Every finding on record at Osage Healthcare & Wellness Centre

Based on observation, interview and record review, the facility failed to: 1. Provide continuous supplemental oxygen (a medical treatment delivering oxygen enriched air to people with breathing problems) at two liters per minute (lpm, unit of measurement the rate of oxygen flow delivered to the resident) through nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) as ordered by the physician for one of three sampled residents (Resident 2). 2. Ensure the oxygen tubing (a flexible, latex-free tubing, to deliver oxygen from a source) was labeled and dated for one of three sampled residents (Resident 22). 3. Implement the facility's policies and procedures to replace the filter of the BiPAP machine (Bilevel positive airway pressure - a breathing machine designed to increase air pressure, keeping the airway open when the person breathes in) every two weeks for one of two sampled residents. (Resident 30) These failures had the potential for Resident 2, Resident 30, and Resident 22 to experience respiratory distress (significant difficulty breathing, where the body struggles to get enough oxygen) and worsening respiratory conditions that may lead to avoidable hospitalization. Findings: 1. During a review of Resident 2's admission Record (Face Sheet), the admission Record indicated the facility admitted Resident 2 on 11/14/2019 with diagnoses including heart failure (a disorder which causes the heart to not pump the blood efficiently), history of cerebral infarction (stroke, loss of blood flow to a part of the brain due to blockage), and dementia (a progressive state of decline in mental abilities). During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 12/10/2025, the MDS indicated Resident 2 experiences shortness of breath lying flat and requires oxygen therapy while a resident in the facility. During a review of Resident 2's Care Plan Report, dated 9/15/2025 indicated an intervention of Administer oxygen settings: Oxygen at 2 lpm via [nasal cannula] to keep [oxygen saturation] above 95% every shift for [shortness of breath] was started on 12/17/202. During an observation on 2/11/2026 at 9:07 a.m. in the facility hallway, Resident 2 was observed sitting on a wheelchair beside an oxygen concentrator (a medical device that extracts, filters and concentrates oxygen from surrounding air). Resident 2 was not wearing nasal cannula or oxygen mask. During a concurrent observation and interview on 2/11/2026 at 10:01 a.m. with Licensed Vocational Nurse (LVN) 1 in the facility hallway, Resident 2 was observed not wearing a nasal cannula or oxygen mask beside an oxygen concentrator. LVN 1 stated Resident 2 should be on supplemental oxygen through nasal cannula as ordered by the physician. During a concurrent interview and record review on 2/12/2026 at 2:20 p.m. with the Director of Nursing (DON), Resident 2's Physician Order, dated 11/25/2025, was reviewed. The DON stated Resident 2 has an order for continuous supplemental oxygen of 2 lpm via nasal cannula to keep oxygen saturation (a measurement of how much oxygen the blood is carrying as a percentage) above 95% for symptoms of shortness of breath. During an interview on 2/13/2026 at 8:13 a.m. with the DON. The DON stated Resident 2 started receiving oxygen therapy for episodes of shortness of breath and had a recent hospitalization for the same reason. The DON stated Resident 2's health may be at risk if physician's order to administer oxygen was not being followed. The DON stated Resident 2 may experience respiratory distress and shortness of breath that may lead to avoidable re-hospitalization. During a review of the facility's policies and procedures (P&P), titled Oxygen Therapy, dated 10/31/2025. The P&P indicated administer oxygen and obtain oxygen saturation levels as ordered by the provider and oxygen will be initiated with a provider order. 2. During a review of Resident 22's admission Record, the admission Record indicated the facility admitted Resident 22 on 12/26/2025 with diagnoses including respiratory failure with hypoxia (inadequate oxygen), dementia (a progressive state of decline in mental abilities) and history of cerebral infarction (stroke). During a concurrent observation and interview on 2/11/2026 at 9:56 a.m. with LVN 1 in Resident 22's room. Resident 22's oxygen tubing did not have a label or date when it was last changed. LVN 1 stated oxygen tubing should be replaced every seven days and should have a label that indicates when it was last changed. LVN 1 stated labeling oxygen tubing was important to ensure staff are aware when it was last changed, the oxygen tubing may have been clogged with nasal drainage, or the integrity of the tubing was compromised, and the residents are not receiving the correct supplemental oxygen ordered by the physician. During an interview on 2/12/2026 at 2:11 p.m. with the Director of Nursing (DON). The DON stated licensed nurses are expected to change oxygen tubing once a week and label the tubing with the date, time, and the name of the staff that completed the task. The DON stated labeling the oxygen tubing will ensure that the tubing was changed, to ensure the tubing is free from debris or kinks and residents would not receive enough oxygen that causes respiratory distress. During a review of the facility's P&P, titled Oxygen Therapy, dated 10/31/2025. The P&P indicated Oxygen equipment shall be maintained as follows: The tubing and mask should be changed at least every seven days and labeled with the date change. 3. During a review of Resident 30's admission Record, the admission Record indicated the facility admitted Resident 30 on 11/18/2025 with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), respiratory failure with hypoxia and hypercapnia (excessive buildup of carbon dioxide), heart failure and obstructive sleep apnea (a condition throat muscles relax excessively during sleep causing airway to collapse). During a review of Resident 30's Physician Orders, dated 11/22/2025, the Physician Orders indicated BiPAP Frequency: at bedtime when sleeping and [as needed]. During a concurrent observation and interview on 2/10/2026 at 10:03 a.m. with Resident 30 in the resident's room. A BiPAP machine on the bedside table was observed. Resident 30 stated she uses the BiPAP machine at night when she sleeps and has been using it for several months. During a concurrent observation and interview on 2/12/2026 at 8:02 a.m. with LVN 1 in Resident 30's room. LVN 1 stated he was not aware where the filter system of the BiPAP machine was located. During a concurrent interview and record review on 2/12/2026 at 8:22 a.m. with the DON. Resident 30's Medication Administration Record (MAR) was reviewed. The DON stated there was no documentation that the filter system of Resident 30's BIPAP machine was replaced. The DON stated no one has been responsible for this task and the facility does not have a filter replacement. The DON stated the filter of the BiPAP machine should be replaced every two weeks. The DON stated Resident 30 may inhale particles when using the BIPAP machine that may lead to respiratory infection and worsen current respiratory condition. During a review of facility's P&P, titled BiPAP and CPAP, dated 10/17/2019. The P&P indicated [BiPAP] filters are foam, disposable paper and bacterial filters and cleaning instructions includes but not limited to filters should be changed every 2 weeks.

Based on observation, interview, and record review, the facility failed to: 1. Ensure Resident food brought from outside was labeled, dated and stored in the designated resident's refrigerator in the activity room for one of one sampled resident (Resident 30). 2. Ensure 1 week old lettuce in a clear container was labeled and dated in the vegetable refrigerator in the kitchen. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (an infection or irritation of the gastrointestinal tract caused by eating or drinking food or beverages contaminated with harmful bacteria, viruses, parasites, or chemicals). Findings: 1. During a review of Resident 30's admission Record, the admission Record indicated Resident 30 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 30's diagnoses included obstructive sleep apnea ([OSA] – a common, serious sleep disorder where breathing repeatedly stops and starts because throat muscles relax and block the airway during sleep), chronic obstructive pulmonary disease ([COPD] – a chronic lung disease causing difficulty in breathing), 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 30's History and Physical (H&P), dated 11/21/2025, the H&P indicated, Resident 30 had the capacity to understand and make decisions. During a review of Resident 30's Minimum Data Set ([MDS] – a resident assessment tool), dated 11/25/2025, the MDS indicated, Resident 30's cognitive (ability to think and reason) skills for daily decision making were moderately impaired (decisions poor, cues/supervision required). The MDS indicated Resident 30 required setup assistance (helper assists only prior to or following the activity) from with eating and oral hygiene. During an interview on 2/11/2026 at 9:07 a.m., with Resident 30, Resident 30 stated her family brought her one bottle of Italian dressing and 1 jar of Hamburger Dill Chips one month ago. During a concurrent observation and interview on 2/11/2026 at 9:17 a.m., with the Dietary Service Supervisor (DSS), in Resident 30's room. The DSS stated there were one bottle of opened Italian dressing and 1 jar of opened Hamburger Dill Chips with no date and label. The DSS stated the opened Hamburger Dill Chips are perishable and should be kept in the resident's refrigerator in the activity room. The DSS stated opened Hamburger Dill Chips when not refrigerated could spoil easily and potentially harm the resident. The DSS stated resident's food brought from outside should be labeled with resident's name, the date received, and the date opened. The DSS stated she does not know who brought Resident 30's outside food. During an interview on 2/11/2026 at 10:48 a.m., with the Director of Nursing (DON), the DON stated all resident's food brought from outside should be labeled and kept in the resident's refrigerator in the activity room especially the perishable food items because of the risk of foodborne illness. During a review of the facility's policy and procedure (P&P) titled, Food Brought in by Visitors, dated 5/22/2025, the P&P indicated, The facility staff will place the food in a food container that is clearly labeled with the resident's name and date received and stored in the refrigerator. 2. During a concurrent observation and interview, of the initial kitchen tour, on 2/10/2026 at 8:45 a.m., with the Dietary Services Supervisor (DSS), a large clear Tupperware container with 6 heads of lettuce was noted in the vegetable refrigerator without a date label. The DS stated the lettuce was approximately 1 week old. The DS stated food items in the refrigerator were required to have an open and used by date. The DS stated the risk of not labeling the dates on the lettuce container could result in residents consuming possibly expired food. During a review of the facility's policy and procedures (P&P), titled Food Storage and Handling, dated 6/4/2024, the P&P indicated all food items were to be correctly labeled and dated.

Based on observation, interview, and record review, the facility failed to: 1.Ensure that one of five residents, Resident 35, was provided a call device within their reach. This failure had the potential to result in Resident 35's inability to notify staff when in need of care or in distress.Findings: During a review of Resident 35's admission Record, dated 7/10/2025, the admission Record indicated that Resident 35 has Dementia (decline in memory, thinking, and reasoning) and Dysphagia (difficulty swallowing), Lack of Coordination, and Generalized Muscle Weakness. During a review of Resident 35's History & Physical, dated 7/14/2025, the History & Physical indicated that Resident 35 does not have the capacity to understand and make decisions. During a review of Resident 35's Order Summary Report, dated 7/10/2025, the Order Summary Report indicated Resident 35's discharge potential as poor and that Resident 35 was ordered to receive skilled occupation therapy services (specialized services to improve, restore, or maintain the ability to perform daily living activities) every day, three times a week, for four weeks, for generalized weakness using therapeutic exercise, and therapeutic activities. During an observation on 2/10/2026, at 12:11 p.m., in room [ROOM NUMBER]A, Resident 35 was sitting in a wheelchair at the doorway of their room. The call alert device was on Resident 35's bed, approximately 3 feet behind Resident 35, and there were no facility staff in the room with Resident 35. During an interview on 12/10/2026, at 12:13 p.m., with Certified Nursing Assistant (CNA) 2, CNA 2 stated that Resident 35 would not be able to call for help. CNA 2 stated it's not safe for residents to not have a call alert device available, they should be close to the call device or around others to see them. During an interview on 2/13/2026 at 8:03 a.m., with the Director of Nursing (DON), the DON stated that the call alert device should be in reach of the resident, if not, the resident would not be able to call for assistance. The resident could fall, have a health crisis, or not receive the needed attention. During a record review of P-NP29 Communication-Call System policy, undated, the P-Np29 Communication-Call System policy indicated that the call alert device will be placed within the resident's reach.

Based on interview and record review, the facility failed to:1. Obtain a written informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) from interdisciplinary team (([IDT] - team members from different disciplines who come together to discuss resident care) before initiation of a psychotropic drug (Any drug that affects brain activities associated with mental process and behavior) for resident with diagnosis of dementia (a progressive state of decline in mental abilities) for one of six sampled residents (Resident 39).This deficient practice placed Resident 39 at risk for sustaining adverse effects (undesired effect of a drug) from psychotropic medication. Findings:During a review of Resident 39's admission Record, the admission Record indicated Resident 39 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 39's diagnoses included dementia (a progressive state of decline in mental abilities), legal blindness (severe vision loss), and schizophrenia (a mental illness that is characterized by disturbances in thought).During a review of Resident 39's History and Physical (H&P), dated 10/10/2025, the H&P indicated, Resident 39 did not have the capacity to understand and make decisions.During a review of Resident 39's Neuropsychiatric (branch of medicine that deals with the diagnosis, treatment, and prevention of mental disorders) Progress Note, dated 12/15/2025, the Neuropsychiatric Progress Note indicated, Resident 39 suffered from dementia and cognitive (ability to think and reason) communication deficit (lack or impairment in function) and any recommendations are subject to the approval of the interdisciplinary team (([IDT] - team members from different disciplines who come together to discuss resident care).During a review of Resident 39's Minimum Data Set ([MDS] - a resident assessment tool), dated 1/15/2026, the MDS indicated, Resident 39's cognitive skills for daily decision making were moderately impaired (decisions poor, cues/supervision required). The MDS indicated, Resident 39 required moderate assistance (helper does less than half the effort) from staff with toileting hygiene, upper and lower body dressing, and personal hygiene.During a review of Resident 39's Order Summary Report (a document containing active orders), dated 2/12/2026, the Order Summary Report indicated, the physician placed a telephone order on 2/5/2026 for Resident 39 to start on Olanzapine (anti-psychotic medication used to treat severe mental health conditions) 5 milligrams ([mg] - metric unit of measurement, used for medication dosage and/or amount) to give one tablet at bedtime (9 p.m.) for schizophrenia manifested by disorganized speech and thought processes. The Order Summary Report indicated, Resident 39 was incapable of making healthcare decisions due to dementia.During a review of Resident 39's medication administration records ([MAR] - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) from 2/6/2026 to 2/11/2026, the MAR indicated, Resident 39 was given Olanzapine 5 mg one tablet at bedtime (9 p.m.).During a concurrent interview and record review on 2/12/2026 at 1:14 p.m., with the Director of Nursing (DON), Resident 39's Psychotherapeutic Drug Informed Consent Form, dated 2/5/2026 was reviewed. The Psychotherapeutic Drug Informed Consent Form indicated, Resident 39, is on Olanzapine 5mg daily for schizophrenia manifested by disorganized speech and thought processes. The DON stated, Resident 39's informed consent for Olanzapine was not signed by the IDT. The DON stated Resident 39 lacks capacity to give informed consent because she has a diagnosis of dementia. The DON stated there were no IDT meeting that were completed before the initiation of Resident 39's psychotherapeutic drug. The DON stated long term use of psychotherapeutic drug can cause adverse reaction such as dizziness and other cardiovascular (heart) complications that would impair resident's health and safety.During a review of the facility's Policy and Procedure (P&P) titled, Informed Consent, dated 1/30/2026, the P&P indicated, If the resident lacks capacity to provide informed consent and does not have a surrogate decision-maker, the facility will convene a Surrogate interdisciplinary team (IDT). The P&P indicated the licensed nurse will confirm that the healthcare practitioner obtained informed consent and will document the verification in the resident's medical record, before administering the first dose of psychoactive medications.

Based on interview and record review, the facility failed to: 1. Notify the physician for one of one sampled resident (Resident 30) refusing Bilevel Positive Airway Pressure ([BIPAP] - a noninvasive, mask-based ventilation device that assists with breathing by delivering two distinct levels of pressure) treatment.This failure had the potential for Resident 30 to experience severe shortness of breath that would likely require hospitalization.Findings:During a review of Resident 30's admission Record, the admission Record indicated Resident 30 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 30's diagnoses included obstructive sleep apnea ([OSA] - a common, serious sleep disorder where breathing repeatedly stops and starts because throat muscles relax and block the airway during sleep), chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty in breathing), 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 30's History and Physical (H&P), dated 11/21/2025, the H&P indicated, Resident 30 had the capacity to understand and make decisions.During a review of Resident 30's Minimum Data Set ([MDS] - a resident assessment tool), dated 11/25/2025, the MDS indicated, Resident 30's cognitive (ability to think and reason) skills for daily decision making were moderately impaired (decisions poor, cues/supervision required). The MDS indicated Resident 30 required setup assistance (helper assists only prior to or following the activity) from with eating and oral hygiene.During a review of Resident 30's Order Summary Report (a document containing active orders), dated 2/11/2026, the Order Summary Report indicated, the physician placed a telephone order on 11/21/2025 for Resident 30 to start on BIPAP with Inspiratory Positive Airway Pressure ([IPAP] - higher pressure setting) of 18/5 centimeter ([cm] - unit of measurement) of H2O (water), Fraction of Inspired Oxygen ([FiO2] - the percentage or concentration) of 28 percent ([%]- unit of measurement) with full face mask size 18, at bedtime when sleeping and as needed.During a concurrent interview and record on 2/11/2026 at 10:10 a.m., with the Minimum Data Set Nurse (MDSN), Resident 30's medication administration records ([MAR] - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) from January 1, 2026, to 2/11/2026, was reviewed. The MDSN stated Resident 30 was non-compliant and refused BIPAP treatment on 1/3/2026, 1/4/2026, 1/10/2026, 1/23/2026, 1/24/2026, 2/5/2026, and 2/8/2026. The MDSN stated the physician was not notified of Resident 30's refusal for BIPAP treatment. The MDSN stated when resident refused treatment as ordered by the physician, the physician should be notified because it is considered as a resident's change of condition. The MDSN stated Resident 30's refusal to have BIPAP treatment would put her at risk for shortness of breath.During an interview on 2/11/2026 at 10:52 a.m., with the Director of Nursing (DON), the DON stated it is important to notify the physician when a resident refuses treatment so the physician would be aware and make some treatment adjustment and provide intervention.During a review of the facility's policy and procedure (P&P) titled, Refusal of Treatment, dated 1/1/2012, the P&P indicated, The attending physician will be notified of refusal of treatment in a timeframe determined by the resident's condition and potential serious consequences of the refusal.During a review of the facility's P&P titled, Change of Condition Notification, dated 8/25/2022, the P&P indicated, To ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner.

Based on observation, interview and record review, the facility failed to: 1. Inform a resident of how to file a grievance for missing glasses for one of four sampled residents (Resident 32). This deficient practice had the potential to violate the resident's right to have a grievance filed and ensure resident was comfortable at the facility. Findings: During a review of Resident 32's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 32 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The face sheet indicated Resident 32's diagnoses' list included glaucoma (an eye condition that damages the optic nerve), cataracts (a cloudy or foggy area that develops in the lens of the eye, which is normally clear), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness, numbness, or reduced movement on one side of the body). During a review of Resident 32's History and Physical (H&P) form, dated 9/5/2025, the H&P indicated Resident 32 had the capacity to understand and make decisions. During a review of Resident 32's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 12/17/2025, the MDS indicated Resident 32's cognitive (thinking) skills were cognitively intact. The MDS also indicated Resident 32 was dependent on staff with Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During an interview, on 2/10/2026 at 9:24 a.m., with Resident 32, Resident 32 stated she had been wearing prescription eyeglasses since she was 8 years old. Resident 32 stated she had eyeglasses upon admission, and her eyeglasses were misplaced sometime during a room change. Resident 32 stated she informed the social worker and the Director of Nursing (DON) of her missing eyeglasses but was not informed on how to file a grievance. Resident 32 stated she had blurry vision due to not wearing her eyeglasses which resulted in her feeling frustrated. During an interview, on 2/12/2026 at 8:55 a.m., with the DON, the DON stated the protocol for filing a grievance was to inform all residents that if an issue arises, all resident had a right to file a grievance with a staff member. The DON stated after a resident files a grievance, the grievance would had been given to the Social Services Director (SSD) to follow up on any concerns. The DON stated all staff members can inform a resident on how to file a grievance. The DON stated Resident 32 informed her of her missing eyeglasses a week prior and the night before. The DON stated she did not inform Resident 32 on how to file a grievance. The DON stated the risk of not informing a resident on how to file a grievance could result in a delay in necessary care and services. During a review of the facility's policy and procedures (P&P), titled Grievances, dated 11/14/2025, the P&P indicated, When a Facility Staff member overhears or receives a grievance/complaint from a resident, a resident representative, or family member, the Facility Staff member encourages and offers to facilitate the completion of a Grievance/Complaint Investigation Report.

