerge. House fly larvae, or maggots, appear similar to pale worms. A review of a facility ' s current policy and procedure titled, Activities of Daily Living (ADL), Supporting, last revised ,d+[DATE] indicated, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. A review of the facility ' s current policy and procedure titled, [CONDITION(S)] Care last revised ,d+[DATE], indicated procedure guidelines to inspect skin and stoma (surgical opening) site for signs or symptoms of infection, leakage, subcutaneous crepitus (air pockets under the skin) or dislodged tube. The policy also states, Document the procedure, condition of the site, and the resident ' s response. A record review of an undated facility provided job description titled Respiratory Therapist indicated the position summary as, The purpose of your job is to perform the duties of respiratory care upon the physician ' s request by following the federal, state, and local guidelines that govern the facility and as directed by the DON and Administrator. The job description also stated that Respiratory Therapists will Relate all pertinent information concerning a resident ' s condition to a charge nurse as required. They will be committed to always doing the right thing. A record review of an undated facility provided job description titled Licensed Vocational Nurse indicated the position summary, The purpose of your job position is to provide each resident with routine daily nursing care in accordance with current federal, state, and local standards that govern the facility, and as directed by your supervisors. The job description also indicated that essential duties and responsibilities include, Dressing wounds and Accurate and detailed charting of resident ' s progress notes. A review of the facility provided Policy & Procedure titled Safety and Supervision of Residents last revised ,d+[DATE] stated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The policy also indicated that when accident hazards are identified, the Quality Assurance and Performance Improvement (QAPI)/safety committee shall evaluate and analyze the cause(s) of the hazards and develop strategies to mitigate (to lessen severity) or remove the hazards to the extent possible.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services in accordance with its policy and procedures and professional standards of practice for one of eight sampled residents (Resident 1). The facility failed to: 1) Provide care to Resident 1 ' s [CONDITION(S)] (a surgical hole [stoma] created at the front of the neck so a tube can be inserted into the windpipe to assist in breathing); 2) Implement care plan interventions to cleanse Resident 1 ' s stoma site; and 3) Accurately assess and document Resident 1 ' s [CONDITION(S)] condition. These deficient practices resulted in Resident 1 having multiple fly larvae ([maggots] soft bodied , worm-like immature form of an insect) surrounding the [CONDITION(S)], potentially affecting Resident 1 ' s breathing status, increasing the risks for infection and [CONDITION(S)], and the potential need for hospitalization and/or possible death. On [DATE] at 5:10 p.m., the State Survey Agency (SSA) identified an Immediate Jeopardy (IJ, a situation in which the facility ' s non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) situation under 42CFR §483.25(i) Respiratory care, including [CONDITION(S)] care and tracheal suctioning. The Administrator (ADM) and the Director of Nursing (DON) were notified of the IJ situation from the facility ' s failure to provide adequate [CONDITION(S)] care. On [DATE] at 4:30 p.m., the ADM provided The Department with an IJ Removal Plan for the health and safety of Resident 1 which included the following summarized actions: 1) Resident 1 was assessed by Registered Nurse and Treatment Nurse at bedside on [DATE]. All hygiene and appropriate cares were provided to ensure removal of larvae at [CONDITION(S)] site. 2) The findings were reported to the Nurse Practitioner on [DATE] with new order to draw laboratory work (lab work, a medical procedure that involves testing blood samples) and a chest x-ray (a photographic or digital image of internal body parts). 3) Resident 1 ' s care plan was updated on [DATE] to reflect findings and new interventions added. 4) Maintenance responded on [DATE] to inspect environmental surroundings of Resident 1 ' s room to ensure no other flies/larvae were identified. 5) Pest control company was present in the building on [DATE] and [DATE] for monthly servicing and to offer additional services for the external building to help prevent flies from entering the building. On [DATE], the pest control company will install 18 fly traps outside the building and will change the bulbs inside the building. 6) 18 additional residents on affected unit were assessed on [DATE] and no signs of flies, eggs, or larvae were found. 7) On [DATE], the facility educated the nursing and respiratory staff on signs and symptoms of infection, following physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] 8) Maintenance Supervisor/designee will make visual rounds twice daily for presence of flies/eggs/larvae. 9) DON or designee will make visual rounds twice daily assessing [CONDITION(S)] sites to ensure dressing area is clean, dry, intact, and free from signs and symptoms of infection. 10) DON or designee will audit daily charts to ensure accuracy of [CONDITION(S)] assessments. 11) The Quality Assurance Performance Improvement (QAPI) committee will review and discuss accuracy of charting and effectiveness of fly (pest) control monthly. On [DATE] at 4:45 p.m., the SSA was onsite and confirmed the facility ' s implementation of the immediate corrective actions through observation, interview, and record review. The IJ Removal Plan was approved and the IJ removed in the presence of the ADM and DON. Cross Reference with F600, F880, and F925. Findings: On [DATE], an unannounced visit was conducted to investigate a complaint and a facility-reported incident (FRI) about presence of maggots in Resident 1 ' s [CONDITION(S)] (around the stoma site). On [DATE] at 1:05 p.m., during entrance conference, the ADM stated the in-house census (population count) in the Sub-Acute (a lower level of care setting from a General Acute Care Hospital [GACH]) unit was nineteen (19) residents. A review of Resident 1 ' s Admission Record indicated an admitted [DATE]. List of Resident 1 ' s diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1 ' s care plan on [CONDITION(S)], revised on [DATE] and current, indicated interventions that included to change [CONDITION(S)] dressing every shift and as needed for soiling (when dirty), and observe site every shift, and document findings. A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and screening tool), dated [DATE], indicated Resident 1 was severely impaired with thought process and decision-making tasks. Further review of the MDS indicated Resident 1 required total dependence from staff for bed mobility (turning side to side), dressing, eating, toilet use (how resident uses toilet room, cleansing after elimination), and personal hygiene. A review of Resident 1 ' s care plan on Activities of Daily Living Function, revised on [DATE] and current, indicated interventions that included to anticipate (expect or predict) and meet the resident ' s needs daily, do skin inspection every shift and as needed, and observe for redness, open areas, scratches, cuts, bruises, and report changes to the nurse. A review of Resident 1 ' s record titled, Change in Condition Evaluation, dated [DATE] at 1:45 p.m., indicated Resident 1 had Small white bugs noted around [CONDITION(S)]. On [DATE] at 1:24 p.m., during an interview, Respiratory Therapist 1 (RT 1) stated each resident in the Sub-Acute unit received assessment for pulse rate (measurement of heart rate), oxygen saturation (amount of oxygen measured in the blood), changing and checking the [CONDITION(S)] and securing the ties. RT 1 stated calling off for [DATE] and notifying the Director of Nursing twenty-four (24) hours prior to the scheduled shift. RT 1 stated the importance of having a twenty-four (24) hour Respiratory Therapist present in the sub-acute unit because of the presence of the ventilators and the residents with tracheostomies. RT 1 stated the facility needed to accommodate the needs of the residents requiring use of ventilators. On [DATE] at 1:57 p.m., during an interview, Registered Nurse 1 (RN 1) stated entering Resident 1 ' s room on [DATE] around after 1:20 p.m. and assessing Resident 1 ' s [CONDITION(S)]. RN 1 stated, I have never encountered anything like that before. RN 1 stated the gauze (surgical dressing) was clean on the outside. RN 1 stated, When we opened up the gauze, it looked like fly larvae or maggots. RN 1 stated the licensed nurses were assigned to do the [CONDITION(S)] care for that morning as there were no respiratory therapists on duty. RN 1 stated Resident 1 did not receive [CONDITION(S)] care for the shift prior to identifying the maggots. RN 1 stated, This was sad, really horrible. RN 1 then stated, It is true, the maggots, it is what I saw. I never want to see that again. On [DATE] at 2:50 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 was not alert and was totally dependent on staff for hygiene needs and feeding. LVN 1 stated that on [DATE] Resident 1 ' s [CONDITION(S)] was checked. LVN 1 stated, There were maggots around the stoma. LVN 1 stated there was no respiratory therapist present in the morning and that the [CONDITION(S)] care was not provided to Resident 1 not until after the maggots were seen. LVN 1 was presented a series of five (5) photos. LVN 1 stated Photo # 1 was dated [DATE] at 1:33 p.m. For Photo # 2, LVN stated that the image was of Resident 1. For Photo #3, LVN 1 stated the zoomed in photo focusing on [CONDITION(S)] dressing was still of Resident 1. For Photo # 4, LVN 1 confirmed it was a photo of Resident 1 ' s [CONDITION(S)] showing a saturated (thoroughly soaked) gauze with mucous (thick liquid produced by the body) and maggots present. For Photo # 5, LVN 1 stated there were four (4) to five (5) maggots present in the photo. LVN 1 stated that there were maggots observed on Resident 1 and that it cannot be dry mucous because they were moving when seen. On [DATE] at 2:15 p.m., during a phone interview with the facility ' s contracted pest control company, Service