Based on interview and record review the facility failed to: 1. Ensure one of two residents (Resident 2) Preadmission Screening and Resident Review (PASARR- a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) Level 1 screening (a mandatory preliminary screening required for all individuals seeking admission to a Medicaid-certified nursing facility) indicated diagnosed mental illnesses. This failure had the potential for Resident 2 not being appropriately identified for further evaluation of serious mental illness leading to resident not receiving necessary specialized services, treatment planning interventions, or appropriate placement.Findings: During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated the facility admitted Resident 2 on 9/11/2019 and was readmitted on [DATE] with diagnoses including schizoaffective disorder [a serious, long-term mental health condition that combines symptoms of schizophrenia (psychosis - a mental health condition that causes a person to lose touch with reality) and mood disorders], major depressive disorder (a state of low mood, irritability, or loss of interest in activities lasting at least two weeks that significantly interferes with a person's life), psychotic disorder with delusions (a serious mental health condition where a person loses touch with reality and has a very hard time telling the difference between what is real and what is not), and anxiety disorder (a mental health condition characterized by persistent, excessive, and uncontrollable worry that goes beyond normal nervousness). During a review of Resident 2's History and Physical (H&P) dated 9/18/2025, the H&P indicated Resident 2 did not have the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 12/10/2025, the MDS indicated Resident 2 had severe cognitive (ability to think or make decisions) impairment. The MDS indicated Resident 2 was dependent on staff with oral, toileting and personal hygiene, showering, upper and lower body dressing, and putting or taking off footwear. The MDS indicated Resident 2 had active diagnoses of anxiety disorder, depression, and psychotic disorder. During a review of Resident 2's PASARR level 1 screening dated 3/15/2024, the PASARR indicated Resident 2 did not have a serious diagnosed mental disorder. During a concurrent interview and record review on 2/11/2026 at 1:35 p.m. with Medical Records Assistant (MRA), Resident 2's PASARR level 1 screening was reviewed. The MRA stated he should have accurately documented Resident 2's mental health diagnoses. The MRA stated if the mental health diagnoses were not included in the PASARR level 1 screening, the resident would not have received the appropriate services or treatment. During an interview on 2/12/2026 at 3:10 p.m. with the Director of Nursing (DON), the DON stated the importance of documenting the resident's mental health diagnoses was to ensure a level 2 evaluation (an in-depth, person-centered assessment triggered when a level 1 screen suspects a serious mental illness, intellectual disability, or related condition in nursing facility applicants) was completed to indicate recommendations to help develop plan of care. The DON stated if the PASARR level 1 screening was not completed accurately, there would be potential for the resident to not receive the appropriate treatment in the facility. During a review of the facility's policy and procedure (P&P) titled P-NP04 admission Screening Resident Review (PASRR) revised 4/14/2025, indicated .5. The Facility MDS Coordinator will be responsible for accessing and sure updates to the PASRR are completed per MDS guidelines (e.g Significant Change of Statues MDS).

Based on interview and record review, the facility failed to develop a person-centered care plan for one of 17 sampled residents (Resident 30) by failing to: 1. Develop a comprehensive care plan addressing Resident 30's refusal to use Bilevel Positive Airway Pressure ([BIPAP] - a noninvasive, mask-based ventilation device that assists with breathing by delivering two distinct levels of pressure).This deficient practice had the potential to place Resident 30 at risk for delay of care and treatment.Findings:During a review of Resident 30's admission Record, the admission Record indicated Resident 30 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 30's diagnoses included obstructive sleep apnea ([OSA] - a common, serious sleep disorder where breathing repeatedly stops and starts because throat muscles relax and block the airway during sleep), chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty in breathing), 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 30's History and Physical (H&P), dated 11/21/2025, the H&P indicated, Resident 30 had the capacity to understand and make decisions. During a review of Resident 30's Minimum Data Set ([MDS] - a resident assessment tool), dated 11/25/2025, the MDS indicated, Resident 30's cognitive (ability to think and reason) skills for daily decision making were moderately impaired (decisions poor, cues/supervision required). The MDS indicated Resident 30 required setup assistance (helper assists only prior to or following the activity) from with eating and oral hygiene. During a review of Resident 30's Order Summary Report (a document containing active orders), dated 2/11/2026, the Order Summary Report indicated, the physician placed a telephone order on 11/21/2025 for Resident 30 to start on BIPAP with Inspiratory Positive Airway Pressure ([IPAP] - higher pressure setting) of 18/5 centimeter ([cm] - unit of measurement) of H2O (water), Fraction of Inspired Oxygen ([FiO2] - the percentage or concentration) of 28 percent ([%]- unit of measurement) with full face mask size 18, at bedtime when sleeping and as needed. During a concurrent interview and record on 2/11/2026 at 10:10 a.m., with the Minimum Data Set Nurse (MDSN), Resident 30's medication administration records ([MAR] - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) from January 1, 2026, to 2/11/2026, was reviewed. The MDSN stated Resident 30 was non-compliant and refused BIPAP treatment on 1/3/2026, 1/4/2026, 1/10/2026, 1/23/2026, 1/24/2026, 2/5/2026, and 2/8/2026. During a concurrent interview and record review on 2/11/2026 at 12:13 p.m., with the Director of Nursing (DON), Resident 30's care plans were reviewed. The DON stated there was no comprehensive care plan to address Resident 30's refusal to use BIPAP. The DON stated the purpose of care plan is for the healthcare team to identify and treat the problem and to provide intervention appropriately in order to provide standard of care to the resident. The DON stated without care plan, problem or issues of the resident will be left unattended. During a review of the facility's policy and procedure (P&P) titled, Person-Centered Care Planning, dated 5/22/2025, the P&P indicated, The facility must develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights, that includes measurable objectives, and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.

Based on observation, interview and record review, the facility failed to: 1. Ensure missing eyeglasses were replaced for one of four sampled residents (Resident 32). This deficient practice had the potential to violate the resident's right to have a grievance filed and ensure resident was comfortable at the facility. Findings: During a review of Resident 32's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 32 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The face sheet indicated Resident 32's diagnoses' list included glaucoma (an eye condition that damages the optic nerve), cataracts (a cloudy or foggy area that develops in the lens of the eye, which is normally clear), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness, numbness, or reduced movement on one side of the body). During a review of Resident 32's care plan, dated 11/2024, the care plan indicated to ensure Resident 32 wore glasses when awake at all times. During a review of Resident 32's History and Physical (H&P) form, dated 9/5/2025, the H&P indicated Resident 32 had the capacity to understand and make decisions. During a review of Resident 32's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 12/17/2025, the MDS indicated Resident 32's cognitive (thinking) skills were cognitively intact. The MDS also indicated Resident 32 was dependent on staff with Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During an interview, on 2/10/2026 at 9:24 a.m., with Resident 32, Resident 32 stated she had been wearing prescription eyeglasses since she was 8 years old. Resident 32 stated she had eyeglasses upon admission, and her eyeglasses were misplaced sometime during a room change. Resident 32 stated she was nearsighted (a common vision condition where close objects appear clearly, but distant objects look blurry). Resident 32 stated she informed the social worker and the Director of Nursing (DON) of her missing eyeglasses but had not received replacement eyeglasses. Resident 32 stated she had blurry vision due to not wearing her eyeglasses which resulted in her feeling frustrated. During a concurrent interview and record review, on 2/12/2026 at 8:14 a.m., with the Social Services Director (SSD), the SSD stated the protocol for misplaced eyeglasses was to call the facility's outside ophthalmology clinic immediately, see if the resident qualified for a replacement and have the eyeglasses replaced. The SSD stated if a resident did not qualify for a replacement, the facility would offer to pay for the resident. The SSD stated Resident 32 had a care plan indicating resident 32 should had been wearing eyeglasses at all times. The SSD stated she could not recall if Resident 32 told her about the missing eyeglasses and if Resident 32's glasses were missing, they should have been replaced. The SSD stated the risk of not replacing eyeglasses could result in eyesight deterioration, further decline in cataracts and glaucoma diagnoses. During an interview, on 2/12/2026 at 8:55 a.m., with the DON, the DON stated she was informed by Resident 32 of her missing eyeglasses. The DON stated Resident 32 had informed her a few days prior and the night before. The DON stated she did not inform Social Services nor any documentation regarding the missing eyeglasses. The DON stated the risk of not replacing lost glasses could result in worsening impaired vision. During a review of the (P&P), titled Theft and Loss, dated 11/14/2025, the P&P indicated Social Services staff or designee documents report(s) of lost and stolen resident property on the Theft and Loss Log. During a review of the (P&P), titled Social Services Coordinator Job Description, undated, the P&P indicated, Arrange ancillary services that have been determined necessary to maintain the residents' concrete needs.

Based on observation, interview and record review, the facility failed to: 1.Ensure a Stage 4 pressure ulcer wound care treatment was provided for 4 days for one of four sampled residents (Resident 6). This deficient practice had the potential to result in further skin breakdown.Findings: During a review of Resident 6's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 6 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 6's diagnoses included Stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of the hip, paraplegia (loss of movement and/or sensation, to some degree, of the legs), peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs) and methicillin-resistant staphylococcus aureus (MRSA - a bacteria that does not respond to antibiotics) carrier. During a review of Resident 6's history and physical (H&P) form, dated 11/13/2025, the H&P indicated Resident 6 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 11/18/2025, the MDS indicated Resident 6's cognitive (thinking) skills were cognitively intact. The MDS also indicated Resident 6 requires maximal assistance from staff with 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 6's February 2026 Treatment Administration Record (TAR- a legal, daily log used by healthcare staff to track, sign off, and verify that a patient received their prescribed medication or treatment at the correct time and dose), the TAR indicated Resident 6's pressure ulcer wound care treatment of the left hip was not administered for 4 days: February 5th, 2026; February 8th, 2026; February 9th, 2026; and February 10th, 2026. During a concurrent interview and record review, on 2/11/2026 at 3:02 p.m., with the Treatment Nurse (TN 1), TN 1 stated Resident 6 had a left hip stage 4 pressure ulcer. TN 1 stated Resident 6 had an order to cleanse and pack his left hip wound daily. TN 1 stated she had been the treatment nurse for Resident 6 during the month of February. TN 1 stated on Resident 6's February 2026 TAR, there was no documentation of providing wound care treatment for 4 days. TN 1 stated the physician order for wound care treatment to the right hip should had been reordered for Resident 6. TN 1 stated she provided wound care treatment but maybe forgot to document. TN 1 stated the risk of not providing wound care treatment as order could result in further skin breakdown. During a review of the facility's policy and procedures, titled Skin Integrity Management, dated 7/30/2024, the P&P indicated, The facility will identify, evaluate, and intervene to prevent further pressure injury and/or heal pressure ulcers and any other skin integrity conditions. and Treatments administered will be documented in the resident medical Record.

Based on observation, interview, and record review, the facility failed to: 1. Ensure two of three residents' (Resident 2 and Resident 22) oxygen concentrator (machine that converts normal air to a more concentrated oxygen) was turned off when not in use. This failure had the potential to create an oxygen enriched environment, increased risk of fire hazards, equipment malfunction, and compromised resident safety.Findings:During a review of Resident 2's admission Record (Face Sheet). The Face Sheet indicated the facility admitted Resident 2 on 11/14/2019 with diagnoses including heart failure (a disorder which causes the heart to not pump the blood efficiently), history of cerebral infarction (stroke - loss of blood flow to a part of the brain due to blockage), and dementia (a progressive state of decline in mental abilities). During a review of Resident 2's History and Physical (H&P) dated 9/18/2025, the H&P indicated Resident 2 did not have the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 12/10/2025, the MDS indicated Resident 2 had severe cognitive (ability to think or make decisions) impairment. The MDS indicated Resident 2 was dependent on staff for toileting, oral and personal hygiene, showering, upper and lower body dressing, and putting or taking off footwear. The MDS indicated Resident 2 needed oxygen therapy. During a review of Resident 22's admission Record (Face Sheet). The Face Sheet indicated the facility admitted Resident 22 on 12/26/2025 with diagnoses including respiratory failure with hypoxia (sudden inability to move oxygen from the lungs into the bloodstream), dementia (a progressive state of decline in mental abilities) and history of cerebral infarction (stroke - loss of blood flow to a part of the brain due to blockage). During a review of Resident 22's History and Physical (H&P) dated 12/16/2025, the H&P indicated Resident 22 had the capacity to understand and make decisions. During a review of Resident 22's Minimum Data Set (MDS - a resident assessment tool) dated 12/5/2025, the MDS indicated Resident 22 had moderate cognitive (ability to think or make decisions) impairment. The MDS indicated Resident 22 was dependent on staff with toileting, showering, lower body dressing and putting off and taking off footwear, needed maximum assistance (staff does more than half the effort to complete activity) with oral hygiene, upper body dressing and personal hygiene). The MDS indicated Resident 22 needed oxygen therapy. During an observation on 2/11/2026 at 9:07 a.m. in Resident 2's room, Resident 2 was not wearing her oxygen and the concentrator remained switched on. During an observation on 2/11/2026 at 9:56 a.m. in Resident 22's room, Resident 22 was not in the room and the concentrator remained switched on. During a concurrent observation and interview on 2/11/2026 at 10:01 a.m. with Licensed Vocational Nurse (LVN) 1 in the hallway near nurse's station one, Resident 2 was not receiving oxygen through nasal cannula (a flexible tube that delivers supplemental oxygen through the nose) and the concentrator remained switched on in Resident 2's room. LVN 1 stated the importance of turning off oxygen concentrators when not in use was to prevent equipment malfunction and accidents such as electrical fires. During an interview on 2/12/2026 at 3:15 p.m. with the Director of Nursing (DON), the DON stated the importance of turning off oxygen concentrators when not in use was to prevent the machine from overheating causing the machine to break and to prevent accidents such as fires. During a review of the facility's policy and procedure (P&P) titled P-NP94 Oxygen Therapy revised 10/10/2025, the P&P did not indicate procedures regarding maintaining oxygen equipment when not in use.

Based on interview and record review, the facility failed to: 1. ensure employee performance, competency validation, initial orientation validation, and orientation activities checklist were completed for 3 of 6 employees, RN1, LVN 2, and CNA 2. This failure had the potential to result in residents not receiving the required care based on the employee performance competency, orientation validation, and orientation activities provided for the proper care of the residents. Findings: During a review of the employee file of RN 1, the 2024 Annual Evaluation (yearly performance review) was not in the employee's file. During a review of the employee file for LVN 2, the Licensed Nurse Onboarding Activities Checklist (structured steps, training, and social interactions that integrate a new employee into an organization), dated 12/24/24, were missing validation of the following care requirements: Resident's Rights, admission Procedures, Discharge/Transfers, Psychotropics (medications to alter brain function, mood, perception, consciousness, and behavior) , Treatment Procedures, Enteral (methods of delivering nutrients, fluids, or medications directly into the stomach or intestines) , Change of Condition (a noticeable, significant, or unexpected difference in the physical, mental, or financial state of a person), Falls Management, Weights, Resident Care Plans (a written, personalized document that outlines a person's health conditions, needs, goals, and the specific daily actions or treatments required to support them), Interdisciplinary Referrals (a process where a healthcare provider directs a patient to a team of experts from different professional fields), Lab (a facility where tests are performed on blood, urine, or tissue samples, to obtain information about a patient's health), Advance Directive Documentation (a written statement of a person's wishes regarding medical treatment), Medicare Documentation (a federal health insurance program in the United States, primarily designed for people age [AGE] or older), Medical Records, Death of a Resident, Rounds (the daily, structured process of healthcare professionals visit patients to evaluate their condition, treatment plans, and update care), Committees (a small group of people appointed to investigate, discuss, and make decisions or recommendations), and External Resources (services for patient care obtained outside of an organization). During a review of the employee file for CNA 3, the Initial CNA Orientation Validation Checklist, undated, was not checked as completed, to indicate the procedure (step by step process for care of someone) for Basic Tuberculosis was met or not met. The Sit-to-Stand Lift Competency for CNA 3 did not have check marks to indicate CNA 3's competency for that task. During an interview and record review on 2/12/2026 at 2:27 p.m., with the Director of Staff Development (DSD), the DSD stated the sit to stand competency for CNA 3 was not completed. DSD stated staff need to know how to complete the task. If staff do not know, the resident could fall, the machine could slide if the brake was not placed, could hurt the resident if the device used is not adjusted properly or if it is not cleaned, it could spread germs to the residents. During an interview on 2/12/2026 at 2:48 p.m., with the Director of Nursing (DON), the DON stated that staff could fail to provide the right care and residents would not receive the proper care if the expected documents are not completed. Also, the residents could become sick from not receiving the care according to the facility's education process. During a review of the facility's policy and procedure titled, HR01 Staff Competency Validation Policy & Procedure, dated 3/28/2024, indicated, competency validation is completed to evaluate an individual's performance, evaluate group performance, meet standards set by regulatory agencies, address problematic issues, and enhance performance reviews. Competency validation is a determination based on an individual's satisfactory performance of each specific element of his/her job description, and of the specific requirements for the area in which he or she is employed. The purpose is to protect the health, safety, and well-being of residents.

Based on observation, interview, and record review the facility failed to: 1. Ensure one of one resident's (Resident 49) mouth was rinsed after administration of prescribed inhaler Breo Ellipta [an inhaler used as a maintenance medication for asthma (a condition that causes the respiratory airways to swell up, shrink, and fill with mucus)].This failure had the potential to result in Resident 49 developing irritation of the mouth, discomfort, and an increased risk of infection of the mouth and throat due to medication remaining in the mouth after inhaler use.Findings:During a review of Resident 49's admission Record (Face Sheet), the Face Sheet indicated the facility admitted Resident 49 on 10/9/2025 and was readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), mild intermittent asthma with acute exacerbation (a sudden or worsening of shortness of breath, wheezing, cough, chest tightness leading to a decline in lung function triggered by infection, allergens, or pollutants) and dysphagia (difficulty swallowing). During a review of Resident 49's History and Physical (H&P) dated 1/29/2026, the H&P indicated Resident 49 did not have the capacity to make needs known or make decisions. During a review of Resident 49's Minimum Data Set (MDS - a resident assessment tool) dated 2/4/2026, the MDS indicated Resident 49 had moderate cognitive (ability to think and understand). The MDS indicated Resident 49 was dependent (helper does all of the effort to complete the activity) on staff with toileting, showering, lower body dressing, and putting on or taking off footwear, needed partial assistance (helper lifts, holds, or supports trunk or limbs, but provides less than half the effort to complete the activity) with eating and oral hygiene, and needed maximum assistance (helper lifts or holds trunk or limbs and provides more than half the effort to complete the activity) with upper body dressing and personal hygiene. During a review of pharmacy's label for Breo Ellipta 100 mcg/25 mcg (micrograms - a unit of measurement) inhaler started on 1/28/2026 indicated, inhale 1 puff by mouth once daily, rinse mouth thoroughly after each use. During an observation 2/12/2026 at 9:05 a.m. with Licensed Vocational Nurse (LVN) 3 in Resident 49's room, LVN 3 did not instruct Resident 49 to rinse her mouth after administration of inhaler Breo Ellipta. During an interview on 2/12/2026 at 9:20 a.m. with LVN 3, LVN 3 stated she should have instructed Resident 49 to rinse her mouth after taking the inhaler. LVN 3 stated the importance of rinsing mouth after the inhaler was to prevent growth of fungus or bacteria in the mouth. LVN 3 stated if the resident did not rinse her mouth after taking the inhaler, there would be a potential that the resident could develop sores in the mouth that could get infected leading to a greater infection. During an interview on 2/12/2026 at 3:05 p.m. with the Director of Nursing (DON), the DON stated the importance of following pharmacy instructions to rinse mouth after administration of inhaler was to prevent fungal infection in the mouth. The DON stated if resident did not rinse her mouth after taking the inhaler, the resident would experience pain while eating and potentially lead to other infections of the body. During a review of the facility's policy and procedure (P&P) titled Oral Inhaler, dated 1/1/2012, the P&P did not indicate procedures regarding administration of corticosteroid [steroid - medication to reduce inflammation (swelling) in the body].