Manager (SM 1) stated flies land on food sources where they can leave their eggs, which then become larvae (maggots). SM 1 stated that it could be from twenty-four (24) hours to a week for the eggs to develop into maggots. A review of the document provided by the facility ' s contracted pest control company titled, House Fly Larvae, undated, indicated, House fly populations can be harmful to human health: they carry multiple pathogens (microorganisms that cause or can cause diseases) and have been linked to the spread of a number of diseases. The document also stated, House fly eggs look like small grains of rice. Eggs hatch within 24 hours, and house fly larvae emerge. House fly larvae, or maggots, appear similar to pale worms. On [DATE] at 3:52 p.m., during an observation together with LVN 1, Resident 1 ' s [CONDITION(S)] area and surrounding skin were observed to be red in color. On [DATE] at 4:52 p.m., during an interview, the Director of Nursing (DON) stated that for the [CONDITION(S)], the dressing used was a T-drain (surgical gauze dressing with a T-slit to provide a snug fit around tubes) and was not taped down onto Resident 1 ' s skin. When the DON was asked why the status of Resident 1 ' s dressing was not checked underneath, the DON stated the staff do not open the wound dressings if it does not look soiled from the outside. DON stated that having maggots in the [CONDITION(S)] can lead to infection because flies transmit bacteria. On [DATE] at 7:24 p.m., during an interview, the DON stated that for the sub-acute unit, the Licensed Nurses and Respiratory Therapists chart on the form titled Daily Sub-Acute Charting. DON stated that twenty-four (24) to forty-eight (48) hours was what was understood on the developmental stages from fly eggs to becoming maggots. DON indicated the staff were to document the findings every shift and that the importance of the findings would be to assess for any changes in condition and to identify those findings as soon as possible. During a concurrent record review with the DON, there were no documentation or description of [CONDITION(S)] or skin condition on Resident 1 ' s Daily Sub-Acute Charting on the following dates and times: 1. [DATE] at 12:01 a.m.; 2. [DATE] at 10:33 a.m.; 3. [DATE] at 1:58 a.m. (approximately less than thirty-six (36) hours from when the maggots were identified); 4. [DATE] at 10:44 a.m.; and 5. [DATE] at 10:57 p.m. (approximately fourteen (14) to fifteen (15) hours to when the maggots were identified). On [DATE] at 1:55 p.m., during an interview, Registered Nurse 2 (RN 2) stated that for signs and symptoms of infection, the site could be reddened. RN 2 stated that if the staff assessed and saw redness, they should chart redness as a description. On [DATE] at 2:49 p.m., during an interview, the Infection Prevention Nurse (IP) stated Resident 1 ' s [CONDITION(S)] care plan included observing the site every shift and any findings should be documented. Concurrent record review with IP of Resident 1 ' s Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Concurrent record review on Resident 1 ' s MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident 1 ' s MAR for [DATE], the 7p.m. to 7a.m. shift staff also documented negative for signs and symptoms of infection. When IP was asked to describe infection, IP stated that staff should check the skin for redness, and to feel for warmth. IP was informed that on [DATE] at 3:52 p.m., Resident 1 ' s [CONDITION(S)] was observed with reddened skin. IP was then asked why the staff were documenting negative for the signs and symptoms of infection on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . IP was unable to answer why the documentation was different from the observation but stated that the assessments should be consistent with what was seen on Resident 1. A review of an undated facility ' s job description titled, Respiratory Therapist, indicated the position summary as, The purpose of your job is to perform the duties of respiratory care upon the physician ' s request by following the federal, state, and local guidelines that govern the facility and as directed by the DON and Administrator. The job description indicated Respiratory Therapists will Relate all pertinent information concerning a resident ' s condition to a charge nurse as required. They will be committed to always doing the right thing. A review of an undated facility provided job description titled, Registered Nurse Supervisor, indicated the position summary, The purpose of your job is to supervise the day-to-day activities of the facility during your shift in accordance with current federal, state, and local standards that govern the facility, and as directed by your management. The job description indicated essential duties which include Monitoring nursing staff to ensure they are complying with resident ' s care plan. A review of an undated facility ' s job description titled, Licensed Vocational Nurse, indicated the position summary, The purpose of your job position is to provide each resident with routine daily nursing care in accordance with current federal, state, and local standards that govern the facility, and as directed by your supervisors. The job description indicated that essential duties and responsibilities included, Dressing wounds and Accurate and detailed charting of resident ' s progress notes. A review of the facility ' s policy and procedure titled, Care Plans, Baseline, last revised on ,d+[DATE], indicated that the baseline care plan included instructions needed to provide effective, person-centered care of the resident that meet the professional standards of quality of care. A review of a facility ' s policy and procedure titled, Activities of Daily Living (ADL), Supporting, last revised on ,d+[DATE], indicated, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. A review of the facility ' s policy and procedure titled, [CONDITION(S)] Care, last revised ,d+[DATE], indicated procedure guidelines to inspect skin and stoma (surgical opening) site for signs or symptoms of infection, leakage, subcutaneous crepitus (air pockets under the skin) or dislodged tube. Document the procedure, condition of the site, and the resident ' s response.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program and be free of flies for one of eight sampled residents (Resident 1). As a result, on [DATE], Resident 1 had growth and presence of multiple fly larva ([maggots] soft bodied , worm-like immature form of an insect) surrounding the [CONDITION(S)] (a surgical hole [stoma] created at the front of the neck so a tube can be inserted into the windpipe to assist in breathing) which could lead to respiratory tract infection. Based on the reasonable person concept, due to Resident 1 ' s severely impaired cognition and medical condition, an individual with growth of worms on the body may have psychological effects including feelings of hopelessness and helplessness. Cross Reference with F600, F695, and F880. Findings: On [DATE] at 1:05 p.m., during entrance conference, the ADM stated the in-house census (population count) in the Sub-Acute (a lower level of care setting from a General Acute Care Hospital [GACH]) unit was nineteen (19) residents. On [DATE] at 1:09 p.m., during observation and concurrent interview with the Infection Control nurse (IP), IP observed and confirmed the presence of a live fly resting on the window curtains of the conference room. A review of Resident 1 ' s Admission Record indicated the facility admitted the resident on [DATE] with diagnoses including chronic respiratory failure (when airways carrying oxygen to the lungs are narrow or damaged), [CONDITION(S)] tube, dependence on ventilator, and persistent vegetative state. A record review of Resident 1 ' s current Care Plan for the resident having a [CONDITION(S)], last revised on [DATE], included in the interventions changing the [CONDITION(S)] dressing every shift and as needed for soiling (when dirty) and observing site every shift and document findings. A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated [DATE] indicated the resident was unable to communicate and required total care from staff for all ADLs. A review of Resident 1 ' s Change in Condition Evaluation, dated [DATE] at 1:45 p.m., indicated the resident had small white bugs noted around [CONDITION(S)]. A review of the Pest Control Report dated [DATE] indicated the pest to be treated were house flies. On [DATE] at 1:24 p.m., during an interview, Respiratory Therapist (a health care discipline specializing in the promotion of optimum cardiopulmonary function) 1 (RT 1) stated the RTs in the Sub-Acute unit assessed the residents ' respiratory status, oxygen saturation (amount of oxygen measured in the blood), changing and checking [CONDITION(S)] and securing the ties (to hold the tube in place) and checking the ventilators setting and proper functioning. RT 1 stated calling off for [DATE] and notifying the DON 24 hours prior to the scheduled shift but no replacement was provided to the unit. RT 1 stated it was very important to have RTs around the clock due to the residents having [CONDITION(S)] and ventilators. RT 1 indicated neglect was a form of abuse and not providing the residents with RT services was an example of neglect. During the interview, a fly was observed in the conference room which was confirmed by RT 1. On [DATE] at 1:57 p.m., during an interview, Registered Nurse 1 (RN 1) stated assessing Resident 1 ' s [CONDITION(S)] on [DATE] after 1:20 p.m. RN 1 stated, I have never encountered anything like that before. RN 1 indicated the gauze (a loosely woven, almost translucent fabric that is used to bandage wounds) was clean on the outside. RN 1 stated, When we opened up the gauze, it looked like fly larvae or maggots. RN 1 stated the licensed nurses were assigned to do the [CONDITION(S)] care for that morning as there was no RT on duty. RN 1 said Resident 1 did not receive [CONDITION(S)] care for the shift prior to identifying the maggots. RN 1 stated, this was sad, really horrible. RN 1 then stated, It is true, the maggots, it is what I saw. I never want to see that again. On [DATE] at 2:50 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated on [DATE], Resident 1 ' s [CONDITION(S)] had maggots around the stoma, and they were alive and moving. LVN 1 confirmed that there was no RT in the morning and the [CONDITION(S)] care was not provided to Resident 1 until after FM 1 saw the maggots. On [DATE] at 2:15 p.m., during a telephone interview, the facility ' s contracted pest control company Service Manager 1 (SM 1), stated flies land on food sources where they can leave their eggs, which then become larvae (maggots). SM 1 stated that for the eggs to develop into maggots, it could be from twenty-four (24) hours to a week. On [DATE] at 2:15 p.m., during a telephone interview with the facility ' s contracted pest control company Service Manager (SM 1), SM 1 indicated flies land on food sources where they can leave their eggs, which then become larvae (maggots). SM 1 stated that for the eggs to develop into maggots, it could be from 24 hours to a week. On [DATE] at 4:43 p.m., a live fly was observed at the facility lobby doors beside the Administrator ' s (ADM) office. The live fly was concurrently observed by the Director of Nursing (DON). On [DATE] at 4:52 p.m., during an interview with the DON, DON indicated that having maggots in the [CONDITION(S)] can lead to infections because flies transmit bacteria. On [DATE] at 2:49 p.m., during interview and record review with Infection Prevention Nurse (IP), IP indicated that for flies to be present in the facility, they can cause infection. Flies seek trash or food or debris. IP indicated that there are goats in the neighboring building, and flies rest on the goats ' droppings. On [DATE] at 5:52 p.m., while exiting the facility, a live fly was observed at the glass exit doors. The observation was made in the presence of the Activity Director (AD), who confirmed the fly sighting. A review of an undated document provided to the facility by the pest control company titled, House Fly Larvae, indicated, House fly populations can be harmful to human health: they carry multiple pathogens (microorganisms that cause or can cause diseases) and have been linked to the spread of a number of diseases . House fly eggs look like small grains of rice. Eggs hatch within 24 hours, and house fly larvae emerge. House fly larvae, or maggots, appear similar to pale worms. A review of the facility ' s current policy and procedure titled, Pest Control with a revised date of ,d+[DATE] indicated, Our facility shall maintain an effective pest control program. The policy also stated, This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) who lacked the capacity to consent to sexual activities, was kept free from sexual abuse by Resident 2. Certified Nursing Assistant 1 (CNA 1) found Resident 2 inside Resident 1 ' s room inserting his fingers into Resident 1 ' s vagina. The facility Administrator (ADM) and Director of Nursing (DON) continued to allow Resident 2 to have access to Resident 1 after the incident. This deficient practice resulted in Resident 1 being subjected to continued sexual assault by Resident 2. On [DATE] at 5:00 p.m., the State Survey Agency (the Department) called an Immediate Jeopardy (IJ-a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) in the presence of the DON and the Assistant Director of Nursing (ADON) due to the facility's failure to prevent a resident-to-resident sexual abuse . On [DATE] at 1:02 p.m., the ADM provided the Department with a IJ Removal Plan which included the following summarized actions: 1. Resident 1 was assessed on [DATE] by the DON and ADON and a complete body assessment was done. 2. Resident 1 was advised on [DATE] by the Social Service Director (SSD) not to have contact with Resident 2 until further notice. 3. Psychiatrist assessed Resident 1 on [DATE]. 4. Resident 1 was educated on rights to privacy and options for safe sexual practices on [DATE]. 5. Resident 1 ' s care plan was reviewed and updated to reflect education provided on [DATE]. 6. Resident 2 was assessed on [DATE] and advised not to have any contact with Resident 1 until further notice. 7. Psychiatrist assessed Resident 2 on [DATE]. 8. Resident 2 was educated on right to privacy and options for safe sexual practices on [DATE]. 9. Resident 2 ' s care plan was reviewed and updated to reflect education provided on [DATE]. 10. All residents were to be evaluated for capacity to consent to sexual activity by the psychiatrist by [DATE]. 11. Social Service Director conducted resident and staff interviews regarding known resident to resident relationships on [DATE] with no known relationships noted. 12. DON, ADON, and Director of Staff Development (DSD) initiated in-service and education to staff regarding determinations of capacity to consent to sexual contact which was to be completed by [DATE]. 13. Medical Records Director reviewed all current resident ' s History and Physical for capacity on [DATE]. All History and Physical ' s capacity status will be reviewed by resident ' s primary physician and psychiatrist and reflect resident ' s current capacity by [DATE]. 14. New admission and newly identified residents that express interest to engage in sexual activity will be evaluated by a psychiatrist using the Capacity Assessment for Sexual Activity Screening Tool to assess a resident ' s capacity to consent to sexual activity. 15. Resident identified as having capacity to consent to sexual activity will be reviewed annually by psychiatrist and as needed using the Capacity Assessment for Sexual Activity Screening Tool. 16. The DON and Interdisciplinary Team (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of the resident) will review Capacity Assessment for Sexual Activity Screening Tool daily for all new admissions who express interest to engage in sexual activity, residents with annual review and newly identified residents to review capacity. 17. Medical Records Director or designee will audit all new admissions, annual review, and any newly identified residents who require a capacity assessment for sexual activity screening and audit findings will be reported daily to Administrator for follow up. 18. All staff will be educated and in-serviced regarding evaluation of capacity to consent to sexual activity and how to utilize the Capacity Assessment for Sexual Activity Screening Tool. On [DATE] at 1:54 p.m., while onsite and after confirming the facility's implementation of the immediate corrective actions, the Department accepted the IJ Removal Plan and removed the Immediate Jeopardy in the presence of the ADM and the DON. Findings: A review of Resident 1 ' s Admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included, metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body) and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 1 ' s History and Physical, dated [DATE], indicated Resident 1 has mild cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life) and has a fluctuating capacity (situations where a person's decision-making ability varies) to understand and make decisions. A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated [DATE], indicated Resident 1 required limited assistance from staff with activities of daily living that includes bed mobility, transferring to or from bed or chair, dressing, toileting, and personal hygiene. A review of Resident 1 ' s Psychiatric Examination, dated [DATE], indicated Resident 1 has a tangential (a disturbance in the thought process that causes the individual to relate excessive or irrelevant detail that never reaches the essential point of a conversation or the desired answer to a question) thought process. A review of Resident 1 ' s psychiatric progress note, dated [DATE], indicated the resident was delusional (having false or unrealistic beliefs or opinions), had difficulty to express self, and believed her deceased father comes daily to visit her. The note further indicated Resident 1 ' s thought process to be tangential with loose association (lack of connection between ideas) and having possible visual hallucinations (seeing of objects or the experiencing of feelings that are not real but are usually the result of mental disorder). A review of Resident 1 ' s psychiatric progress note, dated [DATE], indicated the resident displays a tangential thought process. A review of Resident 1 ' s Multidisciplinary Care Conference, dated [DATE], indicated the IDT met with and discussed discharge plans with Resident 1 who indicated she wanted to be discharge home with her father. The note indicated Resident 1 ' s father was deceased . A review of Resident 1 ' s Nursing Progress note dated [DATE], indicated that Registered Nurse 1 (RN 1) was notified by Licensed Vocational Nurse 2 (LVN 2) regarding an incident in which CNA 1 witnessed Resident 2 performing a sexual act on Resident 1. The progress notes further indicated that CNA 1 verbalized she entered Resident 1 ' s room and observed Resident 1 lying in bed with her pants down and Resident 2 was standing next to the bed inserting his finger in Resident 1 ' s vagina. The note indicated that CNA 1 told Resident 2 to stop and get out of the room. When LVN 2 asked Resident 2 what he was doing, Resident 2 did not respond to her question and quickly left the unit. The note indicated that when staff asked Resident 1 what happened, Resident 1 denied there was a man in her room touching her inappropriately. Per the progress note, facility staff then notified the DON and ADM. A review of Resident 1 ' s Progress Note dated [DATE] and timed at 9:20 p.m., indicated Resident 1 was interviewed by the DON with LVN 2 and RN 1 present in the room. When Resident 1 was asked if she felt that she was in danger or if she had a consensual sexual relationship with Resident 2, Resident 1 verbalized, Yes he is my family, he is my uncle, he visits me all the time. During an interview with Resident 1 on [DATE] at 1:12 p.m., Resident 1 stated she was never touched sexually by any resident. When asked what her relationship with Resident 2 is, Resident 1 stated that Resident 2 was her grandfather and denied having a sexual relationship with the resident. During an observation, on [DATE] at 1:46 p.m., observed Resident 2 entering Resident 1 ' s room going behind the privacy curtains. During a concurrent observation and interview with Licensed Vocational Nurse 1 (LVN 1) on [DATE] at 1:46 p.m., observed Resident 2 entering Resident 1 ' s room and going behind the privacy curtain. LVN 1 stated that Resident 1 and Resident 2 have an ongoing consensual sexual relationship. LVN 1 explained Resident 2 is allowed to enter Resident 1 ' s room as long as Resident 1 allows him to