Based on observation, interview and record review, the facility failed to: 1. Ensure medication error rate was less than five percent (%). Two errors out of 34 total opportunities contributed to an overall medication error rate of 5.88% for one of five residents (Resident 49) observed during medication administration (med pass).Resident 49's cholecalciferol (Vitamin D) 400 units [(IU - international units) a unit of measurement] tablet and fluticasone propionate suspension 50 mcg/act (micrograms per actuation- a unit of measurement) nasal spray were administered per physician's order. This failure had the potential to result in impaired bone health, increased fracture risk, respiratory complications, worsening allergy symptoms, nasal congestion and decreased comfort.Findings:During a review of Resident 49's admission Record (Face Sheet), the Face Sheet indicated the facility admitted Resident 49 on 10/9/2025 and was readmitted on [DATE] with diagnoses including fracture (broken bone) of left femur (the longest, strongest, and heaviest bone in the human body, located in the left thigh), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), mild intermittent asthma with acute exacerbation (a sudden or worsening of shortness of breath, wheezing, cough, chest tightness leading to a decline in lung function triggered by infection, allergens, or pollutants) allergic rhinitis (allergy - when the immune system mistakenly identifies harmless air particles such as pollen, pet dander, or dust mites as dangerous) and dysphagia (difficulty swallowing). During a review of Resident 49's History and Physical (H&P) dated 1/29/2026, the H&P indicated Resident 49 did not have the capacity to make needs known or make decisions. During a review of Resident 49's Minimum Data Set (MDS - a resident assessment tool) dated 2/4/2026, the MDS indicated Resident 49 had moderate cognitive (ability to think and understand). The MDS indicated Resident 49 was dependent (helper does all of the effort to complete the activity) on staff with toileting, showering, lower body dressing, and putting on or taking off footwear, needed partial assistance (helper lifts, holds, or supports trunk or limbs, but provides less than half the effort to complete the activity) with eating and oral hygiene, and needed maximum assistance (helper lifts or holds trunk or limbs and provides more than half the effort to complete the activity) from staff with upper body dressing and personal hygiene. During a review of Resident 49's Physician Orders dated 1/28/2026, the physician orders indicated cholecalciferol tablet 400 unit, give 1 tablet by mouth one time a day for supplement and fluticasone propionate suspension 50 mcg/mct micrograms per actuation- a unit of measurement) 1 spray each nostril one time a day for allergy. During an interview on 2/12/2026 at 9:20 a.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated she did not administer the Vitamin D because the medication cart only had a 1000 unit dose available and she needed to check with central s upply if the facility had the 400 unit dose in stock. LVN 3 could not provide a reason why she did not administer the nasal spray. LVN 3 stated the importance of administering prescribed medications was to prevent allergy symptoms from getting worse and to supplement the resident's Vitamin D for her bones. LVN 3 stated if medications were not administered as prescribed, the resident's allergies can get worse and Vitamin D levels would be low. During an interview on 2/12/2026 at 3:05 p.m. with the Director of Nursing (DON), the DON stated the importance of administering prescribed medications was to ensure that any ongoing symptoms or disease were treated. The DON stated if medications were not administered as prescribed, the resident's symptoms could worsen placing the resident at risk for unresolved or uncontrolled medical issues. During a review of the facility's policy and procedure (P&P) titled NP76 Medication - Administration revised 6/26/2025, the P&P indicated All medications shall be administered by licensed nursing staff according to physician orders, current best practices, and federal and state regulations.

Based on interview and record review, the facility failed to: 1. Ensure a resident who had a diagnosis of dementia (a progressive state of decline in mental abilities) and legally blind (severe vision loss) understands the legal documents (documents affecting the legal rights of any person) including Binding Arbitration Agreement (a binding agreement by the parties to submit to arbitration all of certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not, the decision is final and can be enforced by a court, and can only be appealed on very narrow grounds) she signed during admission to the facility for one of three sampled residents (Resident 39). This deficient practice resulted for Resident 39 signing a facility contractual agreement without her full understanding.Findings: During a review of Resident 39's admission Record, the admission Record indicated Resident 39 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 39's diagnoses included dementia (a progressive state of decline in mental abilities), legal blindness (severe vision loss), and congestive heart failure ([CHF] - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 39's History and Physical (H&P), dated 10/10/2025, the H&P indicated, Resident 39 did not have the capacity to understand and make decisions. During a review of Resident 39's Neuropsychiatric (branch of medicine that deals with the diagnosis, treatment, and prevention of mental disorders) Progress Note, dated 12/15/2025, the Neuropsychiatric Progress Note indicated, Resident 39 suffered from dementia and cognitive (ability to think and reason) communication deficit (lack or impairment in function) and any recommendations are subject to the approval of the interdisciplinary team (([IDT] - team members from different disciplines who come together to discuss resident care). During a review of Resident 39's Minimum Data Set ([MDS] - a resident assessment tool), dated 1/15/2026, the MDS indicated, Resident 39's cognitive skills for daily decision making were moderately impaired (decisions poor, cues/supervision required). The MDS indicated Resident 39's vision was highly impaired. The MDS indicated, Resident 39 required moderate assistance (helper does less than half the effort) from staff with toileting hygiene, upper and lower body dressing, and personal hygiene. During a concurrent interview and record review on 2/12/2026 at 9:28 a.m., with the admission Coordinator (AC), Resident 39's Arbitration Agreement was reviewed. The AC stated Resident 39's Arbitration Agreement was signed electronically by resident on 12/30/2025. The AC stated he is responsible for completing the Arbitration Agreement with the resident upon admission. The AC stated Arbitration Agreement is a legal document, and both parties are bound to agreement. The AC stated Resident 39 is legally blind and has a diagnosis of dementia. The AC stated he should have not asked Resident 39 to sign the Arbitration Agreement. During an interview on 2/12/2026 at 10:11 a.m., with Resident 39, Resident 39 stated her vision was so blurry and she could hardly see. Resident 39 stated she could not recall signing the Arbitration Agreement. During an interview on 2/12/2026 at 10:17 a.m., with the Social Service Director (SSD), the SSD stated Resident 39 does not have an intact cognition. The SSD stated legal documents such as Arbitration Agreement should not be signed if resident did not have the capacity to understand. During an interview on 2/12/2026 at 1:24 p.m., with the Director of Nursing (DON), the DON stated Resident 39's Arbitration Agreement was not valid since Resident 39 is visually impaired and has diagnosis of dementia. The DON stated having Resident 39 sign the Arbitration Agreement is unacceptable because it takes away her rights to go to court. During a review of the facility's Policy and Procedure (P&P) titled, Arbitration Agreements, dated 5/26/2023, the P&P indicated, Residents should be given the opportunity to ask questions and clarify their understanding of the implications of signing the agreement. During a review of the facility's P&P titled, Informed Consent, dated 1/30/2026, the P&P indicated, If the resident lacks capacity to provide informed consent and does not have a surrogate decision maker, the facility will convene a Surrogate interdisciplinary team (IDT).

Based on observation, interview, and record review the facility failed to: 1. Ensure staff wore Personal Protective Equipment (PPE) when handling one of five resident's (Resident 21) gastrostomy tube (gtube - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) who was on enhance barrier precautions (EBP - is an approach of targeted gown and glove use during high contact resident care activities).This failure had the potential to increase the risk of infection and cross-contamination (the transfer of bacteria, viruses, microorganisms, or other harmful substances from one surface to another through improper or unsanitary equipment, procedures, or products) among residents.Findings:During a review of Resident 21's admission Record (Face Sheet), the Face Sheet indicated the facility admitted Resident 21 on 7/2/2022 with diagnoses including hemiplegia (a medical condition characterized by paralysis or severe weakness on one entire side of the body) and hemiparesis (weakness on one entire side of the body) after a stroke (occurs when blood flow to a part of the brain is suddenly interrupted or a blood vessel in the brain bursts), dysphagia (difficulty swallowing), and gastrostomy status. During a review of Resident 21's History and Physical (H&P) dated 12/7/2025, the H&P indicated Resident 21 did not have the capacity to understand and make decisions. During a review of Resident 21's Minimum Data Set (MDS - a resident assessment tool) dated 1/2/2026, the MDS indicated Resident 21 had severe problems with thinking and memory. The MDS indicated Resident 21 was dependent on staff with eating, toileting, oral and personal hygiene, showering, lower body dressing and putting on or taking off footwear and needed maximum assistance (helper does more than half the effort to complete activity) with upper body dressing. During a review of Resident 21's Physician's Order dated 10/28/2024, the Physicians Order indicated Resident 21 was placed on Enhanced Barrier Precautions related to criteria being met every shift for Transmission-Based Prevention. During an observation on 2/12/2026 at 7:59 a.m. with Licensed Vocational Nurse (LVN) 3 in Resident 21's room, LVN 3 did not wear gloves when assessing Resident 21's gtube. During an interview on 2/12/2026 at 8:30 a.m. with LVN 3, LVN 3 stated she should have worn gloves prior to touching the gtube. LVN 3 stated the importance of wearing gloves while conducting high contact activities was to prevent the spread of bacteria throughout the facility. LVN 3 stated there would be a higher risk of spreading infection to other residents in the facility. During an interview on 2/12/2026 at 3:00 p.m. with the Director of Nursing (DON), the DON stated the importance of wearing PPE when taking care of residents on EBP was to prevent the spread of infection to other residents. The DON stated if PPE was not worn during high contact resident care activities there would be an increased risk for spreading the infection to other residents. During a review of the facility's policy and procedure (P&P) titled Personal Protective Equipment revised 1/1/2012, the P&P indicated .B. Gloves (sterile, non-sterile, heavy duty and/or puncture resistant) i. Facility staff wear gloves whenever there is touching blood, body fluids, secretions, excretions, mucous membranes, and/or non-intact skin. During a review of the facility's P&P titled Enhanced Barrier Precautions revised 8/22/2019, the P&P indicated .II. Standard precautions will be used when there is any resident contact regardless of transmission risk of MDRO status. Standard precautions will include: . B. Gown, gloves, mask and face shield when a healthcare worker anticipates their hands, clothes or mucous membranes of the eyes, nose, mouth or skin on their face will be exposed to blood or other body fluids.

Based on interview, and record review, the facility failed to: 1. ensure that one of five residents, Resident 49, was provided COVID-19 and Influenza vaccines. This failure had the potential to place Resident 49 at risk of being infected with COVID-19 and Influenza viruses.Findings:During a review of Resident 49's admission Record, dated 1/28/2026, the admission Record indicated Resident 49 has Chronic Obstructive Pulmonary disease (a lung disease that makes it difficult to breathe) , mild intermittent asthma (a low-severity, lung condition characterized by infrequent coughing, wheezing, chest tightness) , and cognitive communication deficit (difficulty communicating due to underlying thinking disruptions rather than just language or speech problems). During a review of Resident 49's History & Physical, dated 1/29/2026, the History & Physical indicated Resident 49 does not have the capacity to understand and make decisions and Resident 49's potential for rehabilitation is fair to poor. During a review of Resident 49's Order Summary Report, dated 1/28/2026, the Order Summary Report indicated to elevate head of bed at 30-45 degrees due to resident experiences shortness of breath when lying flat. During a review of Resident 49's Minimum Data Set, dated [DATE], the Minimum Data Set indicated Resident 49 has an active diagnosis of malnutrition (not eating the proper amount of calories and nutrients needed for the body to function properly), an active disease of the lungs (lungs not functioning properly, making it difficult to breathe and get enough oxygen), and shortness of breath when lying flat. During a review of Resident 49's Care Plan Summary, dated 2/3/2026, the Care Plan Summary indicated that Resident 49 is at risk for COVID-19 infection related to complex medical conditions. During a review of Resident 49's electronic immunization (the process of making a person immune or resistant to an infectious disease by administering a vaccine) record, not dated, the immunization record indicated that Resident 49 did not have any vaccines for COVID-19, and influenza. During an interview on 2/12/2026 at 9:15 a.m. with the Infection Preventionist (IPN) (a specialized healthcare professional who acts as a germ detective within hospitals and clinics), IPN stated, resident vaccines are supposed to be listed under immunizations in the electronic medical record. IPN stated they did not have an answer for why or when vaccine information is to be entered into the medical record. IPN stated staff would not be able to observe residents for adverse (any unexpected, unintended, and harmful reaction caused by a medication taken at normal doses) reactions if vaccines are not documented in the medical record. During an interview on 2/13/2026 at 8:03 a.m., with the Director of Nursing (DON), the DON stated residents should have immunizations and it is important for them to have a choice in receiving them. If residents do not receive immunizations, it could affect their overall health. During an interview on 2/13/2026 at 9:16 a.m., with the Administrator (ADM), the ADM stated that residents should have their immunizations. During a review of the facility's policy and procedure (P&P) titled, Management of COVID-19, dated 2022, the P&P indicated, Residents are encouraged to receive COVID-19 vaccination and boosters (an extra dose of a vaccine given after an initial, primary, vaccination), and the facility will maintain documentation of resident and staff vaccine status. During a review of the facility's policy and procedure (P&P) titled, Influenza Prevention and Control, dated 9/10/2020, the P&P indicated, the Resident's medical record will include documentation that indicates, at a minimum, the following: Whether the Resident received the influenza vaccine, could not receive the vaccine due to a medical contraindication, or refused the vaccine.

Based on interview and record review, the facility failed to: 1. Ensure two of 19 sampled resident rooms (room [ROOM NUMBER] and 18) accommodated no more than four residents per room. This deficient practice had the potential to result in and/or create safety hazards, lack of privacy, and care issues for the residents.Findings:During facility tour on 2/12/2026 at 8:31 a.m., it was observed in room [ROOM NUMBER] that there was space for the beds, side tables, and resident care equipment's and there were no concerns with privacy and safety issues to the residents, and room [ROOM NUMBER] has five empty beds. During an interview on 2/12/2026 at 8:35 a.m., with the Administrator (ADM), the ADM confirmed room [ROOM NUMBER] bed (A, B, C, D, E) and room [ROOM NUMBER] beds (A, B, C, D, E) accommodated five residents. During a review of the facility's letter, titled Request for Waiver/Variations to Section 483.70, dated 2/10/2026, completed and submitted by the ADM, indicated the facility is submitting a renewal variation for accommodation of needs of more than four residents in one room. The facility waiver indicated the rooms with 5 residents are room [ROOM NUMBER] and 18 and each room has approximately 420 square feet ([sq. ft.] unit of measurement). The facility waiver indicated there were approximately 50% non-ambulatory and 50% ambulatory residents in each 5-bed room when fully occupied and both 5-bed rooms have a door with direct access to the corridor and to outside exposure at floor level.

Based on interview and record, the facility failed to ensure a Minimum Data Set ([MDS] - a resident assessment tool) assessment was completed accurately for one of three sampled residents (Resident 1) by failing to: 1. Ensure Resident 1's hearing aid (a device worn in or behind the ear designed to amplify sound for individuals who have difficulty of hearing) was encoded and assess her hearing ability properly. This deficient practice had the potential to negatively affect the plan of care and delivery of care services for Resident 1.Findings:During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included fracture of left femur (a break, crack, or crush injury in the bone of the left thigh), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), and dysphagia (difficulty of swallowing). During a review of Resident 1's History and Physical (H&P), dated 11/17/2025, the H&P indicated, Resident 1 did not have the capacity to understand and make decisions. During a review Resident 1's MDS assessment, dated 10/29/2025, the MDS assessment indicated, Resident 1's cognitive (ability to think and reason) skills for daily decision making were severely impaired (never/rarely made decisions). The MDS assessment indicated, Resident 1 was totally dependent (helper does all of the effort) from staff with oral hygiene, toileting hygiene, and lower body dressing. During a review of Resident 1's Social Services Assessment, dated 10/27/2025, the Social Services Assessment indicated, Resident 1 has right and left hearing aid. During a concurrent interview and record review on 2/4/2026 at 11:43 a.m., with the Minimum Data Set Nurse (MDSN), Resident 1's MDS assessment, dated 10/29/2025, was reviewed. The MDSN stated MDS Section B (Hearing, Speech, and Vision) look back period (the specific time frame within which certain resident conditions and events are assessed) was 7 days before the completion date. The MDSN stated Resident 1's MDS assessment was completed inaccurately. The MDSN stated Resident 1's MDS, Section B0200 (Hearing) was coded 0 (Adequate), however, it should have been coded as 1 (Minimal difficulty). The MDSN stated Resident 1's MDS, Section B0300 (Hearing Aid) was coded 0 (No), however, it should have been coded as 1 (Yes). The MDSN stated she did not see Resident 1's using her hearing aid at the time of the MDS assessment on 10/29/2025. The MDSN stated she did not follow the Resident Assessment Instrument ([RAI] - a standardized tool used in nursing homes and long-term care facilities to assess resident's needs, strengths, and potential risks) Section B guidelines in completing the MDS assessment. The MDSN stated MDS assessment reflects resident's present condition and facility's plan of care. The MDSN stated if the MDS assessment was not completed accurately then the facility won't be able to provide quality of care to residents.During an interview on 2/4/2026 at 12:15 p.m., with the Director of Nursing (DON), the DON stated MDS assessment should be completed accurately to meet the needs of the resident and for the facility to develop appropriate plan of care for the residents. During a review of the facility's policy and procedure (P&P) titled, RAI Process, dated 10/4/2016, the P&P indicated, To provide resident-assessments that accurately depict and identify resident-specific issues and objectives as required, while meeting state and federal guidelines and data submission requirements. During a review of the Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, version 1.20.1, dated 10/2025, page B-2, under Steps for Assessment, indicated number 1. Ensure that the resident is using their normal hearing appliance if they have, 5. Review the medical record, 6. Consult the resident's family, caregivers, direct care staff, activities personnel, and speech or hearing specialist. During a review of the Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, version 1.20.1, dated 10/2025, page B-5, under Steps for Assessment, indicated number 1. Prior to beginning the hearing assessment, ask the resident if they own a hearing aid or other hearing appliance and if so, whether it is at nursing home, 4. Check the medical record for evidence that the resident had a hearing appliance in place when hearing ability was recorded.

Based on interview and record review, the facility failed to develop a person-centered care plan for one of one sampled resident (Resident 1) by failing to: 1. Develop a comprehensive care plan addressing Resident 1's missing right hearing aid. This deficient practice had the potential to result in a lack of meeting necessary care and addressing medical needs for Resident 1.Findings:During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included fracture of left femur (a break, crack, or crush injury in the bone of the left thigh), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), and dysphagia (difficulty of swallowing). During a review of Resident 1's History and Physical (H&P), dated 11/17/2025, the H&P indicated, Resident 1 did not have the capacity to understand and make decisions. During a review Resident 1's Minimum Data Set ([MDS] - a resident assessment tool) assessment, dated 10/29/2025, the MDS assessment indicated, Resident 1's cognitive (ability to think and reason) skills for daily decision making were severely impaired (never/rarely made decisions). The MDS assessment indicated, Resident 1 was totally dependent (helper does all of the effort) from staff with oral hygiene, toileting hygiene, and lower body dressing. During a review of Resident 1's Theft/Loss Report, dated 11/21/2025, the Theft/Loss Report, indicated Resident 1 had missing right hearing aid. During a concurrent interview and record review on 2/4/2026 at 11:23 a.m., with Registered Nurse 1 (RN 1), Resident 1's care plans were reviewed. RN 1 stated there was no comprehensive care plan to address Resident 1's missing right hearing aid. RN 1 stated care plan is a communication tool among interdisciplinary team ([IDT] - team members from different disciplines who come together to discuss resident care) that has a problem, goal, and interventions. RN 1 stated failure to develop a care plan would result in lack of resident's continuity of care. During an interview on 2/4/2026 at 11:50 a.m., with the Minimum Data Set Nurse (MDSN), the MDSN stated development of care plan is a consolidated team effort. The MDSN stated the IDT should develop care plan to address any resident's problem or concerns identified to come up with a goal and interventions. During an interview on 2/4/2026 at 12:17 p.m., with the Director of Nursing (DON), the DON stated care plan serves as a guidance on how to care properly of the residents. The DON stated it is important to develop a comprehensive care plan in order to provide appropriate care to each resident. During a review of the facility's policy and procedure (P&P) titled, Person-Centered Care Planning, dated 5/22/2025, the P&P indicated, The facility must develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights, that includes measurable objectives, and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.

Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was adequately supervised to prevent residents who were at risk for leaving the facility unaccompanied. Resident 1, who had a documented history of depression (characterized by persistent feelings of sadness and hopelessness) with attempts to harm self, left the facility unsupervised and went missing from the facility for seven (7) days. Resident 1, who used the wheelchair for mobility and had multiple medical conditions that required medications for treatment, was without her medications for 7 days. The facility also failed to report Resident 1 being missing until eight days after the incident. This deficient practice resulted in Resident 1, who was wheelchair bound (unable to walk due to illness; relying on a wheelchair for mobility to move around), leaving out the facility's front door unnoticed and unsupervised and a delay in the Department conducting an investigation placed Resident 1 at risk for harm. Resident 1 was found almost 6 miles away from the facility and once found required a transfer to a general acute care hospital (GACH) for evaluation, care, and treatment. Resident 1 was diagnosed with a [CONDITION(S)] ([CVA (a stroke)] blockage in the blood vessels supplying blood to the brain) in the GACH requiring an admission on the telemetry unit (a specialized unit that monitors and records resident's heart beats and patterns), for close monitoring and was hospitalized for six (6) days. During an interview on 3/18/2021 at 5:34 p.m., with the facility's Administrator (ADM) and the Director of Nursing (DON), they were informed that an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm, impairment, or death to a resident) was identified and declared for F689. The facility's ADM and the DON were notified of the immediate action that needs to be taken and seriousness of the residents' health and safety being threatened. During an interview on 3/19/2021 at 4:35 p.m., the ADM and DON provided an acceptable plan of action (POA) for correction of the IJ. The IJ was lifted at that time, after the team verified, while onsite, through observation, interview, and record review, the POA was implemented. The acceptable POA included the following: 1. The staff will ensure each resident received adequate supervision. 2. The staff will ensure residents with physician's order to go out on pass with a responsible party would be implemented as ordered. 3. The facility will provide education to the staff regarding elopement prevention and management, as well as unusual occurrence reporting with the emphasis on reporting elopement incidents within 24 hours to the Department. 4. An alarm was installed and activated on the main entrance door of the building as of 3/8/2021. 5. A staff member was immediately assigned to supervise the main lobby and main entrance door and will continue daily on all three shifts. 6. The ADM and the DON will be re-educated by the nurse consultant regarding elopement and unusual occurrences policy and procedure (P/P) with emphasis on timely reporting of incidents such as elopement to the department within 24 hours. Findings: During a review of Resident 1's History and Physical (H/P), dated 6/23/2020, the H/P indicated Resident 1 had the capacity to understand and make decisions. The H/P indicated Resident 1 had a history of depression (persistent feelings of sadness and hopelessness) and attempted to harm herself in the past. During a review of Resident 1's Admission Record (face sheet), the face sheet indicated Resident 1 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's diagnoses included, but not limited to [CONDITION(S)] (abnormal brain activity with the absence of body jerking), abnormalities of gait (walk) and mobility, [CONDITION(S)] (the loss of the ability to move and sometimes to feel anything on one side) following a cerebral infarct (blockage in the blood vessels supplying blood to the brain) of the dominant (main) right side, diabetes mellitus (high sugar levels in the blood) and hypertension (high blood pressure). During a review of Resident 1's recapitulated (a summary) physician's orders, for the month of 3/2021, the orders indicated to administer Resident 1 the following medications: 1. [MEDICATION(S)] (medication used to lower blood sugar) 5 milligrams ([mg] a unit of measurement) by mouth daily for diabetes mellitus (health condition that affects how your body turns food into energy. Most of the food eaten is broken down into sugar (also called glucose) and released into your bloodstream). 2. [MEDICATION(S)] (an antidepressant [reduce feelings of hopelessness and sadness] medication) 10 mg by mouth daily for depression manifested by persistent feelings of hopelessness and helplessness. 3. Aspirin (blood thinning medication) [MEDICATION(S)] coated 81 mg by mouth daily for CVA. 4. [MEDICATION(S)] (medication used to prevent [CONDITION(S)] [a brief episode of uncontrolled body jerking and loss of mental awareness]) 500 mg by mouth twice a day for [CONDITION(S)] (a sudden, uncontrolled electrical disturbance in the brain, it can cause changes in your behavior, movements or feelings). 5. [MEDICATION(S)] (medication used to lower blood sugar) 1, 000 mg orally twice a day for diabetes mellitus. 6. [MEDICATION(S)] (a medication used to treat high blood sugar levels) 14 units subcutaneously (beneath the skin) at bedtime diabetes mellitus. 7. Fasting blood sugar (BS) checks before breakfast and dinner and administer Regular Insulin (a medication used to treat high blood sugar level) Injection 100 units/milliliter (mL) as per sliding scale (often used for periods of insulin adjustment depending on the blood sugar level), before meals and at bedtime subcutaneously. Notify the physician if BS is below 60 or above 400. The summary also indicated Resident 1 may go out on pass ([OOP] allowed to leave the facility for brief periods during the day) with a responsible party/person. During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 1/22/2021, the MDS indicated Resident 1's cognition (thought process) was intact and required limited assistance of a one-person physical assist for transfers and activities of daily living ([ADLs] routine activities that people do every day). The MDS indicated Resident 1 had an impairment on one side of the upper and lower extremities and was dependent of a wheelchair for mobility. During a review of Resident 1's care plan, dated 1/22/2021 and titled, Potential for bleeding, bruising, skin tear secondary to aspirin therapy for CVA, the care plan indicated for the staff to monitor Resident 1 for bleeding episode. During a review of Resident 1's care plan, dated 1/22/2021 and titled, Impaired physical mobility related to loss of balance and coordination secondary to CVA and right [CONDITION(S)], the care plan indicated for the staff to assess Resident 1's degree of weakness in upper and lower extremities, assist Resident 1 in performing movements or task and to begin with the task that require small range of movements and encourage control. During a review of Resident 1's care plan, dated 1/22/2021 and titled, Fall risk prevention and management, resident at risk for fall related to limited mobility, poor balance, decreased endurance, medications, unsteady gait and a history of falls, the care plan indicated for the staff to provide an environment that supports minimized hazards over which the facility has control, monitor for side effects of medications and report side effects to the physician. During a review of Resident 1's care plan, dated 1/22/2021 and titled, Language barrier, primary language is Spanish, at risk for difficulty making needs known, the care plan indicated for the staff to utilize family members and translators as necessary, encourage use of non-verbal communication techniques, provide education to Resident 1, responsible party and staff regarding special needs. During a review of Resident 1's Fall Risk Assessment, dated 1/22/2021, the assessment indicated Resident 1 had a score of 35 (without a range provided) and was at a high risk for falls. During a review of Resident 1's Medication Administration Record (MAR), dated for the month of 3/1/2021 through 3/31/2021, the MAR indicated for the staff to monitor and tally (total) Resident 1's behavior of hopelessness and helplessness by hashmarks (a form of counting). The MAR indicated from 3/1/2021 through 3/5/2021 (four days), Resident 1 had a total of 21 episodes of feeling hopelessness and helplessness. During a review of Resident 1's nurse's note (NN), dated 3/6/2021 and timed between the hours of 3 p.m. to 11 p.m., the NN indicated Resident 1 was OOP in her wheelchair, but did not indicate with whom. The NN indicated Resident 1 was observed by staff at 4:30 p.m., on the same day, propelling backwards in her wheelchair towards a room near the main entrance of the facility. The NN indicated at 5 p.m. on the same day, Resident 1 was not observed in her room when the dinner trays were being served. The NN indicated the facility's staff conducted an internal and external search for Resident 1 but Resident 1 was not located and was missing from the facility. The NN indicated timed at 6:15 p.m., the same day, Resident 1's family member (FM 1) was called to check if FM 1 had taken Resident 1 OOP. The NN indicated at 7:45 p.m., the same day, the police arrived at the facility and was made aware that Resident 1 was self-responsible and was missing and a police report was obtained. The NN indicated at 8:30 p.m. and at 10:30 p.m., the same day, the staff conducted a search around facility's perimeter and community looking for Resident 1, but the staff were not able to locate Resident 1. During a review of Resident 1's Social Services note, dated 3/8/2021 and timed at 2:17 p.m., the note indicated Resident 1 left the faciity on [DATE] between the time of 4:30 p.m. and 4:50 p.m. According to the note, FM 1 stated someone probably assisted Resident 1 out of the facility because Resident 1 was heavy (262 pounds) and hard to push and Resident 1 could not get far propelling herself in the wheelchair. During a review of the facility's Discharge Against Medical Advice (AMA) form, dated 3/13/3021 (seven days after Resident 1 left from the facility) and timed at 2:45 p.m., the AMA form indicated Resident 1 refused to sign. During a review of the facility's investigative report, dated 3/13/2021 and timed at 3 p.m., the report indicated FM 2 found Resident 1 and could not take care of her so, she went to the facility and attempted to drop off Resident 1 at the facility. According to the report, FM 2 stated she received an anonymous call indicating Resident 1 was seen at a supermarket, almost 6 miles away from the facility. FM 2 requested for the facility to readmit Resident 1 but was instructed by the staff to take Resident 1 to the nearest hospital for an evaluation. According to the note, FM 2 stated she should [NAME] the facility because the facility did not take care of Resident 1 and the resident was not supposed to be on the street unsupervised. During a review of Resident 1's Social Services note, dated 3/16/2021 and timed at 12:44 p.m., the note indicated Resident 1 was hospitalized and reported being physically assaulted by one of the facility's staff. According to the note, Resident 1 stated she left the facility because the glass door opened by itself, no one would believe it, wheeled herself onto the street and a man put her into his car, gave her five dollars and drove her to the bus stop. According to the note, Resident 1 stated she caught a bus in the area, received food from some friends, and was at a church 5.5 miles away from the facility and was found near the church by FM 2. During an interview on 3/16/2021 at 1:18 p.m., Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 could not walk, was wheelchair dependent, was self-responsible, could make her own decisions and had been missing from the facility for one week. During an interview on 3/16/2021 at 3:20 p.m., the DON stated the facility did not have a surveillance camera (used for close monitoring). The DON stated Resident 1 left out of the front (main entrance) door of the facility. During a concurrent observation and interview on 3/17/2021 at 3:45 p.m., Resident 1 was lying in a bed at the GACH with her right arm contracted (tightening of muscles that prevents normal movement) with tremors (unintentional trembling or shaking) of the left hand, an intravenous line ([IV] in the vein) in her left hand and had a telemetry monitor (a device that records heart beats and patterns) attached. Resident 1 stated a week prior she left from the main entrance of the facility at approximately 3 p.m. Resident 1 stated she had asked a stranger walking by her on the street for the time and then met a man who helped her by giving her five dollars and pushed her to the bus stop (approximately 0.4 miles away from the facility). Resident 1 stated she rode the bus for approximately 12.5 miles from the facility, then took another bus where she exited the bus at the supermarket. Resident 1 stated she slept sitting upright in her wheelchair by a bus stop near the supermarket and some people gave her food to eat. Resident 1 stated she began feeling sick because she was a diabetic and did not have any of her prescribed diabetic medications. Resident 1 stated she was found by her family, after her family (FM 2) heard about a woman who resembled her (Resident 1) was sleeping on the streets. Resident 1 stated FM 2 found her, brought her back to the facility but the facility instructed FM 2 to transport her to the GACH. During an interview on 3/18/2021 at 9:15 a.m., LVN 1 stated when someone enters and exits through the facility's main entrance door the alarm would sound, but the sound would stop once the door was closed. During an interview on 3/18/2021 at 9:55 a.m., Certified Nursing Assistant 1 (CNA 1) stated the facility's main door only alarm if a wander guard (a device that alarms when residents attempt to elope or wander from a safe environment) was near the door. CNA 1 stated the facility's main door had no alarm. During a concurrent observation of the facility's main entrance and interview on 3/18/2021 at 9:58 a.m., a buzzing sound was heard when the door of the facility's main entrance was opened, and the buzzing sound was not heard when the door was closed. The Maintenance Supervisor (MS) stated the only alarm on the door of the main entrance was a wander guard alarm. During an observation on 3/18/2021 at 10:04 a.m., the buzzing sound from the facility's main front door could be heard while standing by the DON's office, which was at the rear of the facility. During an interview on 3/18/2021 at 12:51 p.m., the Administrator stated he did not report Resident 1 missing to the Department in a timely manner because Resident 1 was self-responsible and Resident 1's physician indicated that she could make decisions on her own. The Administrator was informed of Resident 1's physician's order which indicated the resident could go OOP with a responsible person, the Administrator stated he was not aware of the physician's order. During a review of Resident 1's GACH H/P, dated 3/13/2021 and timed at 4:09 p.m., the H/P indicated Resident 1 was transported by ambulance to the Emergency Department and stated she was hit in the head by the facility's staff. The H/P indicated Resident 1's blood pressure was 214/82 millimeters of mercury [mmHg], (normal reference range [NRR] 139/79- 90/60 mm/hg), a white blood cell ([WBC] part of the body's immune system; helps fight infections) count of 12.3 x10³ per microliter (uL) (normal reference range [NRR] = 4.50 -10.00 x10³) and a glucose level of 208 mg/dL (normal reference range [NRR] for blood glucose level is 70 and 130 mg/dL). The GACH H/P indicated Resident 1's computerized tomography ([CT scan] combines a series of X-ray images taken from different angles and uses a computer for processing the images; more-detailed than x-rays) of the brain indicated Resident 1 had a new CVA. Resident 1 was discharged to another facility on 3/19/2021. During a review of the facility's revised P/P, dated 1/11/2016 and titled, Out on Pass, indicated a responsible person is considered to be a person who is over the age of 18 and could call for medical assistance if required, and when indicated, a person who has received education with regard to the administration of medications indicated by the resident's specific needs.

Based on interview and record review, the facility failed to provide the necessary urinary catheterization (insertion of a catheter (soft tubing) into the urethra (hollow tube that leads from the bladder and transports and discharges urine outside the body) to release the urine) care and treatment for one of two sampled residents (Resident 1). Resident 1 required urinary catheterization to drain urine and Licensed Vocational Nurse 2 (LVN 2), after noticing resistance upon insertion, forced the catheter into the urethra. As a result, Resident 1 had gross hematuria (blood in the urine that can be seen with the naked eye). Resident 1 required transfer to General Acute Care Hospital 1 (GACH 1), underwent a cystoscopy (a procedure that lets the urologist view the inside of the bladder and urethra in detail with the use of a hollow tube (cystoscope) equipped with a lens) and required blood transfusion of five units of blood due to blood loss. Resident 1 was hospitalized for [REDACTED]. Findings: A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS - standardized assessment and care-screening tool) dated 6/17/19, indicated Resident 1 was able to make decisions and did not have memory problems. Resident 1 required intermittent urinary catheterization. A review of Resident 1's physician's orders [REDACTED]. A review of Resident 1's History and Physical (H/&) exam completed by the attending physician on 6/11/19, indicated Resident 1 had the capacity to understand and make decisions and could self-catheterize as needed. A review of Resident 1's Nurses' Progress Note from 6/11 to 6/27/19, indicated Resident 1 did not have signs and symptoms of adverse reaction (any unexpected or dangerous reaction to a drug) from the antibiotic (medication to treat infections) treating a urinary tract infection (UTI - an infection in any part of the urinary system: kidneys, ureters, bladder and urethra) and Resident 1 did not have complaints. A review of Resident 1's Nurses' Progress Note dated 6/27/19, for the 3 p.m. to 11 p.m. shift, indicated Resident 1 performed an in-and-out catheterization obtaining clean yellow urine drainage without any sediment (matter that settles to the bottom, causing the urine to be dark/cloudy) and Resident 1 did not have discomfort. A review of Resident 1's Nurses' Progress Note completed by LVN 1 on 6/28/19 and timed at 4 p.m., indicated LVN 1 inserted a urinary indwelling catheter (this catheter remains in the bladder and drains urine to a drainage bag continuously) with clear urine return (drainage). The amount of urine was not included. A review of Resident 1's Nurses' Progress Note completed by LVN 2 on 6/30/19 and timed 9:30 a.m., indicated Resident 1 had a change of condition because the indwelling urinary catheter was leaking. LVN 2 documented that a new indwelling catheter was inserted without resistance, obtaining yellow urine return. There was no bleeding and Resident 1 did not have complaints. There was no documentation of Resident 1's amount of urine output after the procedure and by 3 p.m., the end of the LVN 2's shift (7-3 p.m.). A review of Resident 1's Nurses' Progress Note completed by LVN 3 on 6/30/19 at 4:50 p.m., indicated Resident 1 had a change in condition because of hematuria. The amount of urine drained was no documented. The physician was notified and ordered transferring Resident 1 to GACH 1 for evaluation. A review of Resident 1's GACH 1 Physician emergency room (ER) note dated 6/30/19, indicated a Foley (indwelling catheter brand name) was inserted at the nursing home at 9:30 a.m. today with significant resistance. The patient has had hematuria since that time. Resident 1's laboratory test results, performed at the ER, indicated: - Low hematocrit (the proportion of the blood that consists of packed red blood cells) at 33.2 percent (%) with a reference range of 42-52%. - Low hemoglobin (a protein in red blood cells that transports oxygen and carbon [MEDICATION NAME], and gives blood its red color) at 10.3 grams per deciliters (g/dl - unit of measurement) with a reference range of 14-18.0 g/dl. A review of Resident 1's GACH 1 ER note dated 7/1/19 indicated Resident 1 went to Telemetry Unit (close monitoring unit) for admission and observation. A review of Resident 1's GACH 1 Urology (a doctor specialized on the function and disorders of the urinary system) consultation dated 7/1/19 indicated, the nursing facility's staff inserted a Foley catheter, but had significant resistance in passing the Foley catheter tube. The patient had hematuria (blood in the urine) since that time. Upon physical exam, a Foley catheter was in place with bloody urine output. The urologist documented Resident 1 usually managed self-catheterization four times a day himself until recently due to UTI and then, an indwelling urinary catheter was placed. A review of Resident 1's GACH 1 Post-Operative report dated 7/2/19, indicated Resident 1 had [MEDICAL CONDITION] and hematuria with urethral injury from a catheter placement. A review of Resident 1's GACH Discharge Summary dated 7/9/19 (nine days after admission), indicated Resident 1 experienced significant urethral trauma from an attempt to place an indwelling catheter. Resident 1 required a cystoscopy with a catheter placement done properly. Resident 1 had a precipitous (dangerous, sudden reduction) drop in hemoglobin requiring the transfusion of five units of packed red blood cells. On 11/21/19 at 11:45 a. m., during a telephone interview, LVN 2 stated there was no problem during the insertion of the indwelling urinary catheter on 6/30/19. LVN 2 stated there was no bleeding and the urine was clear yellow. LVN 2 stated she could not remember the amount of urine returned upon insertion and/or the amount at the end of the shift. During a telephone interview on 12/18/19 at 2 p.m., LVN 3 stated on 6/30/19, during her shift starting at 3 p.m., Resident 1 did not have urine output but Resident 1's bed sheets were bloody. A review of an online article titled, Current Trends in the Management of Difficult Urinary Catheterizations by the National Library of Medicine Institution of Health, indicated proper placement technique is critical, as failed attempts at catheterization may lead to injury. Forcing a catheter past the point of resistance can cause injuries ranging from a mucosal tear to more serious false passages (perforations (a hole made by boring or piercing; passing through or into something)), which are associated with infection, urethral stricture, and subsequent surgical management. A review of the facility's policy and procedure, dated 9/1/14 and titled, Indwelling Catheter indicated to record intake and output in accordance with intake and output recording. A review of the facility's policy and procedure, dated 10/27/16 and titled, Intake and Output Recording, indicated to record intake and output when the following conditions exist as a nursing measure: all residents who have an indwelling catheter will have intake and output recorded for 30 days.