during the daytime. During an interview on [DATE] at 12:41 p.m., CNA 1 stated that she had previously witnessed Resident 2 inserting his finger in Resident 1 ' s vagina on [DATE]. CNA 1 stated that on [DATE] between the hours of 8:,d+[DATE]:00 p.m., she went to Resident 1 ' s room and noticed the privacy curtains were closed. CNA 1 stated that upon opening the curtains, she saw Resident 1 lying in bed with her pants down and Resident 2 had put his finger inside Resident 1 ' s vagina. CNA 1 stated that she told Resident 2 to stop and to get out of the room. CNA 1 stated she then reported what she witnessed to LVN 2 and told her that Resident 2 is abusing Resident 1. CNA 1 stated LVN 2 reported to social services and was told to not say anything because Resident 1 is accepting of what Resident 2 is doing to her and that everything was okay. CNA 1 stated she did not think it was okay and the incident was part of the reason why she quit her job at the facility. CNA 1 stated she would see Resident 2 continue to go into Resident 1 ' s room after the incident multiple times each day. During an interview on [DATE] at 1:32 p.m., LVN 2 stated that on [DATE] sometime between 8:,d+[DATE]:00 p.m., CNA 1 came out of Resident 1 ' s room and reported to her that Resident 2 was sticking his finger inside Resident 1 ' s vagina. LVN 2 stated she reported to RN 1 who then notified the DON. LVN 2 stated that the DON was then called and over the phone the DON asked Resident 1 if she was having a sexual relationship with Resident 2, to which Resident 1 replied that Resident 2 was her uncle and that everything was fine . When asked how the facility determined Resident 1 ' s ability to make decisions and consent to a sexual relationship, LVN 2 stated the DON determined capacity to consent based solely on the interview the DON conducted over the phone with Resident 1 on [DATE]. During a phone interview on [DATE] at 2:07 p.m., RN 1 stated that on [DATE] sometime between 8:00 to 9:00 p.m., she was notified of the alleged abuse incident by LVN 2 who informed her that CNA 1 had witnessed Resident 2 putting his finger inside Resident 1 ' s vagina. RN 1 stated that she reported to the DON and the ADM on [DATE] sometime between 8:00 to 9:00 p.m. and a meeting was held with the DON on the phone with Resident 1. RN 1 stated that the DON was trying to determine if Resident 1 was a victim of sexual abuse or if the resident was engaging in a relationship with Resident 2. RN 1 stated she tried to tell the DON and the ADM that she and the other facility staff did not think Resident 1 had the capacity of making her own decisions, but the DON told her that the resident did have capacity to make her own decisions based on the resident ' s medical record. During a concurrent interview and record review with the DON on [DATE] at 10:43 a.m., Resident 1 ' s History and Physical dated [DATE], Multidisciplinary Care Conference Note dated [DATE], and Psychiatric Progress Notes dated [DATE] and [DATE] were reviewed. DON stated that on [DATE] sometime between 8:00 to 9:00 p.m., she was informed by RN 1 of a possible sexual abuse incident. The DON stated she was told that CNA 1 had walked into Resident 1 ' s room and found Resident 1 lying on her back with her pants down in bed while Resident 2 was penetrating her vagina with his hands. The DON stated that her immediate intervention was to determine if both residents had the capacity to consent to a sexual relationship. The DON stated that she determined Resident 1 had the capacity to make decisions and had the ability to consent to sexual relationships by reviewing the resident ' s medical records. The DON reviewed Resident 1 ' s History and Physical dated [DATE] and confirmed that Resident 1 ' s physician had indicated that the resident has mild cognitive impairment and has fluctuating capacity to understand and make decisions. The DON also reviewed Resident 1 ' s psychiatric progress notes dated [DATE] and [DATE], and the resident ' s Multidisciplinary Care Conference Note dated [DATE]. The DON confirmed that the psychiatric progress notes dated [DATE] and [DATE], the Multidisciplinary Care Conference notes dated [DATE], and the progress note dated [DATE] indicated that Resident 1 had a tangential thought process, believed her deceased father visited her daily, and that Resident 2 was her uncle. When the DON was asked if Resident 1 who was noted with tangential thought process by a psychiatrist, who indicated that her deceased father was alive and visited her daily, and that Resident 2 was her uncle had the capacity to consent to a sexual relationship, the DON stated that Resident 1 has 100 percent (%-unit of measure) capacity to consent to sexual relationships. During a concurrent interview and record review on [DATE] at 1:02 p.m. with the facility ' s Medical Director (MD 1), Resident 1 ' s History and Physical dated [DATE] and Psychiatric progress notes dated [DATE] and [DATE] were reviewed. MD 1 stated that after reviewing Resident 1 ' s medical records, he did not believe Resident 1 had the capacity to make decisions. MD 1 stated that Resident 1 ' s psychiatrist should be the one to evaluate the resident to make the determination if Resident 1 had the capacity to consent to sexual contact. During a concurrent interview and record review with Resident 1 ' s psychiatrist (MD 2) on [DATE] at 1:49 p.m., Resident 1 ' s History and Physical dated [DATE] and Psychiatric progress notes dated [DATE] and [DATE] were reviewed. MD 2 stated that at the time of [DATE] he was the psychiatrist assigned to Resident 1. MD 2 stated he was never notified of the alleged abuse involving Resident 1 and Resident 2. MD 2 stated that he recalls that Resident 1 was depressed and psychotic (a serious mental illness characterized by defective or lost contact with reality often with hallucinations [seeing or hearing things that are not there or delusions) with nonviolent behavior. MD 2 stated that he remembers that Resident 1 was different every time he saw her. MD 2 reviewed his psychiatric progress notes dated [DATE] and [DATE] and verified that Resident 1 was delusional and thought that her father deceased father would come to visit her. MD 2 stated that Resident 1 had a tangential thought process which was not good and meant that the resident ' s thought process was inappropriate, and speech was poor and limited. MD 2 stated that based on his notes and evaluation of Resident 1, Resident 1 did not understand what was going on and does not have full capacity to make decisions and lacks the capacity to consent to sexual activity. During an interview, on [DATE] at 1:22 P.M with the ADM, the ADM stated that Resident 1 was able to formulate sentences and articulate her wants and desires and unless there was court documents such as conservatorship (appointment of a responsible person to manage a person ' s affairs who is unable to handle them due to their mental capacity, age, or physical disability) to show that someone lacks capacity that she will let Resident 1 and Resident 2 ' s relationship continue. A review of the facility ' s policy and procedure titled, Abuse and Neglect - Clinical Protocol, last reviewed and updated on [DATE], indicated the following: 1. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. 2. Willful used in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. A review of the facility ' s policy and procedure titled, Abuse Prevention Program, last reviewed and updated on [DATE], indicated residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation that includes sexual abuse. A review of the facility ' s policy and procedure titled, Abuse Prevention Program, last reviewed and updated on [DATE], indicated residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation that includes sexual abuse.

Based on observation, interview, and record review, the facility staff failed to ensure effective pain management for one of 27 sampled residents (Resident 59), by failing to: 1. Conduct a comprehensive pain assessment and evaluation for Resident 59's abdominal pain and gastrostomy tube (GT- a tube inserted into the stomach through a surgical incision use for feeding and administration of medication for a resident unable to swallow) [MEDICAL CONDITION] (a common, potentially serious bacterial skin infection) identified on (MONTH) 18, (YEAR). 2. Identify possible causes of pain and any situations or interventions where an increased in Resident 59's pain may be anticipated, as indicated in the facility policy and procedure on Pain Assessment and Management. 3. Promptly implement pain management strategies (pain medication, non-pharmacological interventions, notification of physician) to address Resident 59's pain as indicated in the facility policy and procedure on Pain Assessment and Management. 4. Respond immediately to Resident 59's complaint of unrelieved pain at the GT site on (MONTH) 22, (YEAR). 5. Provide Resident 59 with controlled pain medication ([MEDICATION NAME]) timely, when the medication was available in the emergency kit supply. Resident 59 complained of moderate pain on (MONTH) 22, (YEAR) at 3:45 p.m., but did not receive [MEDICATION NAME] till 7:24 a.m. on (MONTH) 23, (YEAR) (13 hours later). These deficient practices resulted in Resident 59 experiencing unnecessary pain and negatively affected Resident 59's psychosocial well-being manifested by crying. Resident 59 was transferred to the General Acute Care Hospital (GACH) for evaluation of pain and identified with abdominal distention and GT [MEDICAL CONDITION]. Findings: A review of the admission record indicated Resident 59 was initially admitted to the facility on (MONTH) 26, 2009 and readmitted on (MONTH) 23, (YEAR), with [DIAGNOSES REDACTED]. foot and shoulder. A review of Resident 59's physician order dated (MONTH) 28, (YEAR), indicated to give the resident, [MEDICATION NAME] Liquid (Tylenol) 160 milligrams per 5 milliliters (160 mg/5 ml), give 640 mg via [DEVICE] every 6 hours as needed for mild pain (1-3) not to exceed 3 grams per day (640 mg=20 ml); Document A (0/10) = no pain (relaxed, calm); B (1/10) = least pain (stressed, tensed); C (2-3) mild pain (guarded movement, grimacing). A review of the care plan dated (MONTH) 21, (YEAR), indicated Resident 59 was at risk for pain related to positioning discomfort, multiple contractures, and [MEDICAL CONDITION]. The goal indicated Resident 59 will not have an interruption in normal activities through the review date. The care plan interventions included: 1. Administer [MEDICATION NAME] as per orders, 2. Anticipate the resident's need for pain relief and respond immediately to any complaint of pain, 3. Evaluate the effectiveness of pain interventions. Review for compliance, alleviating symptoms, dosing schedules and resident satisfaction with results, impact on functional ability, and impact on cognition, 4. Identify and record previous pain history and management of that pain. 5. Monitor/document for probable cause of each pain episode, 6. Monitor/record/report to nurse any signs and symptoms of non-verbal pain. 7. Monitor/record/report to nurse resident complaints of pain or requests for pain treatment, 8. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain, and 9. Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, withdrawal or resistance to care. A review of the Minimum Data Set (MDS- a comprehensive assessment and care screening tool) dated (MONTH) 2, (YEAR), indicated Resident 59 had severe impairment of cognitive skills for daily decision making. The MDS also indicated Resident 59 had a feeding tube and did not experience any pain. A review of the physician progress notes [REDACTED]. site was tender to touch and was with redness. The progress note also indicated Resident 59 had GT [MEDICAL CONDITION]. A review of Resident 59's Change in Condition Evaluation Form dated (MONTH) 18, (YEAR), indicated the resident had GT site redness and guarded pain. The pain evaluation section indicated Resident 59 had abdominal pain (moderate diffuse or localized pain, unrelieved by antacids or laxatives) at the GT site. The note indicated Resident 59 was not cognitively able to rate his pain and had occasional moan or groan, and facial grimacing; was rigid, his fists clenched, knees pulled up, and the resident was pulling or pushing away. A review of the Medication Administration Record [REDACTED]. On (MONTH) 21, (YEAR) at 12 p.m., during an observation, Resident 59 was lying in bed, awake, alert, and oriented to person. During a concurrent interview, Resident 59 stated that he had been having abdominal pain for about two days or more, could not sleep, and had told the facility staff more than once. Resident 59 stated he was not feeling good (resident started to cry), and that his current pain level was seven out of 10 (on a zero to 10 pain scale). Resident 59 also stated that he did not think he received pain medicine today (August 21, (YEAR)) and that his acceptable pain level was three out of 10. A review of Resident 59's Nurses Notes dated (MONTH) 18, 19, and 20, (YEAR), did not indicate Resident 59's pain at the GT site was addressed. On (MONTH) 21, (YEAR) at 2:44 p.m., during an interview, Certified Nursing Assistant/Restorative Nursing Assistant 1 (CNA 1/RNA 1) stated that Resident 59 was able to make his needs known. On (MONTH) 21, (YEAR) at 3:08 p.m., during an observation in the presence of Licensed Vocational Nurse 3 (LVN 3) Resident 59 was lying in bed, awake, alert, and oriented to person. After obtaining permission to look at the GT site, Resident lifted his gown, and redness was noted at the GT site with no dressing. LVN 3 told Resident 59 he was going to put a dressing on the GT site and the resident became guarded, putting both hands over the GT site and saying no to the dressing; Resident 59 stated it was painful and that even without touching the GT site the pain level was five out of 10. Resident 59 stated that during dressing change, the pain was 10 out of 10. The resident stated he had pain all the time and that the facility staff did not do anything about his pain. Resident 59 stated that the GT site hurt pretty bad. When asked to indicate the location of pain, Resident 59 drew a circle around the GT site (diameter of a volley ball), and stated he needed more pain medication (each time the resident would start talking about his pain, he would start to cry). LVN 3 stated that Resident 59 was guarded when it came to the GT site and that the resident had only complained of abdominal pain in the past (for few months). A review of Resident 59's physician order dated (MONTH) 21, (YEAR) and timed 4:11 p.m., indicated to give the resident Tylenol (160mg/5ml) 20 ml via GT every 6 hours for GT site pain for five days. On (MONTH) 22, (YEAR) at 7:20 a.m., during an interview, LVN 4 stated he would provide treatment to Resident 59's GT site redness and that the resident would sometimes refuse dressing change. LVN 4 stated that Resident 59 had complained of pain at the GT site for months. LVN 4 was unable to verbalize the cause of Resident 59's pain. On (MONTH) 8, 22, (YEAR) at 2:45 p.m., during an interview, Resident 59 stated that his current pain was pretty bad, seven out of 10 ( Resident 59 started crying). On (MONTH) 22, (YEAR) at 2:57 p.m., Registered Nurse 1 (RN 1) stated that Resident 59 was alert and able to rate his pain. RN 1 stated that he was unable to provide documented evidence Resident 59 received pain medication on (MONTH) 18, (YEAR) (date RN 3 identified the resident's pain). RN 1 stated that RN 3 should have inquired about Resident 59's pain level and administer pain medication accordingly. On (MONTH) 22, (YEAR) at 3:57 p.m., during an observation, Resident 59 was pointing at his GT site, crying, and stated that he was in pain, eight out 10. On (MONTH) 22, (YEAR) at 4:06 p.m., during an interview, LVN 2 stated that she assessed Resident 59's pain level around 3:45 p.m., and his pain level was four out of 10. LVN 4 stated that Tylenol was due at 6 p.m., and that she would administer Tylenol PRN (indicated for mild pain 1-3/10). A review of the MAR indicated [REDACTED] A review of Resident 59's physician orders dated (MONTH) 22, (YEAR) and timed 6:19 p.m. indicated to give the resident: 1. [MEDICATION NAME] tablet 5-325 mg one tablet via GT every four hours as needed for moderate to severe pain for GT site pain. 2. [MEDICATION NAME] HCL tablet 50 mg via GT every eight hours for GT site pain. A review of Resident 59's MAR indicated [REDACTED]. On (MONTH) 23, (YEAR) at 8:38 a.m., during an interview, CNA 2/RNA 2 stated that Resident 59 complained of pain at the GT site all the time (for over a month) and that even when changing his incontinence brief, the resident would place his hands over the GT site. CNA 2/RNA 2 stated that she had notified the charge nurse. On (MONTH) 23, (YEAR) at 9:07 a.m., during an interview, Resident 59 stated that about two hours ago, his pain was very bad, 10 out of 10. Resident 59 stated that received pain medication and his current pain was 4 out of 10. On (MONTH) 23, (YEAR) at 9:10 a.m., during an interview, LVN 2 stated that she notified the physician on (MONTH) 22, (YEAR) around 6:30 p.m. of Resident 59's unrelieved pain (five out of 10 upon re-assessment) and the physician ordered [MEDICATION NAME] and [MEDICATION NAME] (a controlled medication) for moderate to severe pain. LVN 2 stated Resident 59 did not receive [MEDICATION NAME] after receiving the physician order because the medication was not available and had to be sent from the dispensing pharmacy. LVN 2 stated that Resident 59 received the first dose of [MEDICATION NAME] at 7:15 a.m. for a pain level of 10 out of 10. RN 2, who was present during the interview, stated she re-assessed Resident 59's pain around 4:40 p.m., on (MONTH) 22, (YEAR) and that the resident's pain was four-five (moderate) out of 10. RN 2 stated that [MEDICATION NAME] was available in the emergency kit, but was not administered to the resident. On (MONTH) 23, (YEAR) at 11:56 a.m., during an observation, Resident 59 was not in his room. On (MONTH) 23, (YEAR) at 11:59 a.m., RN 1 stated that Resident 59 requested to be transferred to the GACH for evaluation of his pain at the GT site. A review of the History and Physical report from the GACH dated (MONTH) 23, (YEAR), indicated Resident 59 was brought into the GACH with a chief complaint of abdominal pain, distention, and GT site pain. Upon physical examination, Resident 59 had continuously been complaining of discomfort at the GT site. Assessment findings included abdominal pain with GT site involvement, abdominal distention, and GT site [MEDICAL CONDITION]. On (MONTH) 24, (YEAR) at 9:24 a.m., during an interview RN 3 stated that on (MONTH) 18, (YEAR), Resident 59 was guarded and exhibited signs and symptoms of pain (moan/groan, facial grimacing, rigid, fists clenched, knees pulled up, and pulling or pushing away). RN 3 stated that she noted redness at the GT site and the resident did not want to be touched. RN 3 stated that she did not follow-up on Resident 59's pain to ensure that the pain was addressed. On (MONTH) 24, (YEAR) at 12:50 p.m., during an interview, the Wound Consultant Physician (MD 2) stated that Resident 59 had been had been guarding the GT site for quite some time and would not allow that the GT site area to be touched (even with the CNAs). MD 2 stated that even without touching the area, Resident 59 would become guarded. MD 2 stated that he did not order any topical (to be applied on the affected area) pain medication to be applied prior GT dressing change. MD 2 stated that [MEDICAL CONDITION] at the GT site could be painful. A review of the facility's revised policy and procedure (P&P) dated (MONTH) 2010 and titled Pain Assessment and Management indicated the purposes of the P&P are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying cause of pain. Conduct a comprehensive pain assessment upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. Steps in the procedure include: Recognizing pain, assessing pain, identify the causes of pain, defining goals and appropriate interventions, implementing pain management strategies, and monitoring and modifying approaches. A review of the facility policy and procedure dated (MONTH) 2014, indicated emergency pharmacy service is available on a 24-hour basis. Emergency needs for medication are met using the facility's approved emergency medication supply or by special order from the provider pharmacy. An emergency supply of medications including emergency drugs, antibiotics, controlled substances, and products for infusion is supplied by the provider pharmacy in limited quantities in portable, sealed containers that are in compliance with applicable state regulations.

Based on interview and record review, the facility failed to identify and evaluate accident risks and hazards, and did not implement and modify care plan interventions when necessary for one of three sampled residents (Resident 1). For Resident 1, who was assessed as a high fall risk, had a history of [REDACTED]. The facility also failed to revise the care plan after Resident 1's fall to implement additional or different interventions to prevent future falls, per the facility policy. These deficient practices resulted in Resident 1 suffering a fall with injuries, which included a laceration to the right side of the head. Findings: According to the Admission Face Sheet, Resident 1 was readmitted to the facility, on 1/5/16, with [DIAGNOSES REDACTED]. A review of the Report of Incident SBAR (Situation, Background, Assessment, and Response) for an actual fall, dated 5/28/16, at 5:50 a.m., indicated Resident 1 was found on the floor. A review of the Report of Incident SBAR for an actual fall, dated 9/24/16, indicated Resident 1 was found lying on her right side on top of the padding next to the bed. The resident was unable to communicate what occurred and was noted with redness to the right knee and right temple. A review of the Fall Risk Assessment, dated 5/28/16 and 9/24/16, indicated Resident 1 scored a 10. A score of 10 or greater indicated the resident was a high risk for falls. A review of the Activities of Daily Living (ADL) Functional / Rehabilitation Potential care plan, updated on 7/12/16, indicated Resident 1 was at risk for unavoidable decline secondary to self-care deficits, related to intermittent weakness, decreased strength and endurance, poor balance, and poor safety awareness. The care plan goal indicated to minimize risk of falls or injuries by 90 days. The interventions included nursing to assist the resident with transfers and utilizing the mechanical lift with two person assist. The care plan was not updated after Resident 1's fall on 9/24/16. A review of the Falls care plan updated on 7/12/16 indicated Resident 1 was at risk for falls due to dementia, poor safety judgement/awareness, and confusion/forgetfulness. The goal was to minimize the risk of falls and injury everyday by 90 days. The care plan interventions included assessing the resident's need for an assistive/supportive device and to anticipate the needs of the resident. There was no documented evidence of an updated care plan indicating new interventions to prevent further falls after Resident 1 fell on [DATE]. According to the Minimum Data Set (MDS - an assessment and care screening tool), dated 1/9/17, indicated Resident 1 was totally dependent on staff for bed mobility and transferring from bed to chair or wheelchair. The MDS indicated Resident 1 required two or more person physical assist with transfers, and was impaired with range of motion to both sides of upper and lower extremities. A review of the fall risk assessment, dated 1/9/17, indicated Resident 1 had a score of 12 indicating high fall risk and the resident's vision status was poor. On 2/6/17, at 10:45 a.m., an interview was conducted while reviewing Resident 1's clinical record and the director of nursing (DON) stated the Falls and ADL long term care plans were not updated in a timely manner and the interventions should have been updated after the resident fell on [DATE] to prevent further falls. During an interview and record review, on 2/6/17, at 11:15 a.m., the MDS assistant stated the care plans should be updated immediately after the fall incident. The MDS assistant stated she should have updated the care plan to provide alternative measures and include interventions to prevent further falls. A review of the Report of Incident SBAR for Actual Fall, signed by the physician and dated 1/24/17 indicated Resident 1 fell again in the room while being transferred from the bed to the shower chair. Resident 1 sustained a laceration (cut) on the right side of her head and triple antibiotic was ordered to be applied to the laceration. During an interview, on 2/6/17, at 11:45 a.m., the DON stated Resident 1 was totally dependent on staff for transfers and the ADL care plan indicated the resident should have been transferred by two people, using the mechanical lift. The DON stated the certified nurse's aide (CNA 1), transferred Resident 1 on his own, without using a mechanical lift, the resident fell on to the ground and CNA 1 fell on top of the resident. The DON stated Resident 1 sustained a laceration on the right side of the head and was treated with triple antibiotic ointment. During a phone interview, on 2/6/17, at 12:30 p.m., CNA 1 stated the rest of the staff was too busy to help him so he transferred Resident 1 from the bed to the shower chair on his own. CNA 1 carried the resident by placing his arms under the residents axillary area (underarm). When CNA 1 attempted to place Resident 1 on the chair, the shower chair tilted back and the resident fell to the ground hitting her head. CNA 1 stated he fell on top of Resident 1. He further stated Resident 1 should have been assisted by two people when transferring the resident from bed to chair. A review of the treatment record, dated 1/24/17, indicated Resident 1 received bacitracin (antibiotic) to the laceration on the right parietal area for 14 days. A review of the CNA ADL tracking form for January 2017 indicated Resident 1 the 7 a.m. to 3 p.m. CNA staff transferred Resident 1 with one person on 1/1/17, 1/19/17, and 1/24/17. The CNA ADL tracking form indicated staff from 3 p.m.-11 p.m., transferred Resident 1 with one person on 1/1/17, 1/19/17, and 1/24/17. During an interview, on 2/6/17, at noon, when asked about the CNA ADL tracking form, the DON stated Resident 1 should have been transferred by two person assist in accordance with the resident's care plan. A review of the facility's policy and procedure titled, Assessing Falls and their Causes, dated 10/2010, indicated the facility was to review the resident's care plan to assess for any special needs of the resident. When a resident falls, the facility staff was to fill out a falls risk assessment and document appropriate interventions to prevent future falls. A review of the facility's policy and procedure titled, Falls and Fall Risk, Managing, dated 12/2007, indicated the staff was to identify interventions related to the resident's specific risks and causes to try and prevent the resident from falling and to try and minimize complications from falling based on previous evaluations and current data. If falling recurs despite initial interventions, staff would implement additional or different interventions, or indicate why the current approach remains relevant. If underlying causes cannot be readily identified or corrected, staff would try various interventions, based on the nature or category of falling, until falling was reduced or stopped, or until the reason for the continuation of the falling was identified as unavoidable. The policy indicated if the resident continued to fall, staff would re-evaluate the situation and whether it's appropriate to continue or change current interventions. The staff and/or physician would document the basis for conclusions the specific irreversible risk factors exist that continue to present a risk factor for falling. According to the facility's policy and procedure titled, Care Plans - Comprehensive, dated 9/2010, indicated assessments of residents were ongoing and care plans were revised as information about the resident and the resident's condition change. The Care Planning/Interdisciplinary Team was responsible for the review and updating of care plans when the desired outcome was not met and at least quarterly.

Based on interview, and records review, the facility failed to ensure one of two sampled residents (Resident 1) received the appropriate care and services to prevent gastrostomy tube (GT - a small tube surgically inserted directly through the abdominal wall into the stomach for feeding and medication administration) complication, by failing to: 1. Failure to identify that Resident 1's feeding tube was not in the right location. 2. Failure to hold tube feeding water flushes of 200 cubic centimeters (cc) every six hours and medications given through the GT when Resident 1 had episodes of vomiting, and the physician had an ordered to hold the feeding formula. 3. Failure to check for feeding residual before resuming the feeding formula as ordered by the physician. 4. Failure to implement [DATE] facility's policy and procedures (P&P) on Confirming Placement of Feeding Tubes, by checking the pH level (is a numeric scale used to specify the acidity or alkalinity of GT residual and/or if the GT was in the stomach) of aspirated (withdraw fluid and/or matter by suction from a body cavity) GTF (gastrostomy tube feeding), if the feeding has been interrupted for few hours. These deficient practices resulted in Resident 1 developing fever, septic shock (a potentially deadly drop in blood pressure due to the presence of bacteria in the blood), and went through emergency surgery for [REDACTED]. Surgery left the wound open due to infection with dressing changes and re-evaluation daily of whether resident will need to go to operating room (OR). Resident 1 was placed on hospice care (supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than cure) and expired on [DATE]. Findings: A review of Resident 1's admission records (Face Sheet) indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS - a comprehensive assessment and care-screening tool), dated [DATE], indicated the resident was in persistent vegetative state (completely unresponsive to psychological and physical stimuli and displays no sign of brain function), and was totally dependent on staff for activities of daily living (the basic tasks of everyday life, such as eating, bathing, dressing, toileting, and transferring). A review of Resident 1's care plan dated February 3, 2016 for gastrostomy feeding tube (GTF) indicated that the resident was at risk for aspiration (entry of food/water to the wind pipe to the lungs), and GT site infection related to feeding tube device insertion. The goal was to tolerate prescribed feeding without emesis (vomiting), aspiration, or diarrhea, and be free of GT site infection. The intervention included to provide enteral feeding as ordered, monitor resident for feeding tolerance, flush feeding tube with water as ordered, flush feeding tube with 30 milliliters (ml) of water before and after medication administration, check tube placement and patency (the condition of being open, expanded, or unobstructed), check and record GT residual (remainder) every shift, and if the residual is 100 ml or more to hold the GTF for one hour and then re-check. A review of Resident 1's Medication Administration Record (MAR) for the month of [DATE] indicated the resident had the following physician's orders [REDACTED].