Based on interview and record review, the facility failed to follow its policy, resident's plan of care, and the physician's orders to ensure medication was administered as prescribed by the physician for one of three sampled residents (Resident 1). Resident 1, who had a [DIAGNOSES REDACTED]. This deficient practice resulted in Resident 1 receiving 800 milligram (mg) of [MEDICATION NAME] a day, 300 mg more a day than prescribed by the physician resulting in the resident having [MEDICATION NAME] toxicity with a level of 47.4 micrograms (mcg)/dl (deciliters) (Normal Reference Range (NRR) is 10 to 20 mcg/dl ). Resident 1 required an emergency transfer to a general acute care hospital (GACH) and was diagnosed with [REDACTED]. Findings: A review of Resident 1's Face Sheet (Admission Record) indicated the resident was initially admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. medication), dementia (a chronic or persistent disorder of memory loss) and [MEDICAL CONDITION] (([MEDICAL CONDITION]) a brief episode of uncontrolled body jerking and loss of mental awareness). A review of Resident 1's Minimum Data Set (MDS), an assessment and care- screening tool, dated 12/24/18, indicated the resident's cognitive skills for daily decision-making was moderately impaired. According to the MDS, Resident 1 was non-ambulatory and required total assistance with all activities of daily living ((ADLS) grooming, mobility etc.). A review of Resident 1's history and physical (H/P), dated 12/27/18, indicated the resident did not have the capacity to understand and make decisions. A review the GACH's laboratory record, dated 12/24/18, indicated Resident 1 had a low [MEDICATION NAME] ([MEDICATION NAME]) level of 1.0 mcg/dl (NRR-10 to 20 mcg/dl). A review of the admission orders [REDACTED]. A review of Resident 1's Care Plan, dated 12/27/18 and titled, [MEDICAL CONDITION] Disorder indicated for the staff to administer the anti-[MEDICAL CONDITION] medications as ordered and monitor for signs of adverse effects. A review of a physician's order, dated 1/15/19 and timed at 1 p.m., indicated to discontinue Resident 1's previous order of [MEDICATION NAME] 100 mg and change to [MEDICATION NAME] 150 mg via [DEVICE] twice a day and a repeat the [MEDICATION NAME] level in one week. A review of [MEDICATION NAME] laboratory level results, dated 1/22/19, indicated Resident 1's [MEDICATION NAME] level was low at 5.2 mcg/dl. A review of a Resident 1's physician's order, dated 1/24/19 and timed at 1 p.m., indicated to discontinue the previous [MEDICATION NAME] 100 mg order and change to [MEDICATION NAME] 250 mg twice daily (for a total of 500 mg daily) and recheck the [MEDICATION NAME] level. A review of Resident 1's laboratory result, dated 1/31/19 indicated the [MEDICATION NAME] level was pending. However, after further review of Resident 1's clinical records, there was no documented evidence of a [MEDICATION NAME] level result for 1/31/19. A review of a nurses' note, dated 2/1/19 and timed at 6 p.m., indicated Resident 1's [MEDICATION NAME] laboratory level remained in pending status. According to the note, Resident 1 was observed to be in a somnolent (sleepiness or drowsiness) state. A review of MedlinePlus, an online pharmacy site, indicated under Poisonous Ingredient that [MEDICATION NAME] could be harmful in large amounts. The article indicated the symptoms of [MEDICATION NAME] overdose varied, but included confusion, coma, lethargy (a pathological (disease) state of sleepiness or deep unresponsiveness and inactivity), low blood pressure and sleepiness @ https:/medlineplus.gov/ency/article/ 2.htm A review of an untimed nurses' note, dated 2/2/19, indicated an inquiry was made to the laboratory regarding Resident 1's pending [MEDICATION NAME] level. According to the note, the laboratory's staff indicated that the [MEDICATION NAME] level results were completed within two-three days. A review of an untimed nurses' note, dated 2/3/19, indicated Resident 1's family member expressed concern about the [MEDICATION NAME] level results because of the resident's behavior. A review of a nurses' note, dated 2/4/19 and timed at 11:08 a.m., indicated the staff called the laboratory again regarding Resident 1's [MEDICATION NAME] level that was collected on 1/31/19. According to the note, the laboratory indicated that the resident's [MEDICATION NAME] level was rejected and since the family was concerned about the resident's behavior a STAT (immediate) [MEDICATION NAME] level was repeated. A review of a [MEDICATION NAME] laboratory result, dated 2/4/19 and timed at 1:19 p.m., and verified on the same day at 3:08 p.m., indicated Resident 1 had a critically high [MEDICATION NAME] level of 40 mcg/dl. A review of a nurses' note, dated 2/4/19 and timed at 1:30 p.m., indicated Resident 1's physician was notified of the abnormal [MEDICATION NAME] level results. A review of the Medication Administration Record (MAR), for the month of 1/2019, indicated [MEDICATION NAME] 150 mg/6 ml was administered to Resident 1 twice daily from 1/15/19 to 1/31/19. Another MAR, for the same month, indicated [MEDICATION NAME] 150 mg/6 ml was administered to Resident 1 twice daily from 1/15/19 to 1/24/19 and then discontinued on 1/24/19. According to the two MARs, Resident 1 received 800 mg of [MEDICATION NAME] a day, 300 mg more than prescribed, from 1/25/19 to 1/31/19 (7 days). A review of the MAR for the month of 2/2019 indicated [MEDICATION NAME] 250 mg was administered to Resident 1 twice daily from 2/1/19 to 2/4/19, for a total of 500 mg a day. A review of a physician's order, dated 2/4/19 and timed at 3:30 p.m., indicated to transfer Resident 1 to the GACH for further evaluation of a critical [MEDICATION NAME] level of 40 mcg/dl. A review of the GACH's Emergency Department note, dated 2/4/19 and timed at 6:20 p.m., indicated Resident 1's [MEDICATION NAME] level was critically high at 47.4 mcg/dl and Poison Control (provides expert treatment advice and assistance in case of exposure to poisonous, hazardous, and/or toxic substances) was notified. On 2/22/19 at 7:51 a.m., during a telephone interview, Resident 1's family member (FM 1) stated the resident had [MEDICATION NAME] toxicity due to the facility over medicating the resident. FM 1 stated she informed the Registered Nurse Supervisor (RNS) that Resident 1 had received too much [MEDICATION NAME], but the RNS indicated [MEDICATION NAME] had not been administered to Resident 1. On 4/9/19 at 8:10 a.m., during a concurrent interview and record review, Licensed Vocational Nurse 1 (LVN 1) stated she administered [MEDICATION NAME] 150 mg/6 ml to Resident 1 at 9 a.m., on 1/16/19, 1/21/19, 1/22/19, 1/25/19, 1/26/19, 1/27/19, 1/28/19, 1/30/19 and 1/31/19 and denied administering 250 mg of [MEDICATION NAME] to Resident 1. However, during the interview and record review of the Resident 1's MAR, LVN 1 confirmed her initials indicating she administered [MEDICATION NAME] 250 mg at 9 a.m. on 1/25/19, 1/26/19, 1/27/19, 1/28/19, 1/30/19 and 1/31/19. On 4/9/19 at 9:06 a.m., during an interview, the Director of Nursing (DON) stated Resident 1's [MEDICATION NAME] order for 1/24/19 to receive 250 mg BID was not located until later. The DON stated that they made an effort to cover themselves and documented on the MAR. On 4/11/19 at 1:20 p.m., during a telephone interview, LVN 2 stated he administered 150 mg of [MEDICATION NAME] to Resident 1 on 1/17/19 and 1/21/19 and denied administering the resident 150 mg of [MEDICATION NAME] on 1/30/19 and 1/31/19. LVN 1 stated he administered 250 mg of [MEDICATION NAME] on 1/30/19, 1/31/19. LVN 1 was asked about his initials on the MAR for 1/30/19 and 1/31/19, indicating he administered 150 mg and 250 mg of [MEDICATION NAME] to Resident 1, LVN 1 stated he possibly made a mistake initialing. A review of the facility's revised policy, dated 1/1/12 and titled, Medication, indicated medication and treatments will be administered as prescribed to ensure compliance with dose guidelines. The Licensed Nurse will chart the drug, time administered and initial his/her name with each medication administration and sign full name and title on each page of the Medication Administration Record (MAR). Initials may be used, provided that the signature of the person administering the medication or treatment is also recorded on the medication or treatment record. A review of another facility policy, dated 8/1/10 and titled, Specific Medication Administration Procedures ([MEDICATION NAME] Administration via Feeding Tube), indicated the nurse would observe for signs and symptoms of sub-therapeutic levels, which may include breakthrough [MEDICAL CONDITION] as well as signs of toxic levels which may include drowsiness and dizziness.

Based on interview and record review, the facility failed to ensure residents were free of verbal abuse for one of one sampled residents (Resident 1). A Certified Nursing Assistant 1 (CNA 1) was overheard by Housekeeper 1 being verbally and physically abusive to Resident 1. This deficient practice resulted in Resident 1 being verbally and physically abused. Findings: On (MONTH) 28, (YEAR), at 4:05 p.m., Resident 1 was observed sitting in a chair, in the activity room. Resident 1 was unable to answer questions when asked. A review of Resident 1's Admission Records indicated the resident was admitted to the facility on (MONTH) 14, (YEAR), and last readmitted on (MONTH) 5, (YEAR). Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a standardized resident assessment and care-screening tool, dated (MONTH) 1, (YEAR), indicated Resident 1 had severe cognitive impairment (never/rarely made decisions). The MDS indicated Resident 1 was unable to say the correct year, month, and day. A review of Resident 1's Social Work Progress Note, dated (MONTH) 19, (YEAR), and timed at 10:52 a.m., indicated Housekeeper 1 reported to Social Service Staff (SSS 1) that she witnessed a female nurse, Certified Nursing Assistant 1 (CNA 1), speaking inappropriately to Resident 1. The note indicated CNA 1 grabbed the resident by the elbow in an aggressive manner to redirect him to his room. According to the note, this incident happened at 6:20 a.m., on (MONTH) 19, (YEAR) when CNA 1 observed Resident 1 wandering the hall naked. The note indicated CNA 1 was upset, frustrated, and stated to Resident 1, I don't have time for you, get your naked a-- in the room. This is not my job to be chasing you. During an interview, on (MONTH) 18, (YEAR) at 11:15 a.m., Housekeeper 1 stated on (MONTH) 19, (YEAR), at 6:20 a.m., she witnessed CNA 1 telling Resident 1 to .get your a-- in the room and lay down. On (MONTH) 18, (YEAR) at 11:30 a.m., a telephone interview with CNA 1 was attempted unsuccessfully without a return call. A review of CNA 1's employee file indicated the cna was hired on (MONTH) 14, (YEAR), and terminated on (MONTH) 20, (YEAR). There was no indication for CNA 1's termination documented. A review of the facility's policy titled, Resident Rights, revised (MONTH) 1, 2012, indicated the facility staff were to speak respectfully to residents at all times. The policy indicated demeaning practices and standards of care that compromise dignity are prohibited. A review of the facility's policy titled, Abuse Prevention, dated (MONTH) 6, (YEAR), indicated the facility does not condone any form of resident abuse, and verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms directed to residents regardless of their disability to comprehend.

Based on interview and record review, the facility failed to ensure one of one sampled residents (Resident 1) was free from physical and mental abuse by failing to ensure that Certified Nursing Assistant 1 (CNA 1) did not physically restrain Resident 1 in bed, while making kissing gestures. The deficient practice resulted in Resident 1 being abused, with sexual inappropriate behavior while being restrained, feeling helplessness, disrespected and upset. Findings: A review of Resident 1's Admission Record indicated the resident was admitted to the facility on (MONTH) 23, (YEAR). Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a comprehension screening and care assessment tool, dated (MONTH) 28, (YEAR), indicated the resident's cognition (ability to think and reason) was intact with a Brief Interview for Mental Status (BIMS) score of 15 (13-15 = interviewable). On (MONTH) 1, (YEAR) at 4:20 p.m., during an interview, Resident 1 stated he and CNA 1 were at odds about the bed controls for sometime . Resident 1 stated on the day of the incident (October 18, (YEAR)), CNA 1 was talking to him in a high-toned voice. Resident 1 stated he was lying on his back in bed with his arms crossed when CNA 1 put her weight on his arms where he was unable to move. Resident 1 stated that he asked CNA 1 to get off him, instead she kept pushing him down with more force. Resident 1 stated CNA 1 told him that since he had not been with a girl, he needed to be kissed. Resident 1 stated CNA 1 then made lip smacking gestures at him, while holding him down and he was unable to move. Resident 1 stated he felt helpless and was upset because he never seen a nurse do anything like this to anyone. During an interview on (MONTH) 14, (YEAR), at 3:40 p.m., the Social Services Director (SSD) stated Resident 1 reported to her that on (MONTH) 18, (YEAR), CNA 1 was being disrespectful towards him. The SSD stated she reported the incident to the Director of Nursing (DON) and the Director of Staff Development (DSD). A review of the facility's S[NAME] 341 (confidential elder abuse form), dated (MONTH) 20, (YEAR), indicated Resident 1 reported to the SSD that CNA 1 used her elbows on his shoulders to pin him down while stating, you're just mad because I didn't want to kiss you, while smooching at him. Resident 1 stated he tried to fight her off but could not because he was restrained. According to the report, Resident 1 pointed directly to CNA 1 and stated, I want to report her. The SSD walked out from Resident 1's room to the nursing station and CNA 1 followed her and stated, Can you believe that he (Resident 1) just made all that s--t up? The SSD told CNA 1 that the alleged abuse had to be reported and investigated, CNA 1 got upset and began to speak in a loud and aggressive tone of voice, stating, I don't need this s--t, f--k this patient and f--k this job. According to the report, the DON and the DSD spoke to CNA 1 and asked her to leave the facility. CNA 1 was suspended immediately and terminated on (MONTH) 21, (YEAR). A review of the facility's undated CNAs job description indicated the CNA must have patience, tact, as well as the ability to handle residents based on whatever maturity level they are currently functioning. A review of the facility's undated policy titled, Resident Abuse, indicated abuse of an elderly included physical abuse (unreasonable physical constraint), neglect, intimidation, cruel punishment, fiduciary abuse, abandonment, or other treatment with resulting physical harm, pain, mental suffering or the deprivation by a care custodian of goods and service which are necessary to avoid physical or mental suffering.

Based on observation, interview and record review the facility failed to provide a safe environment for one of 19 residents R 104. Resident 104's left arm was lying on exposed live wire and had fallen twice from a hoyer lift. These failures had the potential to cause serious bodily injury and electrocution. Findings: Resident 104 was re-admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. During observations on 12/09/17 at 9:15 a.m., Resident 104 was observed in bed with his left arm resting on unraveled bedside call light wires in the presence of maintenance (MT) and registered nurse (RN 2). They both witnessed and verified that bedside call light wires were exposed. Resident's left arm was observed as flaccid (without tone) and left leg contracted. In a concurrent interview, MT stated the exposed wires had electricity flowing through them and was dangerous because the resident could get shocked or electrocuted. RN 2 further stated the resident was paralyzed on the left side and was unable to move his arm off the exposed wiring side. During an interview on 12/09/17 at 9:58 a.m., certified nurse assistant (CNA 1) also confirmed that the call light wires were exposed. CNA 1 further stated that the frayed wires could tear, scratch, or cause an electricity injury. During a telephone interview on 12/09/17 at 4:52 p.m., Resident 104's responsible party stated the resident fell through the hoyer lift twice. The resident's responsible party also stated the resident sustained [REDACTED]. On 12/10/17, 9:03 a.m., the resident's responsible party contacted writer at the facility and stated after looking into his notes, the resident had one fall from the hoyer lift. During an interview on 12/10/17, at 7:40 a.m., the Director of Staff Development (DSD) stated when resident falls from a hoyer lift , the hoyer lift is removed from operation and maintenance would be asked to inspect it. DSD also stated the resident will be assessed and is continuously monitored for any decline, and physician notified of the incident. Director of Nursing (DON) confirmed the resident fell from the hoyer lift. During an interview on 12/10/17, at 7:54 a.m., one of the resident's roommate stated his room mate fell from the hoyer lift. The resident's roommate also stated the tall machine was was swaying and the resident looked drowsy. The Resident's roommate further stated a male and a female helped place the Resident 104 back in bed using the tall lifting machine. During an observation and interview on 12/10/17, at 12:37 p.m., Maintenance Supervisor (MS) hoyer lifts maintenance were inspected every six months. MS also stated hoyer lift maximum weight was 400 pounds (lbs) and the check list included; bolts, any signs of wear and tear, boom and mast were firmly attached, sling in good condition. MS also stated it was very important the hoyer lift battery remained charged every night to prevent accidents. MS further stated no one had reported that Resident 104 fell from the hoyer lift and therefore the hoyer was not inspected for possible cause for the fall. During review of the facilities employee files disclosed at 8:02 a.m., CNA 3 had attended hoyer lift training session. During observation on 12/10/17, 1:00 p.m., in the presence of DSD, CNA 1 and Restorative Nurse Assistant (RNA) transferred Resident back to bed from gerichair using a hoyer lift. RNA operated the hoyer lift but failed to lock the brakes on the hoyer lift before resident was suspended in the air. Hoyer lift shifted towards the wall when resident was being lowered in the bed. In a concurrent interview, RNA stated hoyer lift should have bee locked before transferring resident to ensure resident safety but forgot to do so. A review of the facility's undated policy titled Accident Prevention and Management indicated every employee was to be involved in observing and identifying potential hazards in the environment, focusing on the abilities and vulnerabilities.

Based on interview and record review, the facility failed to identify the cause of skin rashes for four of 50 sampled residents (Residents 1, 2, 3, 4), who developed skin rashes while residing in the facility from September 2016 to December 2016. As a result, Resident 1's family member contracted scabies and was diagnosed by her physician to have scabies. Also, Resident 1, 2, 3 and 4 had not received appropriate treatment for [REDACTED]. Additionally, the facility failed to ensure and maintain accurate infection control practices and surveillance for Resident 1, 2 , 3, and 4, who had a rash for more than 90 days, which was not responding to treatment and had not been seen by a Dermatologist and was not tested for scabies. Additionally, the facility's DSD, licensed nurses LVN 3, LVN 4 and LVN 5, who were aware of the skin conditions of the residents failed to follow-up with the Dermatologist, as indicated in the facility's policy. Additionally, the MD 1 failed to wash his hands before and after direct contact with Resident 1, 2, 3 and 4. Also, the facility failed to follow its policy for Prevention and Control of Scabies in California in Longterm Facilities by failing to report an outbreak (Two or more confirmed cases or one confirmed case and at least two suspected case) of suspected cases to the Department. These deficient practices had the potential to result in ineffective control of the transmission of scabies and a lack of immediate action and placed all residents, staff, and visitors at risk of exposure to scabies. Findings: On 12/1/16, an unannounced visit was made to the facility to investigate allegations the facility is not addressing or correcting the problem of scabies. The allegations indicate staff, visitors and residents have contracted scabies. A review of the admission record indicated Resident 1 was originally admitted to the facility on [DATE], and re-admitted on [DATE], with [DIAGNOSES REDACTED]. A review of the Minimum Data Set- (MDS - a comprehensive assessment and care screening tool) dated 11/16/16, assessed Resident 1 as having intact cognitive patterns were required extensive to total dependence with one to two person physical assistance with transfers, dressing, toilet use and personal hygiene. A review of the admission skin assessment dated [DATE], indicated Resident 1 had an upper back rash. A review of a plan of care for Resident 1 titled Skin Rash dated 9/2/16, included to administer treatment as ordered, monitor rash and advise the physician of progress and/or complications, and obtain a dermatologist consultation and follow-up as needed. A review of the physician's orders [REDACTED]. A review of the physician's progress notes dated 9/7/16 indicated Resident 1 had a rash with raised [DIAGNOSES REDACTED]tous papules (patches of redness) to the entire trunk (upper body), upper extremities (arms and legs) and was pruritic (itching). The physician's documented plan indicated Resident 1's body rash was suspected (suspicious) of scabies, and to treat the resident with [MEDICATION NAME] (an anti-parasitic medication that paralyze and kill mites and their eggs) cream including an additional treatment and the plan suggested to treat the roommates (Resident 2 and Resident 3) as well. A review of the physician's orders [REDACTED]. A review of the nurses' notes dated from 9/2/16 to 9/7/16 indicated Resident 1's skin was warm and dry to touch. On 9/8/16, between 3 p.m. to 11 p.m., Resident 1 received [MEDICATION NAME] treatment. A review of Resident 1's treatment records indicated the resident was treated for [REDACTED]. Additionally, the treatment record indicated Resident 1 was treated with [MEDICATION NAME] on 9/8/16 and again on 9/22/16. A review of the physician's orders [REDACTED]. A review of the nurses' notes dated 10/3/16, at 9 a.m. indicated Resident 1's back rashes were improving but had not resolved. A review of the physician's orders [REDACTED]. Further review of Resident 1's treatment records indicated the resident was treated for [REDACTED]. The treatment record indicated the treatment was resolved on 10/14/16. A review of the nurses' notes on the following dates: 10/6/16, 10/12/16, 10/13/16, 10/17/16, 10/18/16, 10/19/16 and 10/20/16 indicated that Resident 1 had a general body rash. After further review there was no treatment record for November 2016 for Resident 1. A review of the nurses notes titled change of condition dated 11/12/16 for the 3 p.m. to 11 p.m. shift indicated Resident 1 had red bumps to the left hand and bilateral (both sides) underarms. A review of the nurses' notes dated 11/16/16 for the 11 p.m. to 7 a.m. shift, indicated Resident 1's red bumps to the left hand and both underarms were in the healing process. A review of the physician's orders [REDACTED]. However, there was no documented evidence the Dermatologist consult was ever done. A review of the nurses' weekly summary for Resident 1 for the following dates: 8/31/16 thru 9/7/16, 9/7/16 thru 9/14/16, 9/14/16 thru 9/21/16, 9/28/16 thru 10/5/16 and 11/16/16 thru 11/23/16 indicated there was no documented skin assessment, but there was a notation to refer to the treatment book. A review of Resident 1's Surveillance Data Collection Form, completed by the DSD dated on 12/2/16, indicated the resident had no current maculopapular (red, flat area of the skin covered with bumps) and/or itching rash. During an interview on 12/1/16, at 8:30 a.m., the Director of Staff Development (DSD) stated there is no documentation in the facility's surveillance infection log indicating Resident 1 had a rash or suspected scabies and stated Resident 1 should have been added to the surveillance log. The DSD stated that she was informed by Resident 1's family member (FM 1) two to three weeks prior that the resident had a history of [REDACTED]. During an interview on 12/1/16 at 1:55 p.m., Licensed Vocational Nurse (LVN 4) stated Resident 1 had a red spotty rash on both arms two weeks ago and was treated. However no labs were performed to confirm scabies and she did not initially check the resident's skin. LVN 4 stated Resident 1's FM 1 took the resident to her private dermatologist. She further stated she did not follow-up on the facility's dermatology consult order dated 11/22/16. LVN 4 further stated that Resident 1 was not placed on contact isolation during that time. During an interview on 12/1/16, at 3:00 p.m., LVN 3 (treatment nurse) stated that she would notify the physician about any resident with a rash or suspected scabies. She further stated if the rash was not improving she would suggest a dermatology consult for further skin evaluation. LVN 3 further stated that Resident 1's family member had taken the resident to an outside dermatologist and had no knowledge of the outside dermatologist results and was not sure if a skin scrapping were performed. LVN 3 was asked if Resident 1 currently had a rash and was seen by a dermatologist, LVN 3 stated No and stated Resident 1 was not receiving skin treatment for [REDACTED]. When asked if any employees involved with the resident's care were treated [MEDICATION NAME], LVN 3 stated all employees were offered [MEDICATION NAME] treatment, but had never received the treatment. During an interview on 12/2/16 at 7:40 a.m., LVN 5 stated that Resident 1 had a red itchy rash on her stomach and left arm last month (November) and was treated with a cream that is placed on the entire body at night then showered off in the morning. LVN 5 stated that she was not aware of any other residents with skin rashes. LVN 5 further stated that she personally had developed a small red rash on her left wrist area, but believed that it was from laundry detergent. LVN 5 stated she was never offered [MEDICATION NAME] treatment and asked LVN 3 before leaving work on 12/1/16 about the bump on her left wrist. LVN 3 stated the bump on LVN 5's left wrist was similar to the rash on Resident 3. During a shower observation on 12/2/16 at 9 a.m., Resident 1 had no rash. During an interview on 12/2/16, at 2:16 p.m., LVN 3 stated that she should have followed-up on the findings, but did not. LVN 3 further stated she was responsible for performing weekly skin checks/sweeps on all residents and had stopped after the prior DON left the facility in July 2016. LVN 3 stated she was offered [MEDICATION NAME] treatment from the prior DON but never used it. During a telephone interview on 12/2/16 at 4:49 p.m., FM 1 stated initially Resident 2 had a bad rash, then Resident 1 developed a rash and a week after visiting Resident 1, FM 1 had developed a red and itchy rash all over her body and under her breast folds. According to FM 1's Dermatologist report dated 10/5/16, FM 1 had a confirmed case and [DIAGNOSES REDACTED]. During an observation on 12/3/16, at 3:45 p.m., the facility's dermatologist was observed performing a skin scrapping to Resident 1's right thigh. MD 1 failed to perform hand washing before and after direct contact. A review of the facility's policy dated 1/1/12 and titled Skin and Wound Management indicated the certified nurse assistants (CNA) will complete body checks on resident's on shower days and report unusual findings to the licensed nurse. Treatments for skin problems, wounds, and non-pressure ulcers will be assessed and documented by a licensed nurse. A licensed nurse will report any changes in the resident's skin condition to the attending physician, Director of Nursing Services (DNS), the interdisciplinary Team (IDT)-skin committee and the responsible party. The licensed nurse will document the status of all skin conditions at least weekly or as otherwise indicated in the resident s care plan, document all notifications following a change in the resident's skin condition and update the resident's care plan as necessary. b. On 12/2/16 at 8:01 a.m., Resident 2 (Roommate of Resident 1) was observed with a scattered red rash on the thighs, hands and feet. The resident's right hand and fingers were patchy and white. Resident 2 was observed scratching her left foot, left lower leg and right upper thigh. A review of the admission record indicated Resident 2 was re-admitted to the facility on [DATE] and on 11/25/16 with [DIAGNOSES REDACTED]. A review of the MDS dated [DATE] indicated Resident 2 had moderately impaired cognition and required limited and one person assistance with activities of daily living. A review of the physician's history and physical (H & P) for Resident 2 indicated the resident had generalized rashes characterized by dry, itchy patches and crusting on the following dates: 8/2/16, 8/3/16, 8/22/16, 9/8/16, 9/14/16, 9/22/16, 9/26/16 and 10/6/16. According to the H & P dated 10/17/16 the rashes had improved. A review of Resident 2's physician's orders [REDACTED]. 8/2/16-[MEDICATION NAME] 2.5 % cream twice a day to both upper arms for itching. 8/3/16-[MEDICATION NAME] 1 % cream twice a day to both upper arms for itching for 30 days. 8/3/16- Dermatology consult. 8/7/16- Apply A&D (vitamins A and D-a medicated ointment used to heal diaper/skin rash) cream three times a day and as needed for rashes and itching, Diagnosis: [REDACTED]. 8/17/16- Appointment with Dermatologist Dr. on 8/31/16 at 9:00 am. 8/23/16- General body dermatitis apply [MEDICATION NAME] 0.1 % cream every other day for 30 days and alternate with [MEDICATION NAME] and Praxomine (a topical medication used for itching that have a numbing effect). 9/7/16-[MEDICATION NAME] 5 % cream from neck to toes in pm, then shower in the am for [MEDICATION NAME] repeat in 14 days. 9/22/16-Generalized body rashes, apply [MEDICATION NAME] (a topical medication used for to relieve itching, redness, dryness, crusting, scaling, inflammation, and discomfort) 0.1% ointment daily for 30 days. 10/19/16-Generalized body rashes, apply [MEDICATION NAME] 0.1 % ointment on M-W-F, then [MEDICATION NAME] 0.5 % ointment on T-TH-S-Sun for 30 days. 11/21/16- Generalized body rashes apply [MEDICATION NAME] 0.1 % ointment daily for 30 days. 11/22/16- Dermatologist consult related to red bumps all over body. 11/30/16-Generalized body rashes apply [MEDICATION NAME] 0.5 % ointment daily for 30 days and [MEDICATION NAME] (medication used to treat allergic reactions) cream daily as needed. A review of the nurses' admission assessment dated [DATE] indicated Resident 2 had generalized body rashes to both arms and hands. An admission assessment dated [DATE] indicated Resident 2 had generalized body rashes from the head to the toes. Another admission assessment dated for 11/29/16 indicated that Resident 2 had a generalized dry and scaly rash. A review of the nurses' notes on the following dates indicated Resident 2: 9/8/16 timed at (3 p.m.11 p.m.) -Refused [MEDICATION NAME] treatment. 9/9/16 timed at (3 p.m.-11 p.m.)- Refused [MEDICATION NAME] treatment for [REDACTED]. 11/21/16 timed at 2 p.m. - The Physician discontinued [MEDICATION NAME][MEDICATION NAME] (medication that blocks allergic and inflammatory reactions) 25 milligrams (mg) by mouth every 6 hours as needed for itching. 11/21/16 at 9 p.m.-Generalized body rashes, improving but not yet resolved. 11/22/16 at 5 p.m.-Had red bumps all over body, physician notified, and dermatologist consult was ordered. The nurses' notes dated from 9/10/16 through 10/31/16, 11/30/16, 12/1/16 and 12/2/16 indicated Resident 2's skin was warm and dry to touch. A review of the treatment records dated for 8/10/16 indicated Resident 2 had a general body rash characterized by elevated red bumps with complaints of itching. On 8/3/16 through 8/22/16 the resident was treated with [MEDICATION NAME] 0.1 % cream twice a day and A&D ointment daily as needed for itching. On 8/23/16 through 8/30/16 Resident 2 was treated with [MEDICATION NAME] 0.1 % cream every other day to the body. A review of the treatment records dated 9/29/16 indicated Resident 2 had generalized, scattered, irritated, red flat skin rashes. According to the treatment record on 10/6/16 the resident's rash was improving well and on 10/13/16 the resident had multiple pinkish/brownish flat rashes. Resident 2's treatment record dated 11/21/16 through 11/30/16 indicated the resident was treated with [MEDICATION NAME] 0.1% ointment daily for generalized body rashes. A review of a nursing assessment document titled change of condition dated 11/22/16 and timed between 3 p.m.-11 p.m., indicated Resident 2 had red bumps on the left arm and hip area, and red areas on the left forearm. The resident had no complaints of pain or discomfort and the Dermatologist was consulted. Further review of the nurses notes titled change of condition dated 11/24/16 and timed between 3 p.m. - 11 p.m., Resident 2 had red raised spots and was itching. A review of Resident 2's Surveillance Data Collection Form, completed by the DSD, dated 12/2/16, indicated the resident had no current maculopapular and/or itching rash. A review of Resident 2 plan of care dated 8/2/16, and titled At Risk for Skin Break/Ulcer formation related to history of skin tears/ulcers/chronic dermatitis indicated to administer medication and treatment as ordered and monitor for effectiveness/delayed healing. Provide skin care frequently, obtain lab tests as ordered and monitor for signs and symptoms of infection. A review of a short term plan of care for Resident 2 titled Skin Rash and dated on 8/3/16 with a target date of 9/3/16 indicated the resident's rash will be resolved without complications daily within 30 days. The interventions were to administer treatment as ordered, monitor rash and advise the physician of progress and/or complications. Dermatological consultation and follow-up as needed and notify Dermatologist of non-response etc. A review of plan of care for Resident 2 titled Scabiesand dated on 9/7/16 indicted the resident will be free of scabies with intervention that included: provide [MEDICATION NAME] 5 % cream from the neck to the toes. Encourage and/or assist the resident with hand washing, check skin daily during care and notify the physician as necessary. Place the resident on contact isolation, wash all clothing and bed linen. Provide education to resident, responsible party and staff regarding special care needs. A review of another plan of care for Resident 2 dated on 9/22/16, 11/30/16 and titled Skin-Short Term Non-Pressure Ulcer for generalized body rashes the goals indicated skin condition will heal within 30 days and the resident will be free from further skin breakdown. The interventions included to administer medication and treatment as ordered and monitor for effectiveness. Provide good skin care and provide education to resident, responsible party and staff regarding special care needs. A review of another plan of care for Resident 2 titled Alteration in Skin Integrity: Generalized Rashes to the body and dated on 12/1/16 had no indicated interventions. During an observation on 12/3/16, at 3:45 p.m., MD 1 was observed performing Resident 2's skin scrapping to the resident's left hand. MD 1 failed to perform hand washing before and after resident care. During an interview on 12/1/16 at 1:55 p.m., LVN 4 stated Resident 2 had a generalized rash with red scratches and red bumps all over her body. LVN 4 stated that resident was readmitted to the facility several times and could not recall how long the rash existed. LVN 4 further stated the resident no longer have a rash. During an interview on 12/1/16 at 3:10 p.m., LVN 3 stated Resident 2 was sent to a GACH for skin evaluation six months ago. When asked of the skin evaluation results, LVN 3 stated I do not know. During an interview on 12/2/16 at 8:30 a.m., LVN 3 stated she had performed all treatments on Resident 2 ever since her admission to the facility. LVN 3 stated Resident 2' s have a generalized scattered flat, red rash all over her body. The resident's hands are patchy and white and improving. LVN 3 stated that no Dermatology consult was conducted due to a disconnected telephone number and the Dermatologist was no longer contracted with the facility. During an interview on 12/2/16 at 1:55 p.m., LVN 3 provided Resident 2's general acute care hospitals (GACH) dermatological report dated on 1/28/16 which indicated a [DIAGNOSES REDACTED]. LVN 3 further stated she was responsible for performing weekly skin checks/sweeps on all residents and stopped after the prior DON left the facility in July 2016. LVN 3 stated she was offered [MEDICATION NAME] treatment from the prior DON but never used it. During an interview on 12/2/16 at 2 p.m., the Director of Nurses (DON) stated there was no endorsement regarding scabies during her transition when acquiring the role of the facility 's DON. A review of the facility's 1/1/12 policy and procedure titled Skin and Wound Management indicated the IDT-Skin Committee would document discussion and recommendations for: i. Non-pressure ulcers, wounds and other skin conditions that do not respond to treatment. ii. Non-pressure ulcers, wounds and other skin conditions that worsen or increase in size. iii. Complaints of increased pain, discomfort or decrease in mobility by a resident. iv. Signs of ulcer sepsis, presence on exudates, odor or necrosis. v. Residents refusing treatment. A review of the admission record indicated Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the MDS dated [DATE] indicated the resident had no cognitive impairment and required extensive assistance from facility staff in dressing, toileting, and personal hygiene. A review of Resident 3's physician's orders [REDACTED]. 9/7/16 - apply [MEDICATION NAME] 5% cream from the neck to the toes in the pm, then shower in am for [MEDICATION NAME]. Repeat in 14 days. 9/23/16 - [MEDICATION NAME] (medication used to treat sneezing, runny nose, itching and other allergies [REDACTED]. 10/19/16 - apply [MEDICATION NAME] 0.1% ointment every day for 30 days. A review of the nurse's admission notes dated 10/18/16 indicated Resident 3's skin was dry/flaking, warm and dry to touch. A review of the Non-Pressure Sore Skin Problem Report dated 10/19/16 indicated Resident 3 had scattered, white pinkish/brownish flat generalized body rashes. A review of the Weekly Skin Progress Report on the following dates indicated: 10/26/16 - Multiple red spots, some brownish old skin from rashes. Improved. 11/2/16 - Improved, less rashes noted. 11/10/16 - Resolving 11/15/16 - Resolved A review of Resident 3's treatment record dated 9/7/16 and 9/22/16 indicated the resident was treated with [MEDICATION NAME] 5% cream from the neck to the toes in the evening (pm), then shower in the morning (am) for [MEDICATION NAME]. Repeat in 14 days. A review of Resident 3's treatment record dated 9/22/16 through 9/30/16 indicated the resident was treated with [MEDICATION NAME] 0.1% ointment and leave open to air (LOA) every day for generalized multiple white patchy skin. Resident 3's treatment record dated 10/1/16 through 10/31/16 indicated the resident was treated with [MEDICATION NAME] 0.1% ointment and LOA every day for generalized multiple white patchy skin. A review of Resident 3's treatment record dated 10/19/16 indicated the resident had generalized body rashes and perianal irritation. Upon further review there was no treatment record for the month of November 2016 in Resident 3's clinical record. A review of Resident 3's Surveillance Data Collection Form, completed by the DSD, dated 12/2/16, indicated the resident had no current maculopapular and/or itching rash. A review of Resident 3's care plan dated 9/7/16 and titled Pruritus/Itching indicated the resident had itching related to an unknown cause. Interventions included assess/observe for itching/persistent rubbing or scratching of the skin, applying [MEDICATION NAME] creams or ointments frequently to prevent dryness, administer medication/treatment as ordered, report to MD for related changes in condition. [MEDICATION NAME] 5% cream one time as [MEDICATION NAME]. During an observation on 12/3/16 at 8:55 a.m., LVN 2 was observed giving CNA 6 [MEDICATION NAME] 5% cream to apply to Resident ' s 1, 2, and 3. During an observation on 12/3/16, at 4:05 p.m., the facility's Dermatologist was observed performing skin scrapping on Resident 3's right thigh. The Dermatologist did not perform hand washing before or after direct resident care. During an interview on 12/1/16 at 2:45 p.m., Resident 3 stated that she was admitted to the facility in August 2016. The resident stated that she did not have a rash at the time of admission but developed a bumpy rash all over her back, buttocks and body two weeks after admission to the facility, due to Resident 1 who had a rash and was itching like crazy and is currently itching. Resident 3 stated that she was not in direct contact with Resident 1; however we used the same shower room. Resident 3 further stated that she was treated with two different types of cream and currently using the prescribed cream to her body. The resident stated she requested to be seen by a dermatologist and was inquiring about the prescribed body cream, and was told by LVN 3 that the facility's dermatologist will return to the facility next year (2017). Resident 3 stated that she had asked if the facility would check her labs, perform a skin scraping or skin cultures, LVN 3 stated No. The resident stated that she did not receive any body inspections and continues to have a rash with itching. During an interview, on 12/1/16, at 3:15 p.m., LVN 3 stated that Resident 3 did not have scabies skin scrapings. LVN 3 stated that Resident 3 had not been seen by a Dermatologist and was aware of the facility's policy indicated to refer to a dermatologist for a skin assessment with a [DIAGNOSES REDACTED]. During an interview on 12/2/16 at 7:40 a.m., LVN 5 stated that she believed that Resident 3 had complaints of a rash but did not have a rash in November 2016. LVN 3 further stated that Resident 3 revealed a rash to her during the night 12/1/16. During an interview on 12/2/16 at 2:16 p.m., LVN 3 stated that she should have followed-up on the findings, but did not. LVN 3 further stated she was responsible for performing weekly skin checks/sweeps on all residents and stopped after the prior DON left the facility in July 2016. LVN 3 stated she was offered [MEDICATION NAME] treatment from the prior DON but never used it. During an interview on 12/3/16 at 8:59 a.m., Resident 3 stated she was itchy all over her body. During an interview on 12/4/16 at 7:00 p.m., Resident 3 stated she was still itching and cream applied to her body on 12/3/16, which she then showered off. A review of Resident 4's admission record indicated the resident was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the MDS dated [DATE] indicated Resident 4 had mild cognitive impairment and required limited assistance with one person physical help in performing activities of daily living (ADLs) such as dressing, toileting, eating, and bathing. A review of Resident 4's physician's orders [REDACTED]. 9/26/16 - Apply A&D ointment daily to Resident 4's lower legs for two weeks for dry skin. 11/3/16 - Apply [MEDICATION NAME] 0.05% ointment daily for three days for a generalized body rash and multiple red spots. 11/22/16 - Dermatologist consult related to red bumps noted all over the body. 12/2/16 - Appointment with Dr. (Dermatologist) on 12/9/16 at 10:15 a.m. A review of Resident 4's Nursing Care Notes dated 11/22/16 indicated a call was placed to the MD to notify of red bumps all over the residents body. MD ordered dermatologist consult. A review of Resident 4's Change of Condition Notes dated 11/22/16 indicated the resident was monitored every shift from 11/23/16 11 p.m.-7 a.m. shift through 11/25/16 7-3 shift for red bumps and marks on the body and lower legs. A review of the nurses' Weekly Summary for Resident 4 between the following dates: 7/6/16 thru 7/13/16, 7/13/16 thru 7/20/16, 7/20/16 thru 7/27/16, 7/27/16 thru 8/3/16, 8/3/16 thru 8/10/16, 8/10/16 thru 8/17/16, 8/17/16 thru 8/24/16, 8/24/16 thru 8/31/16, 8/31/16 thru 9/7/16, 9/28/16 thru 10/5/16,10/5/16 thru 10/12/16, 10/12/16 thru 10/19/16, 10/19/16 thru 10/26/16, 10/26/16 thru 11/2/16, 11/2/16 thru 11/9/16, 11/9/16 thru 11/16/16, 11/16/16 thru 11/23/16, and 11/23/16 thru 11/30/16 there was no documented skin assessment, but there was a notation to refer to the treatment book. A review of Resident 4's Treatment Record indicated the resident was treated with A&D ointment to both legs for dryness on 9/26 through 9/30/16. A review of the Treatment Record indicated Resident 4 was treated with Flucocimide 0.05% ointment and LOA daily from 11/3 through 11/30/16 for generalized body rash with multiple red spots. A review of Resident 4's Surveillance Data Collection Form, completed by the DSD, dated 12/2/16, indicated the resident had no current maculopapular and/or itching rash. A review of Resident 4's care plan dated 10/5/15, revised on 10/16, titled Skin indicated to administer medication and treatment as ordered and monitor for effectiveness/delayed healing, care and reposition with care rounds, provide activities that allow for skin improvement, provide skin care frequently, and clean resident's skin after each episode of incontinence. During a shower observation on 12/2/16 at 1:40 p.m., Resident 4 was observed with a red rash to arms, legs, back, breasts, and stomach. During an interview on 12/2/16, at 2:16 p.m., LVN 3 stated that she should have followed-up on the findings, but did not. LVN 3 further stated she was responsible for performing weekly skin checks/sweeps on all residents and stopped after the prior DON left the facility in July 2016. LVN 3 stated she was offered [MEDICATION NAME] treatment from the prior DON but never used it. During an observation on 12/3/16, at 3:55 p.m., MD 1 was observed performing Resident 4's skin scrapping to the resident's left forearm. MD 1 failed to perform hand washing before or after resident contact. During an observation on 12/4/16, at 1:20 p.m., CNAs 2, 7, and 8 were observed inside Resident 4's room wearing gowns and gloves. CNA's 2, 7, and 8 inquired if they were allowed to step into the hallway to transport the resident to the shower. They stated they never received an in-service and were unaware of the facility's infection control policy and procedures. During an interview with CNA 2 on 12/2/16 at 1:45 p.m., CNA 2 stated the facility was making her give Resident 4 a shower every day since the end of October for the rash. During an interview on 12/2/16 at 1:55 p.m., LVN 3 stated Resident 4 had an improved spotted, pink colored rash for a month. LVN 3 stated the resident was not pending dermatology appointment but had received ointment and daily showers. A review of the facility's 1/1/12 policy and procedure titled Skin and Wound Management indicated the licensed nurse would document the status of all skin conditions at least weekly or as otherwise indicated in the resident's Care Plan and update the resident's Care Plan as necessary. During a face to face interview on 12/2/16 at 12:30 p.m. CNA 1 stated that she started itching around the first week in October 2016 after caring for Resident 2. CNA 1 stated that she had a rash under her breast, over her entire back, both wrist and ankles. Observed two evenly lined, discolored red spots on the CNA 1's right wrist. CNA1 stated that she was informed by LVN 3 that Resident 2 did not have scabies because she had been tested for scabies. However, the previous nurse who cared for Resident 1 had tested positive for scabies. During an interview on 12/2/16 at 12:55 p.m., CNA 2 stated that she began working at the facility on 9/20/16. Soon after working at the facility, CNA 2 stated that she developed small black spots on her left arm, right wrist, under h