>1. Check placement of feeding tube and patency before administration of medication and/or fluids every shift, dated February 3, 2016. 2. Check residual of feeding tube every shift, may hold feeding for one (1) hour if residual is greater than 100 cubic centimeters (cc), dated February 3, 2016. 3. Flush feeding tube with 30 cc - 50 cc of water pre (before) and post (after) medication administration, dated February 3, 2016. 4. Flush feeding tube with a minimum of 200 cc's of water every six hours, dated February 3, 2016. 5. [MEDICATION NAME] 4 milligrams (mg) one tablet via GT every six hours for vomiting dated [DATE]. 6. Glucerna (is the brand name of a family of tube feeding formula, bottled or canned shakes, and snack bars) 1.5 at 60 cc per hour via GTF pumps to provide 1200 cc per 1800 kilocalories (Kcal) in 24 hours. GTF pump on at 12 noon and off at 8 a.m., or until total dose limit is met, dated [DATE]. 7. Increase Glucerna 1.5 to 65 cc per hour for 20 hours to yield 1300 cc per 1950 Kcal over 24 hours or till dose limit is met. Turn the GTF pump on at 12 noon and off at 8 a.m., [DATE]. A review of Resident 1's Change of Condition/Situation, Background, Assessment, Request (COC/SBAR - a technique that can be used to facilitate prompt and appropriate communication) dated [DATE] at 5:30 p.m., indicated Resident 1's vomited at 3 p.m., and [MEDICATION NAME] (medication to treat or prevent nausea and vomiting) 4 milligrams (mg) was given via GT. The notes indicated that resident's feeding was held and was resumed at 4 p.m. and the 5 p.m., medication was given. Resident 1's vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a resident's essential body functions) were documented as: blood pressure (BP - is the strength of blood pushing against the sides of the blood vessels) reading was ,[DATE] millimeters of mercury (mm Hg), (B/P reference range is ,[DATE]), pulse rate (is the speed of the heartbeat measured by the number of contractions of the heart per minute (bpm)) was 118 bpm (Reference range 60 to 100 bpm), respiratory rate (RR - number of breaths per minute) was 20 breaths per minutes (Reference range 12 breaths per minute), and had a body temperature reading of 97.8 degrees Fahrenheit (Reference range 98.6°F). The notes indicated that Resident 1 vomited again at 5:30 p.m., the physician was notified, and the feeding formula was held. A review of Resident 1's care plan dated [DATE] (untimed) indicated the resident had two episodes of vomitus of about 150 cc of feeding formula. The intervention included to monitor resident's vital signs and clinical condition for at least 72 hours, notify medical doctor (MD) promptly of fever, unrelieved and worsening symptoms, and hold feeding for three hours then check residual per MD order. A review of Resident 1's MAR dated [DATE] indicated Resident 1's feeding formula pump was turned off at 5:30 p.m., and restarted at 8:30 p.m. There was no documented evidence that Resident 1's GT residual was checked before the feeding formula was restarted as indicated in the care plan. A review of Resident 1's MAR dated [DATE] to 22, 2016 indicated Resident 1 continued to received 200 cc of water every six hours (12 midnight, 6 a.m., 12 noon, and 6 p.m.,), from [DATE] at 6 p.m., to [DATE] at 12 p.m. and received six different type of medications through the GT. A review of Resident1's COC/SBAR dated [DATE] timed at 7:00 a.m. indicated the resident had small amount of vomitus. There was no documented evidence of the amount of vomitus the resident had. At 8 a.m. indicated Resident 1's body temperature reading was 101.4 degrees Fahrenheit, BP ,[DATE], PR 136 bpm, RR 21 breaths per minute. The notes indicated the resident had positive (present) bowel sounds on four (4) quadrants of the abdomen and the resident's GTF had less than 20 cc residual. At 8:30 a.m., the notes indicated the resident's physician was contacted and the facility was waiting for the response. At 8:45 a.m., Resident 1's responsible party was notified of resident COC. At 11:15 a.m., indicated the physician ordered blood test, chest x-ray and to start intravenous fluids. At 12 p.m., indicated unable to insert an intravenous line and the physician was called. At 1:15 p.m., the notes indicated Resident 1 was noted sweating, pale and had abdominal breathing (breathing supplemented by abdominal wall muscles that compress the contents of the abdomen and indirectly raise the diaphragm). The notes indicated Resident 1's BP ,[DATE], HR 52, RR 28 and the oxygen saturation reading was 81 to 85 percent (Normal ,[DATE] percent) on respiratory ventilator. The physician was called. At 1:20 p.m., the physician returned call and ordered to transfer Resident 1 via 911 (emergency number to summon paramedics). At 1:57 p.m., the notes indicated Resident 1 was transferred out of the facility to general acute care hospital (GACH) by paramedics. A review of Resident 1's GACH - emergency room (ER) Triage (the process of sorting people based on their need for immediate medical treatment as compared to their chance of benefiting from such care) notes, dated [DATE] at 2:32 p.m., indicated Resident 1 was presented with septic shock with diaphoresis (sweating), BP reading was ,[DATE], HR 110 bpm and RR 20 breaths per minute, and abdominal area was soft and non-distended. Urinalysis, chest x-ray and Computed tomography (CT - is an imaging procedure that uses special x-ray equipment to create detailed pictures, or scans, of areas inside the body) of abdomen and pelvis (part of the hind limbs or legs) were ordered. A review of Resident 1's GACH - CT results of the abdomen and pelvis dated [DATE] indicated a displaced percutaneous endoscopic gastrostomy (PEG) tube and significant abscess (an enclosed collection of liquefied tissue, known as pus, somewhere in the body)/food collection into abdominal wall. The notes indicated that this is likely the source of the septic shock and the resident will be taken to the operating room (OR) in the morning for wash out. A review of Resident 1's GACH - Surgical Documentation dated [DATE], at 5:27 p.m., indicated the preoperative (signs and symptoms before the operation) [DIAGNOSES REDACTED]. The operation indicated that an incision and drainage was made at resident's left abdominal muscle, placement of catheter tract for drainage and removal of the dislodged PEG tube. The resident was admitted to the intensive care unit (ICU). Review of Resident 1's GACH - Discharge Documentation dated [DATE] indicated that the resident met 4 out of [MEDICAL CONDITION] criteria, chest x-ray and urinalysis were negative on admission, but CT of abdomen/pelvis done to evaluate for other sources of infection showed soft tissue infection in her abdominal wall because PEG tube had terminated within the wall and the facility had likely re-inflated the balloon with feeding and medication administration directly into the abdominal wall. General surgery was performed, during which removed four liters of purulent and liquid material, revoking the [DEVICE] and leaving a red robin tube in place. Surgery left the wound open with dressing changes and re-evaluation daily of whether resident will need to go to OR. On [DATE] at 12 p.m., during a phone interview, Family Member 1 (FM 1) stated that he was not present at the facility on the day Resident 1 started feeling bad, but Family member 2 (FM 2) was at the resident's bedside. FM 2 saw a swollen area at or around the GT site, which he then notified the nurse (unknown) and was told that it was normal. FM 1 stated that the physician at the hospital - ER had stated that it was evident that the tube had been attempted to be pushed back in because it was not in the right area. Physician also stated that infection had started few weeks before the resident was sent to hospital. FM 1 stated that the resident had an emergency surgery and after was placed in hospice care for comfort and later died on [DATE]. On [DATE] at 1:25 p.m., during an interview, Licensed Vocational Nurse (LVN 1) stated that she performed GT treatment on Resident 1. LVN 1 stated that she was not aware if Resident 1's GT was dislodged. LVN 1 explained, If a GT was dislodged, we put it back in, we get the size of GT that was dislodged, get a new kit with lubricant, check placement, by inserting 25 cc of air in the tube, then listen with stethoscope at the abdominal area for air, secure the GT, and clean the GT site. LVN 1 stated that orders were not needed to place the tube back after dislodgment, especially if it was an emergency. LVN 1 stated that after the procedure then the physician will be informed. On [DATE] at 1:35 p.m., during an interview, LVN 2 stated that she was the medication nurse, and had not noticed anything off in regards to the resident's GT. During another interview at 3:30 p.m., LVN 2 stated that she checked for the GT patency and placement with stethoscope and checked the GT residual. LVN 2 stated that the GT residual was zero and the resident was tolerating the feeding well. On [DATE] at 1:40 p.m., during an interview, Registered Nurse (RN 2) stated on [DATE] Resident 1 was sent out to the hospital for fever. RN 2 stated that she did not recall any issues with the GT, and she checked resident's abdomen at 8:00 a.m. that day, and it was soft and round, and had positive bowel sounds in four quadrants. RN 2 stated that the GT residual was checked which was below 20 cc. On [DATE] at 1:55 p.m., during an interview, DON 2 stated that if a GT is dislodged the physician needs to be notified due to change of condition. Depending on what type of GT, with physician order [REDACTED]. On [DATE] at 4:10 p.m., during an interview, DON 1 stated that after the residual is checked, it is documented in the MAR and it's a standard procedure for NG (nasogastric) or GT prior to administering anything via GT. DON 1 stated, if a GT is dislodged, the GT will not be re-inserted in the facility, rather the resident is sent out to the hospital. DON 1 stated that the staffs do not check the pH as indicated in the facility's policy. On [DATE] at 1:45 p.m. during a phone interview, ER Physician stated she remembered the case very well. When asked what nursing should have done to identify the resident's problem, the ER physician stated With the GT trapped; there should have been a high residual expected and high resistance. ER physician stated that when she examined the resident, the abdomen was soft and skin was normal. The ER physician stated Did not know which part of the liquid was tube feeding and what was not, but with the amount, there was some feeding. I had never seen this happen where the facility will continue to feed a resident with a dislodged feeding tube into the abdomen. On [DATE] at 2:50 p.m., during a phone interview, RN 3 stated on [DATE], she worked the 7 a.m.