Based on observation, interview, and record review, the facility failed to ensure a resident with respiratory problems was provided a thorough respiratory assessment, was assessed by a registered nurse (RN), was provided care according to the care plan and resident's wishes, and failed to follow their policies and procedures regarding proper notification for critical test results for one of 14 sampled residents (Resident 8). Resident 8 had coughing and congestion that prompted the licensed nurse to notify the physician, however there was no thorough respiratory assessment conducted. Resident 8 was not provided treatment as indicated in the Physician order [REDACTED]. The resident was identified having congestion and was coughing at 3:30 p.m. on [DATE], and expired at 10:56 p.m., a total of seven hours without the medical interventions in accordance with the POLST. The facility also failed to follow their policies and procedures regarding providing care for a resident in [MEDICAL CONDITION] and for performing cardio-pulmonary resuscitation (CPR) on one of 14 sampled residents (Resident 13). A code blue emergency was called when Resident 13 was discovered unresponsive, not breathing and without a heartbeat. During the resuscitation attempt the facility staff did not administer oxygen support until two minutes after the CPR was started, did not monitor the resident's oxygen saturation level, and did not ensure proper hand placement for chest compressions. A situation of Immediate Jeopardy (IJ) was declared by the survey team on [DATE], at 3:40 p.m., with the administrator. On [DATE], at 2 p.m., the IJ was abated with the administrator after the facility provided a written plan of correction (POC) that included the following actions: The Nurse Consultant, DSD, and DON began conducting inservices to all of the facility's nursing staff on the following policies, procedures and protocols: --POLST/DNR/Emergency, respiratory assessment,comfort measures, change of condition, administering oxygen, [MEDICATION NAME] within scope of practice, and code blue drills. The POC included a copy of the lesson plan outlining the information included in the inservices, a copy of all relevant and updated facility policies, a copy of professional materials reviewed when updating the policies, samples of each form to be reviewed, and a signature list of all staff inserviced up to that point. Trainings started on [DATE], and would continue until all relevant facility staff have been inserviced. --All in-house residents with DNR orders and/or on oxygen therapy were to be reviewed by licensed staff to ensure the residents' needs are met and care planned, and their individual wishes communicated. The POC included copies of updated interdisciplinary team conference records (IDT) for each resident. In addition, the POC indicated a review would be conducted on each resident on admission, quarterly, annually, and upon identification of a significant change in condition. To be completed by [DATE]. --On a weekly basis the DON would select five random residents with a DNR order, respiratory condition, and/or on oxygen therapy to review for compliance with all relevant policies and procedures. --The facility's nurse consultant would conduct random reviews on three residents records to ensure the facility's licensed nurses were documenting care provided within the scope of their practices and obtained physician orders [REDACTED]. --For each resident the POLST form would consistently be filed in the clinical record under the tab "POLST", located immediately behind the facesheet, and all staff inserviced on the proper location for the POLST form. The POC included a signature list of all staff inserviced up to that point. To be completed by [DATE]. The POC was accepted by the survey team and the immediate jeopardy lifted on [DATE], at 4:15 p.m. The facility failed to ensure resident's medications were ordered by a physician for one of 14 sampled residents (Resident 9). The DON gave the order to discontinue [MEDICATION NAME] (a narcotic pain reliever) medication to LVN 9 when the facility staff could not get the [MEDICATION NAME] order renewed from the resident's physician. LVN 9 knowingly that the order did not come from the resident's physician, wrote the order in the physician's orders [REDACTED]. This practice is prohibited under State law and had caused Resident 9 not receiving pain medication that could relieve her severe pain. Findings: 1. A review of Resident 8's admission records indicated she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment and care screening tool, dated [DATE], indicated Resident 8 usually understood others and was usually understood by others. The resident required total assistance from staff with her activities of daily living except for eating in which the resident required limited assistance (staff provides guided maneuvering of limbs or other non-weight bearing assistance). The resident had functional limitation in range of motion ((ROM) the extent of movement of a joint) to both upper and lower extremities. A review of the Physician order [REDACTED]. A review of Resident 8's POLST dated [DATE], indicated the resident's wishes included: Do not attempt resuscitation (allow natural death). The section Medical Interventions (if person has pulse and/or is breathing), Limited Additional Interventions indicated "In addition to care described in Comfort Measures Only, use medical treatment, antibiotics, and intravenous (IV) fluids as indicated." The section for Comfort Measures Only indicated to use "oxygen, suction, and manual treatment of [REDACTED]." Review of the Nurses' Progress Notes (notes) dated [DATE], at 3:30 p.m., indicated Resident 8 was awake, alert, verbally responsive and was coughing and congested. Vital signs were: Blood pressure (BP) was ,[DATE] millimeter mercury ((mmHg) normal adult reference range: less than ,[DATE]), pulse rate (PR) was 80 beats per minute (normal adult resting reference range: 60 - 100), respiration rate (RR) was 19 breaths per minute (normal adult reference range: 8 to 16) and temperature (T) was 98.4 degrees Fahrenheit ((?F) normal adult reference range: 98.6?F). The physician was notified and ordered a chest x-ray stat (now) and a laboratory test for complete blood count (CBC). There was no documented evidence of an assessment of the resident's lung sounds by auscultation (listen to the resident's lungs with a stethoscope) and oxygen saturation (a sensor placed on the finger to monitor the percentage of oxygen in the blood). There was no documented evidence the resident was provided with supplemental oxygen as needed. At 5:30 p.m., (two hours later) the notes indicated Resident 8 was awake, alert, verbally responsive, still slightly congested and respirations were unlabored (not having difficulty breathing). The resident ate dinner and consumed 80%. There was no documentation of the status of the resident's vital signs, the quality of breath sounds, the oxygen saturation or the provision of supplemental oxygen. At 7:30 p.m., (four hours later) the notes indicated Resident 8 was in bed with the head of the bed elevated. The resident was awake, alert, verbally responsive, with cough and congestion. Vital signs were: BP-,[DATE], PR-81, RR-19, and T-98.8. There was no assessment of breath sounds, oxygen saturation and provision of supplemental oxygen. At 9:02 p.m., the notes indicated the result of the chest x-ray revealed lower left lung pneumonia (bacterial infection of the lungs, common symptom is cough and may cause a decrease in the flow of oxygen to the blood). The physician was called with no response. The X-ray result was faxed to the physician. At 9:30 p.m., the notes indicated Resident 8 was in bed with the head of the bed elevated, was still verbally responsive, with cough and congestion. Awaiting response from the physician. There was no documented evidence of an assessment of the resident's vital signs, lung sounds, oxygen saturation, and provision of supplemental oxygen as needed. At 10:30 p.m., the notes indicated the licensed vocational nurse (LVN 1) was notified by a certified nursing assistant (CNA) that Resident 8 was unresponsive and a CODE (emergency response) was called. Paramedics arrived and pronounced the resident dead at 10:56 p.m. The physician was notified. On [DATE], at 5 p.m., during an interview with LVN 1 regarding Resident 8's change of condition on [DATE], at about 3:30 p.m., she stated Resident 8 had a physician's orders [REDACTED]. She stated she did not provide oxygen to the resident because the resident "did not seem like she was sick" and she did not check the resident's oxygen saturation level. LVN 1 stated she heard the resident congested but she did not think to auscultate or assess the resident's lungs. LVN 1 did not comment why she did not call the physician again, the director of nursing (DON 1), or the Medical Director when the physician had not called back. On [DATE], at 7:40 a.m., during an interview, LVN 3 stated that for the assessment of a resident who was congested, she would listen to the lungs, give oxygen if needed after assessment and give a hand held nebulizer treatment ((HHN) a small device for administering medication for treatment of [REDACTED]. LVN 3 also stated the medical director can be called if the resident's physician does not return the call and the resident can be transferred to the hospital via 911 in an emergency if unable to contact the physician. On [DATE], further interviews were conducted to verify licensed nursing staffs' knowledge of the proper procedure to follow when a resident had respiratory problems, which revealed: At 12:10 p.m., LVN 6 stated she would observe the chest movement, respiratory rate, check oxygen saturation and if low to call the physician, auscultate the lungs, and look at the [DIAGNOSES REDACTED]. At 12:15 p.m., LVN 19 stated a resident with restlessness, shortness of breath, anxious, congestion with gurgling sounds, she stated she would check the resident's position, check oxygen saturation and if less than 90%, check for orders for oxygen, if there was no order for oxygen, it can be started at 2 liters per minute and then call the physician. At 3:15 p.m., the registered nurse (RN) supervisor stated a resident with congestion can be given oxygen and a pulse oximeter can be taken. On [DATE], at 3:25 p.m. during an interview, CNA 7 stated at the start of the shift (3 p.m. to 11 p.m.), she reported to LVN 1 that Resident 8 was congested. CNA 7 stated she checked the resident throughout the night and heard congestion that had progressed later in the shift, and heard a gurgling sound. CNA 7 stated LVN 1 told her she was waiting for the physician to call back. CNA 7 stated when asked what was being done for the resident, LVN 1 told her a chest x-ray and labs were ordered. CNA 7 stated she was in the resident's room around 10 p.m. to 10:20 p.m. and it appeared the resident's congestion had progressed. When she went back into the room not long after, the resident was unresponsive and she called LVN 1. On [DATE], at 8:15 a.m., during an interview, the DON 1 stated on [DATE], LVN 1 told her that Resident 8 was congested and physician's orders [REDACTED]. The DON 1 stated, "I do not know how long LVN 1 had been a nurse, and yes, I felt she functioned within her scope of practice." The DON 1 further stated, "The RN supervisor was in the facility, I would have expected the RN supervisor to check and assess the resident. I may have been with the other surveyor at the time, around 4:30 p.m. To be honest, I do not know what I was doing at the time." DON 1 stated if an LVN notified the RN supervisor that a resident had a change in condition of coughing with congestion, she would have expected the RN to go assess the resident. When asked why she had not assessed the resident when LVN 1 notified her of the resident's change in condition, she stated she wasn't sure what she was doing at the time, but she left the facility without assessing the resident. During the interview, the DON 1 stated she did not know what positive airway pressure meant, nor whether the resident should have been transferred to the hospital or not, as indicated in the "POLST "Limited Interventions" section. On [DATE], at 8:45 a.m., the RN Supervisor acknowledged LVN 1 had notified her of Resident 8's change in condition. When asked the difference between an LVN and an RN, the RN supervisor stated an RN has been trained to do thorough resident assessments. She stated that a thorough assessment should be conducted on a resident who has a change in condition. When asked why she had not gone to assess Resident 8 when LVN 1 reported the resident's condition to her, the RN supervisor stated she could not remember what she had been doing at the time, but thinks she was starting an IV on another resident. On [DATE], at 12 noon, the director of staff development (DSD) stated there was no documentation indicating training had been given to LVN 1 and licensed staff on the end of life interventions included in the POLST form. The DSD stated she had received training on the POLST while employed at a prior facility. On [DATE], at 4 p.m., during an interview regarding what procedures to follow for a resident with congestion, LVN 16 stated she would give oxygen to the resident with congestion for comfort measures and a pulse oximeter can be taken. On [DATE], at 4:35 p.m., during a follow up interview, LVN 1 stated she had been taught in LVN school to notify an RN if there is any change in a resident's condition. LVN 1 stated she had notified DON 1 and the RN supervisor on [DATE], that Resident 8 was having coughing and congestion, and she had notified the physician. On [DATE] at 4:40 p.m., CNA 7 stated Resident 8 was in her bed at 3:30 p.m. when she first reported the resident was having some breathing problems, and had remained in the bed until she expired. On [DATE], at 8:20 a.m., LVN 10 stated a resident having respiratory problems should have lungs auscultated, and obtain a pulse oximeter check that can be obtained without a physician's orders [REDACTED]. A review of Resident 8's care plan for respiratory/oxygen use, dated [DATE], indicated to assess and monitor the resident for signs of hypoxemia (low blood oxygen), and to monitor lung sounds, cough, character of sputum, and pallor (pale skin color). A review of the facility's policy and procedure titled, "Physician order [REDACTED]. The POLST form is legally sufficient and recognized as a physician order. The POLST is designed to be portable, authoritative and an immediately actionable physician order [REDACTED]. A valid POLST form is to be honored across treatment settings. The facility's undated policy and procedure titled, "Do Not Resuscitate Orders and the Withholding or Withdrawal of Life Support and Life Sustaining Treatment," indicated California law requires health care providers to comply with an individual's health care instructions and health care decisions. The facility's policy and procedure titled, "Laboratory - Critical Values," dated [DATE], indicated critical laboratory values are reported to the resident's attending physician. Critical values are those that, if left untreated, could be threatening or could place the resident at serious risk. If the attending physician does not immediately respond, the licensed nurse contacts the facility's Medical Director for direction and prepares the resident for transfer to an appropriate acute care hospital according to the resident's needed intensity of care. Another policy and procedure titled, Pulse Oximetry (Assessing Oxygen Saturation), dated [DATE], indicated the purpose was to monitor arterial blood oxygen saturation without the use of invasive devices. The resident will be assessed for signs and symptoms of impaired oxygen saturation: altered respirations, difficulty breathing, abnormal breath sounds: cyanotic (bluish) appearance of nail beds, lips, skin, and mucous membranes, restlessness, confusion, and loss of consciousness. A review of the California Licensed Vocational Nurses (LVNs) Scope of Practice Standards dated [DATE] indicated: --LVNs are not independent practitioners, LVNs must practice under the direction of a licensed physician or RN at all times. --Assessment is defined as the collection of data. A LVN may assist in the collection of data, but validation of the data, interpretation of the data and determination of treatment priorities and levels of care must be done by a RN or physician. --if an abnormality is suspected and there are no relevant physician orders [REDACTED]. The LVN may not independently determine or initiate a course of action. A review of the facility's undated policy titled, "Change of Condition" indicated the Nursing Supervisor would be notified of emergency situations. A review of the undated "RN Supervisor Job Description" indicated the RN supervisor would monitor seriously ill residents as necessary and ensure resident care provided by personnel is in accordance with the resident's care plan and wishes. 2. A review of Resident 9's admission records indicated she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An MDS, dated [DATE], indicated Resident 9 had clear speech, made self understood, and was understood by others. The resident required extensive assistance with transfers, dressing, bathing, and personal hygiene. She had functional limitations in range of motion on both lower extremities. A wheelchair was used for mobility. The resident had pain with numeric pain intensity of eight (,[DATE] pain scale, 10 being the worst). A review of Resident 9's physician's orders [REDACTED]. There were physician's orders [REDACTED]. During a medication pass observation on [DATE], at 8:50 a.m., with LVN 9, Resident 9 stated her pain scale was an eight. LVN 9 stated there was no more [MEDICATION NAME] available. Resident 9 was offered Tylenol for her pain rated at eight. Resident 9 refused and stated Tylenol did not relieve her pain. During the same time, LVN 9 stated she had informed the DON on [DATE], at around 2 or 3 p.m., the physician had not renewed the order for [MEDICATION NAME] medication. LVN 9 stated she called the pharmacy on [DATE], and was told the physician would renew the medication on Thursday, [DATE]. LVN 9 stated when she told the DON on [DATE], the resident had one more [MEDICATION NAME] pill left. LVN 9 further stated the DON told her to write a discontinue order for the [MEDICATION NAME]. LVN 9 stated she should not have done so. LVN 9 stated that is why she wrote next to the physician's orders [REDACTED]. LVN 9 stated she did not really consider it as a real physician's orders [REDACTED]. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A review of the physician's orders [REDACTED]. fyi". The physician's orders [REDACTED]. An interview with the DON on [DATE], at 10 a.m., stated she instructed LVN 9 to discontinue Resident 9's [MEDICATION NAME] order because the physician would not renew the pain medication. She did not comment why it was her (DON) and not the physician to give the order for the [MEDICATION NAME] to be discontinued. An interview on [DATE], at 11 a.m., the DON and LVN 9 both confirmed the physician was not notified that they discontinued Resident 8's [MEDICATION NAME] pain medication. LVN 9 stated the pharmacist told her the physician did not fax the triplicate copy of the prescription required to renew the [MEDICATION NAME]. The physician was notified on [DATE], at 11:25 a.m., by the DON, and an order for [REDACTED]. The California Code of Regulations: ? . Nursing Service-Administration of Medications and Treatments. (a) Medications and treatments shall be administered as follows: (l) No medication or treatment shall be administered except on the order of a person lawfully authorized to give such order. (2) Medications and treatments shall be administered as prescribed. 3. On [DATE], at 9:45 a.m., a code blue (emergency) was called over the facility's intercom system for Resident 13. The facility staff were observed positioning Resident 13 for cardio-pulmonary resuscitation in her room. Resident 13 was very pale, unresponsive and LVN 8 stated the resident was not breathing and did not have a heartbeat. The restorative nursing assistant (RNA 2) immediately started chest compressions over the resident's clothing, hand placement was not verified prior to chest compressions. DON 1 started monitoring the resident's radial (pulse located in the wrist) pulse. Two minutes later, DON 2 started administering positive airway pressure (ventilation), and LVN 8 took over chest compressions. The chest compressions were done over the resident's clothing, hand placement verification was again not observed. At 9:50 a.m., DON 1 asked a staff member standing in the hallway to call the paramedics. LVN 8 and DON 2 switched places, DON 2 did not verify hand placement for compressions, placed his hands over the resident's upper abdominal area and resumed compressions. At 9:53 a.m., the physician, MD 1, entered the room and asked if the resident had a pulse, no one answered. DON 1 was attempting to check the resident's pulse in her left wrist. At 9:55 a.m., the surveyor asked what the resident's blood pressure was, no one had been observed checking the blood pressure, and again no one answered. LVN 26 left the room to get a blood pressure cuff and attempted to check the resident's blood pressure. At 9:58 a.m., the paramedics arrived, placed Resident 13 on a hard board, pulled the resident's clothing aside, checked hand placement, and resumed chest compressions and positive airway pressure. The paramedics attempted to shock the resident but was unsuccessful, and announced the resident to be in asystole (flat line on the monitor). The resident was transferred to the hospital. A review of Resident 13's admission face sheet indicated she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 13's POLST form in the clinical record indicated the resident was to receive full resuscitation efforts. A review of Resident 13's MDS dated [DATE], indicated she was fully alert and oriented, able to make herself understood at all times and understand others at all times, and required only limited assistance with walking, dressing and toileting. On [DATE], at 10:30 a.m., an inspection of the facility's emergency cart with DON 1 revealed there was no blood pressure cuff nor a pulse oximeter maintained on the cart. On [DATE], at 11:45 a.m., DON 1 stated if a resident has a change in respiratory rate, different breathing pattern, coughing and/or congestion, she would expect the staff to check the resident's oxygen saturation level every shift. When asked if Resident 13's oxygen saturation had been checked during the code blue, DON 1 stated since the resident was not breathing the staff did not need to check her oxygen saturation level. When asked which areas of the body the heart rate should be checked during CPR, DON 1 replied the radial (wrist), apical (over the heart), and carotid (neck). On [DATE], at 8:30 a.m., LVN 8 stated ensuring correct hand placement was difficult while performing CPR on Resident 13 through her clothing. A review of an on-line article titled "CPR In Depth", published by www.emergencymedical.com indicated clothing should be removed prior to starting chest compressions in order to properly visualize and palpate (feel) the proper hand placement. In addition, the article indicated leaving clothing in place can hinder the depth of compressions. A review of the facility's undated policy titled, "Cardiopulmonary Resuscitation" indicated the facility staff would do the following in the event a resident required cardio-pulmonary resuscitation: -If breath not detected within 10 seconds after opening the airway begin airway breathing. -feel the carotid artery to determine if the resident has a pulse, also check the carotid pulse after two minutes of CPR to determine if the CPR is effective. -ensuring proper hand placement for compressions keeps the compressions on the sternum (a bone in the upper chest area that connects with the ribs) and reduces the risk of a rib fracture, lung puncture, or liver laceration (tear).