-7 p.m. shift, she remembers that in the late afternoon, LVN reported that the resident had vomited. RN 3 stated that resident's feeding was held for one hour and the physician was called, [MEDICATION NAME] was given. The resident then had a second episode of vomiting and the physician was notified again and ordered to hold the feeding for three hours. The feeding was held for three hours, and the night shift resumed the feeding. On [DATE], at 1:30 p.m., during a phone interview, RN 3 stated that the licensed staffs do not check for pH because the facility did not have strips for checking the pH. RN 3 stated that she did not know that checking for pH was in the facility's P/P, and was not aware of any of the other nursing staff checking for pH. According to Resident1's Certificate of Death dated [DATE], Resident 1 immediate cause of death was [MEDICAL CONDITION] (a condition in which the heart suddenly and unexpectedly stops beating). According to facility's [DATE] revised policy and procedures title, Confirming Placement of Feeding Tubes, indicated that the purpose of this procedure was to ensure proper placement of the feeding tube to prevent aspiration during feeding. The policy included the following method of checking the GT placement: i. Using the auscultory method (the action of listening to sounds from the stomach, typically with a stethoscope, as a part of medical diagnosis). Do not rely on this as the singular method to differentiate between respiratory, gastric, [MEDICAL CONDITION] (is a part of human body that connects the throat to the stomach) and bowel placement. ii. Check pH of aspirate GTF. If feeding has been interrupted for a few hours, aspirate a small amount from the stomach or small bowel observe the aspirate and then measure the pH (using the pH strips). a. Fasting stomach acid will have a pH of five (5) or less. b. Fasting stomach contents will have a clear, colorless or green appearance. c. Respiratory secretions may look similar to gastric contents. d. Intestinal contents can be bile-stained (produced continuously by the liver (liver bile), and stored and concentrated in the gallbladder (gallbladder bile), light to dark yellow or greenish-brown e. A pH of five (5) or less suggests that the tube is placed in the stomach. However, a pH of six (6) or greater is not definite of placement outside the stomach. If any of the above suggests improper tube positioning, do not administer feeding or medication. Notify the Charge Nurse or Physician.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided with necessary care and services to attain optimal improvement in condition and did not deteriorate outside the limits of normal and recognized processes. Resident 1, who required monitoring of oxygen saturation (a measure of the amount of oxygen that is carried in the blood), and monitoring of vital signs, did not receive these necessary services, as ordered by the physician. This deficient practice resulted in Resident 1 developing pneumonia (an infection that inflames the air sacs of the lungs, fill with fluid or pus (purulent material), causing cough with phlegm, can be life threatening), [MEDICAL CONDITION] (a potentially life-threatening complication of an infection, chemicals release into the bloodstream to fight the infection trigger [MEDICAL CONDITION] responses throughout the body, the inflammation can trigger a cascade of changes that can damage multiple organ systems, causing them to fail). Findings: A review of the clinical record indicated Resident 1 was [AGE] years of age, and admitted to the facility, on 2/19/16, with [DIAGNOSES REDACTED]. of the body) following an [MEDICAL CONDITION]. A review of the History and Physical, signed by the attending physician, on 2/20/16, indicated Resident 1 did not have the capacity to understand and make decisions. The Nursing Admission and Assessment, dated 2/19/16, indicated the resident's breath sounds were regular and clear. A review of the physician's orders [REDACTED]. A review of Resident 1's plan of care, dated 2/20/16, for [MEDICAL CONDITION] infarction (blood flow stops to a part of the heart) and [MEDICAL CONDITION] manifested by shortness of breath, irregular respiration, and oxygen inhalation indicated the approaches / interventions were to monitor shortness of breath, irregular respiration, wheezing, crackles, rhonch (coarse rattling respiratory sounds, usually caused by secretions in [MEDICATION NAME] airways), excessive secretions, and to inform the physician promptly. The plan of care interventions included to monitor oxygen saturation as ordered, and oxygen inhalation as ordered. A review of Resident 1's plan of care, dated 2/20/16, for potential adverse drug effects and drug interactions indicated the approaches / interventions was to monitor vital signs. A review of the Change of Condition SBAR (Situation, Background, Assessment, Recommendation), dated 2/20/16, at 2 a.m., indicated Resident 1 experienced nausea and vomiting, the physician was notified. The change of condition form indicated Resident 1's blood pressure was 146 millimeter mercury (mmHg) / 88 mmHg (normal 130 / 80 for men over [AGE] years old), pulse was 111 beats per minute (normal range from 60 to 100), and respiration rate was 20 per minute (normal range 16 to 20). The oxygen saturation rate was 95 percent (normal range from 95 to 100), and oxygen was administered at two liters per minute. A review of the progress record indicated, on 2/20/16, at 3 p.m., Resident 1's blood pressure decreaed to 128 mmHg / 70 mmHg, pulse rate decreased to 77 pulses per minute, and respiration rate was monitored at 20 breaths per minute. A review of the Change of Condition SBAR, dated 2/21/16, at 8:50 p.m., indicated Resident 1's temperature was elevated and both right and left lungs were congested. Oxygen saturation was 92 percent, the resident was on oxygen therapy at two liters per minute, and the vital signs were within normal limits. A review of the Change of Condition SBAR indicated, at 10:15 p.m., the physician ordered to transfer Resident 1 via regular transport to general acute care hospital for congestion, shortness of breath, and elevated temperature. At 11 p.m., the resident's blood pressure decreased to 127 mmHg / 63 mmHg, pulse rate increased to 93 beats per minute, and respiration rate increased to 24 breaths per minute. The change of condition form indicated oxygen was administered at 15 liters per minute, at 11:40 p.m., Resident 1's blood pressure decreased to 88 mmHg / 56 mmHg, pulse rate increased to 111 beats per minute, respiration rate was 22 per minute, and oxygen saturation rate changed from 86 percent to 89 percent (normal pulse oximeter readings for oxygen saturation usually range from 95 to 100 percent). A review of the Progress Record, dated 2/21/16, at 11:49 p.m., indicated Resident 1 was transferred to the general acute care hospital via paramedics (over one and a half hours after the physician order). A review of Resident 1's clinical record indicated there was no documented evidence the resident was monitored for oxygen saturation from 2/20/16, at 2 a.m. to 2/21/16, at 8:30 p.m., for 42 hours. Also, there was no documented evidence the resident's vital signs were monitored from 2/20/16, at 3 p.m. to 2/21/16, at 9 a.m., for 18 hours. On 3/15/16, at 11:30 a.m., during an interview, with Registered Nurse 1 (RN 1), she stated she was not able to provide the documented evidence Resident 1 was monitored for oxygen saturation during the dates and times referrenced for the 42 hour period. RN 1 stated she was not able to provide the documented evidence Resident 1's vital signs were monitored during the times referrenced for the 18 hour period. A review of the facility's guidelines titled, Pulse Oximetry, revised on October 2010, indicated the purpose of assessing oxygen saturation was to monitor arterial blood oxygen saturation and to review the physician's orders [REDACTED]. A review of the facility's policy titled, Acute Condition Changes - Clinical Protocol, revised on December 2012, indicated the nurse shall assess and document / report the vital signs. The policy did not indicate when and how often the resident's vital signs should be monitored. On 3/15/16, at 12:20 p.m. during an interview, with the Director of Nursing (DON), she stated the facility nursing staff should have monitored the resident's oxygen saturation rate per the physician order. The DON stated the facility nursing staff should have monitored Resident 1's vital signs every shift for 72 hours from admission. A review of the acute care hospital emergency room documentation, dated 2/22/16, indicated Resident 1 was in respiratory distress, febrile, and hypoxic (deficiency in the amount of oxygen reaching body tissues). The resident was diagnosed with [REDACTED]. A review of Resident 1's chest X-ray finding dated 2/22/16, indicated pneumonia (Healthcare-Associated Pneumonia versus aspiration - inhalation of some foreign material), as well as the urinalysis indicated an infection. A review of the acute care hospital History and Physical, signed by the physician, on 2/23/16, indicated Resident 1 had [MEDICAL CONDITION], was hypotensive (low blood pressure), [MEDICAL CONDITION] (increased heart rate), tachypneic (abnormally rapid breathing), febrile with altered mental status, and elevated [MEDICATION NAME] (lactic acid levels increase with severe infection). A review of the acute care hospital Death Summary discharge documentation, dated 2/24/16, indicated Resident 1 was pronounced dead.