Based on observation, interview, and record review, the facility failed to ensure residents received necessary care and services according to the resident's care plan and wishes for two of 14 sampled residents (8, 13). Resident 8, was identified having congestion and was coughing on [DATE], from 3:30 p.m., to 9:30 p.m., however, there was no thorough respiratory assessment and monitoring as indicated in Resident 8's care plan. As a result Resident 8 was not provided oxygen and other necessary treatments. At 10:30 p.m., the resident was found unresponsive, a CODE (emergency response) was started and the paramedics were called. Resident 8 was pronounced dead at 10:56 p.m. Resident 13, not being fully assessed, and potentially not receiving accurate cardiopulmonary resuscitation during an emergency situation, and the potential for all facility residents not having their end of life wishes honored. The facility also failed to: a. Ensure facility staff performed cardio-pulmonary resuscitation as outlined in the facility's policy and American Heart Association guidelines for Resident 13. b. Ensure a fully operational pulse oximeter was available in the event of an emergency for one of nineteen sampled residents (13). c. Ensure the clinical records for all residents in the facility were maintained in an orderly manner that would allow the facility staff to quickly locate each resident's POLST form to determine the individual resident's end of life wishes. A situation of Immediate Jeopardy (IJ) was declared by the survey team on [DATE], at 3:40 p.m., with the administrator. On [DATE], at 2 p.m., the IJ was abated with the administrator after the facility provided a written plan of correction (POC) that included the following actions: The Nurse Consultant, DSD, and DON began conducting inservices to all of the facility's nursing staff on the following policies, procedures and protocols: --POLST/DNR/Emergency, respiratory assessment,comfort measures, change of condition, administering oxygen, [MEDICATION NAME] within scope of practice, and code blue drills. The POC included a copy of the lesson plan outlining the information included in the inservices, a copy of all relevant and updated facility policies, a copy of professional materials reviewed when updating the policies, samples of each form to be reviewed, and a signature list of all staff inserviced up to that point. Trainings started on [DATE], and would continue until all relevant facility staff have been inserviced. --All in-house residents with DNR orders and/or on oxygen therapy were to be reviewed by licensed staff to ensure the residents' needs are met and care planned, and their individual wishes communicated. The POC included copies of updated interdisciplinary team conference records (IDT) for each resident. In addition, the POC indicated a review would be conducted on each resident on admission, quarterly, annually, and upon identification of a significant change in condition. To be completed by [DATE]. --On a weekly basis the DON would select five random residents with a DNR order, respiratory condition, and/or on oxygen therapy to review for compliance with all relevant policies and procedures. --The facility's nurse consultant would conduct random reviews on three residents records to ensure the facility's licensed nurses were documenting care provided within the scope of their practices and obtained physician orders [REDACTED]. --For each resident the POLST form would consistently be filed in the clinical record under the tab "POLST", located immediately behind the facesheet, and all staff inserviced on the proper location for the POLST form. The POC included a signature list of all staff inserviced up to that point. To be completed by [DATE]. The POC was accepted by the survey team and the immediate jeopardy lifted on [DATE], at 4:15 p.m. The facility's licensed staff also failed to accurately assess a non-pressure sore skin problem and implement the plan of care for one of 14 sampled residents (Resident 8). The Non- Pressure Sore Skin Problem Report dated [DATE], indicated Resident 8's right lower extremity stasis ulcer measured 2.6 centimeters (cm) by 2.7 cm. However, it was observed and when re-measured on [DATE], two days from the report, the skin ulcer measured 6.9 cm x 5.0 cm. This deficient practice had the potential for delayed provision of appropriate treatment required for healing. The facility failed to reassess a resident for pain for one of 14 sampled residents (Resident 9). Resident 9 was receiving "PRN" [MEDICATION NAME] (a narcotic pain reliever) ,[DATE] milligrams (mg) for severe pain daily since admission on February 11, 2013, with a pain scale of eight in a scale of ,[DATE] (being the worst pain) and was not reassessed for the need for "routine" (given regularly on scheduled dose) pain medication according to the plan of care. This deficient practice had the potential for the resident not maintaining the highest level of well being. Findings: 1a. A review of Resident 8's admission records indicated she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment and care screening tool, dated [DATE], indicated Resident 8 usually understood others and was usually understood by others. The resident required total assistance from staff with her activities of daily living except for eating in which the resident required limited assistance (staff provides guided maneuvering of limbs or other non-weight bearing assistance). The resident had functional limitation in range of motion ((ROM) the extent of movement of a joint) to both upper and lower extremities. A review of Resident 8's care plan for respiratory/oxygen use, dated [DATE], indicated to assess and monitor the resident for signs of hypoxemia (low blood oxygen), and to monitor lung sounds, cough, character of sputum, and pallor (pale skin color). A review of the Physician order [REDACTED]. A review of Resident 8's Physician order [REDACTED]. The section Medical Interventions (if person has pulse and/or is breathing), Limited Additional Interventions indicated "In addition to care described in Comfort Measures Only, use medical treatment, antibiotics, and intravenous (IV) fluids as indicated." The section for Comfort Measures Only indicated to use "oxygen, suction, and manual treatment of [REDACTED]." Review of the Nurses' Progress Notes (notes) dated [DATE], at 3:30 p.m., indicated Resident 8 was awake, alert, verbally responsive and was coughing and congested. Vital signs were: Blood pressure (BP) was ,[DATE] millimeter mercury ((mmHg) normal adult reference range: less than ,[DATE]), pulse rate (PR) was 80 beats per minute (normal adult resting reference range: 60 - 100), respiration rate (RR) was 19 breaths per minute (normal adult reference range: 8 to 16) and temperature (T) was 98.4 degrees Fahrenheit ((?F) normal adult reference range: 98.6?F). The physician was notified and ordered a chest x-ray stat (now) and a laboratory test for complete blood count (CBC). There was no documented evidence of an assessment of the resident's lung sounds by auscultation (listen to the resident's lungs with a stethoscope) and oxygen saturation (a sensor placed on the finger to monitor the percentage of oxygen in the blood). There was no documented evidence the resident was provided with supplemental oxygen as needed. At 5:30 p.m., (two hours later) the notes indicated Resident 8 was awake, alert, verbally responsive, still slightly congested and respirations were unlabored (not having difficulty breathing). The resident ate dinner and consumed 80%. There was no documentation of the status of the resident's vital signs, the quality of breath sounds, the oxygen saturation or the provision of supplemental oxygen. At 7:30 p.m., (four hours later) the notes indicated Resident 8 was in bed with the head of the bed elevated. The resident was awake, alert, and verbally responsive, with cough and congestion. Vital signs were: BP-,[DATE], PR-81, RR-19, and T-98.8. There was no assessment of breath sounds, oxygen saturation and provision of supplemental oxygen. At 9:02 p.m., (five hours and 32 minutes) the notes indicated the result of the chest x-ray revealed lower left lung pneumonia (bacterial infection of the lungs, common symptom is cough and may cause a decrease in the flow of oxygen to the blood). The physician was called with no response. The X-ray result was faxed to the physician. At 9:30 p.m., (6 hours from the initial assessment) the notes indicated Resident 8 was in bed with the head of the bed elevated, was still verbally responsive, with cough and congestion. Waiting for the response of the physician. There was no documented evidence of an assessment of the resident's vital signs, lung sounds, oxygen saturation, and provision of supplemental oxygen as needed. At 10:30 p.m., the notes indicated the licensed vocational nurse (LVN 1) was notified by a certified nursing assistant (CNA) that Resident 8 was unresponsive and a CODE (emergency response) was called. Paramedics arrived and pronounced the resident dead at 10:56 p.m. The physician was notified. On [DATE], at 5 p.m., during an interview with LVN 1 regarding Resident 8's change of condition on [DATE], at about 3:30 p.m., she stated Resident 8 had a physician's orders [REDACTED]. She stated she did not provide oxygen to the resident because the resident "did not seem like she was sick" and she did not check the resident's oxygen saturation level. LVN 1 stated she heard the resident congested but she did not think to auscultate or assess the resident's lungs. LVN 1 did not comment why she did not call the physician again, the director of nursing (DON), or the Medical Director when the physician had not called back. On [DATE], at 3:25 p.m. during an interview, CNA 7 stated at the start of the shift (3 p.m. to 11 p.m.), she reported to LVN 1 that Resident 8 was congested. CNA 7 stated she checked the resident throughout the night and heard congestion that had progressed later in the shift, and heard a gurgling sound. CNA 7 stated LVN 1 told her she was waiting for the physician to call back. CNA 7 stated when asked what was being done for the resident, LVN 1 told her a chest x-ray and labs were ordered. CNA 7 stated she was in the resident's room around 10 p.m. to 10:20 p.m. and it appeared the resident's congestion had progressed. When she went back into the room not long after, the resident was unresponsive and she called LVN 1. On [DATE], at 8:15 a.m., during an interview, the DON stated on [DATE], LVN 1 told her that Resident 8 was congested and physician's orders [REDACTED]. The DON further stated, "The RN supervisor was in the facility, I would have expected the RN supervisor to check and assess the resident. On [DATE], at 8:45 a.m., the RN Supervisor acknowledged LVN 1 had notified her of Resident 8's change in condition. When asked why she had not gone to assess Resident 8 when LVN 1 reported the resident's condition to her, the RN supervisor stated she could not remember what she had been doing at the time. On [DATE], at 4 p.m., during an interview regarding what procedures to follow for a resident with congestion, LVN 16 stated she would give oxygen to the resident with congestion for comfort measures and a pulse oximeter can be taken. On [DATE], at 8:20 a.m., LVN 10 stated a resident having respiratory problems should have lungs auscultated, and obtain a pulse oximeter check that can be obtained without a physician's orders [REDACTED]. A review of the facility's policy and procedure titled, "Physician order [REDACTED]. The POLST form is legally sufficient and recognized as a physician order. The POLST is designed to be portable, authoritative and an immediately actionable physician order [REDACTED]. A valid POLST form is to be honored across treatment settings. Another policy and procedure titled, Pulse Oximetry (Assessing Oxygen Saturation), dated [DATE] indicated the purpose was to monitor arterial blood oxygen saturation without the use of invasive devices. The resident will be assessed for signs and symptoms of impaired oxygen saturation: altered respirations, difficulty breathing, abnormal breath sounds: cyanotic (bluish) appearance of nail beds, lips, skin, and mucous membranes, restlessness, confusion, and loss of consciousness. 1b. On [DATE], at 8:45 a.m., during an wound treatment observation of Resident 8's right lower extremity stasis ulcer with LVN 6, the size of the wound was significantly larger than what was documented on the NON- Pressure Sore Skin Problem Report, dated [DATE]. The report indicated the resident's wound measured 2.6 centimeters (cm) by 2.7 cm. LVN 6 was asked to re-measure the wound and the wound measured 6.9 cm x 5.0 cm. An interview with LVN 6 on [DATE], at 9:10 a.m., stated she had not noticed a difference in size to the leg wound. LVN 6 stated she was one of two treatment nurses scheduled weekly and was treating the resident's wounds weekly. LVN 6 stated she could have requested for a wound consult evaluation but had not done so. An interview with the DON on [DATE], at 10 a.m., stated weekly wound measurements were given to the nurse consultant and herself. She stated she had not observed the wound before. The DON stated she will start to make weekly rounds with the treatment nurses to ensure accurate assessments. An interview with LVN 11 on [DATE], at 4 p.m., stated she measured Resident 8's right leg wound every Wednesday on her own, and had done so on [DATE]. She could not explain the increase in the size of the wound. A review of the NON-Pressure Skin Problem Report indicated weekly wound measurements from February, March, and [DATE], the wound had measured largest at 2.9 cm x 2.8 cm. On [DATE] and 10, 2013, the wound had measured 2.6 x 2.7cm. According to the NON-Pressure Skin Problem Report, dated [DATE], Resident 8's right leg stasis ulcer wound was identified on [DATE], and measured 3.8 cm x 4.0 cm and had been decreasing in size. On [DATE], the wound measured 2.9 cm x 3.0 cm. A plan of care for [MEDICAL CONDITION], dated [DATE], indicated to check extremities for peripheral pulses, color, coolness and swelling, and for a wound consultation. This was not done. 2. A review of Resident 9's admission records indicated she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An MDS, dated [DATE], indicated Resident 9 had clear speech, made self understood, and was understood by others. The resident required extensive assistance with transfers, dressing, bathing, and personal hygiene. She had functional limitations in range of motion to both lower extremities. A wheelchair was used for mobility. The MDS indicated Resident 9 had pain with numeric pain intensity of eight (,[DATE] scale, 10 being the worst pain). A review of Resident 9's physician's orders [REDACTED]. There were physician's orders [REDACTED]. During a medication pass observation on [DATE], at 8:50 a.m., with LVN 9, Resident 9 stated her pain was eight. LVN 9 stated there was no more [MEDICATION NAME] available. Resident 9 was offered Tylenol for her pain and the resident refused, she stated Tylenol did not relieve her pain. LVN 9 stated she had informed the DON on [DATE], the physician had not renewed the [MEDICATION NAME] pain medication order. LVN 9 stated she called the pharmacy and was told the physician would renew the medication on Thursday. LVN 9 stated pain medications should be ordered from the pharmacy 10 days prior to the refill date. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] A review of the Nurses' Progress Notes, dated [DATE], at 12:05 p.m., physician's orders [REDACTED]. A review of Resident 9's MAR for February 2013 (resident was admitted on [DATE]), indicated [MEDICATION NAME] ,[DATE] mg was given to the resident every day from February 13 to 23, 2013, then on February 25 and 28, 2013. [MEDICATION NAME] ,[DATE] mg was given to the resident twice on February 18, 20, and 21, 2013, for a total of 16 doses. The MAR for [DATE], indicated for 30 days, [MEDICATION NAME] ,[DATE] mg was given, and 20 of those 30 days, [MEDICATION NAME] was given twice. The MAR for [DATE] to 15, 2013, indicated pain medication was given every day and nine of the 15 days, the resident received the [MEDICATION NAME] ,[DATE] mg two times per day. A review of the pain scale monitoring for February 2013, for twelve days, the resident's pain was rated an eight (severe pain), for [DATE], pain was rated at eight for 20 days, and for [DATE]-15, 2013, every day, the pain was rated at eight. A review of the Interdisciplinary Team (IDT) Conference Record, dated February 25, 2013, indicated in a checked box, the resident's pain was less than daily and did not address the resident's daily pain rated at eight (severe pain). A plan of care for Resident 9's chronic pai[DIAGNOSES REDACTED], frequent complaints of left shoulder pain, dated February 11, 2013, the goal was for pain rate to decrease to two. On [DATE], to apply topical (applied to the skin) gel [MEDICATION NAME] 1% (nonsteroid anti-[MEDICAL CONDITION] medication) every 12 hours PRN as needed for pain. The approach was to assess pain medication and treatments for effectiveness, and to evaluate the need for "routine" pain medication rather than PRN. There was no documented evidence of this assessment and evaluation for the need for "routine" pain medication in the IDT conference record. A review of a two view left shoulder x- ray, dated February 9, 2013, indicated extensive [MEDICAL CONDITION] changes was noted in the left shoulder with no fracture. A review of the Change of Condition Notes, dated [DATE], 7 am- 3 pm shift, indicated increasing levels of pain in shoulder, legs, and back. A review of the Progress/Evaluation Notes, dated [DATE], indicated the chief complaint was left shoulder pain. physician's orders [REDACTED]. 3a. On [DATE] at 9:45 a.m., a code blue was called over the facility's intercom system for Resident 13. The facility staff were observed positioning Resident 13 for cardio-pulmonary resuscitation. Resident 13 was very pale, unresponsive and LVN 8 stated the resident was not breathing, and did not have a heartbeat. RNA 2 immediately started chest compressions over the resident's clothing, hand placement was not verified prior to chest compressions. DON 1 started monitoring the resident's radial pulse. Two minutes later DON 2 started administering positive airway pressure, and LVN 8 took over chest compressions. The chest compressions were done through the resident's clothing, hand placement verification was again not observed. At 9:50 a.m., DON 1 asked a staff member standing in the hallway to call the paramedics. LVN 8 and DON 2 switched places, DON 2 did not verify hand placement for compressions , placed his hands over the resident's upper abdominal area and resumed compressions. At 9:53 a.m., MD 1 entered the room and asked if the resident had a pulse, no one answered. DON 1 was attempting to check the resident's pulse in her left wrist. At 9:55 the surveyor asked what the resident's blood pressure was, no one had been observed checking the blood pressure, again no one answered. LVN 26 left the room to get a blood pressure cuff and attempted to check the resident's blood pressure. At 9:58 a.m., the paramedics arrived, placed Resident 13 on a board, pulled the residents clothing aside, checked hand placement, and resumed chest compressions and positive airway pressure. The paramedics attempted defibrillation, and announced the resident was in asystole (flat line on the monitor). The resident was transferred to the hospital. A review of Resident 13's admission facesheet indicated she was a [AGE] year old female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 13's POLST form in the clinical record indicated the resident was to receive full resuscitation efforts. A review of Resident 13's MDS dated [DATE], indicated she was fully alert and oriented, able to make herself understood at all times and understand others at all times, and required only limited assistance with walking, dressing and toileting. At 10:30 a.m., a check of the facility's emergency cart with DON 1 revealed there was not a blood pressure cuff nor a pulse oximeter maintained on the cart. On [DATE] at 11:45 a.m., DON 1 stated if a resident has a change in respiratory rate, different breathing pattern, coughing and/or congestion, she would expect the staff to check the resident's oxygen saturation level every shift. When asked if Resident 13's oxygen saturation had been checked during the code blue, DON 1 stated since the resident was not breathing the staff did not need to check her oxygen saturation level. During the same interview with DON 1 when asked which areas of the body the heart rate should be checked during CPR, DON 1 replied the radial (wrist), apical (over heart), and carotid (throat). On [DATE] at 8:30 a.m., LVN 8 stated ensuring correct hand placement was difficult while performing CPR on Resident 13 through her clothing. In addition, when asked if the resident's oxygen saturation had been checked, the LVN responded the facility had two pulse oximeters, one pulse oximeter was in the other building and the other was broken. LVN 8 stated he had seen the pulse oximeter sitting at the nurses station in front of DON 1, and he could tell it was broken because it was "stretched open" and he had assumed she was in the process of calling someone to have it repaired. When asked when he had seen the broken pulse oximeter on the desk, the LVN stated, "I don't remember what day it was, I think it might have been the day of the code or the day before." On [DATE], at 11:30 a.m., during an interview, the central supply manager stated he had been given a broken pulse oximeter to repair on [DATE]. A review of an on-line article titled "Pulse Oximetry in Critically Ill Patients", published in 2001, www.heartlung.com, indicated changes in oxygen saturation identify improvement and deterioration. The article further indicated oxygen saturation monitoring can identify response to oxygen administration, and also lack of response to oxygen administration. A review of the facility's undated "Cardiopulmonary Resuscitation" policy indicated the facility staff would do the following in the event a resident required cardio-pulmonary resuscitation: -If breath not detected within 10 seconds after opening the airway begin airway breathing. Resident 13 did not receive rescue breathing until 9:47, two minutes after the code blue was called. -feel the carotid artery to determine if the resident has a pulse, also check the carotid pulse after two minutes of CPR to determine if the CPR is effective. At no time was staff observed checking the carotid pulse. DON 1 was feeling for a radial pulse during CPR. -ensuring proper hand placement for compressions keeps the compressions on the sternum (a bone in the upper chest area that connects with the ribs) and reduces the risk of a rib fracture, lung puncture, or liver laceration (tear). 3b. On [DATE], at 8:30 a.m., while reviewing a POLST form with DON 1, when asked what limited interventions meant as indicated under Section B of the POLST form, DON 1 stated she believed it meant a resident could maybe have an IV (intravenous-fluid delivered via a vein) and antibiotics (medications to fight infections), but it did not indicate any respiratory interventions. When Section B of the POLST, which indicated the resident with this section checked should receive positive airway pressure (a treatment used for resident's with respiratory difficulty in which air pressure is used to maintain a patient's airway open and/or provide oxygen to a patient in respiratory distress or not breathing at all), was read to DON 1, she stated she did not know what positive airway pressure was. On [DATE], at 8:45 a.m., during an interview, the RN supervisor stated she did not know what positive airway pressure was and was not familiar with what limited interventions indicated for a resident with a Do Not Resuscitate (DNR) order. (Positive airway pressure is the process used to deliver oxygen to a patient during CPR). A review of the personnel files for DON 1 and the RN supervisor revealed both RNs were currently CPR certified. On [DATE], at 4 p.m., LVN 16 stated she had been the person that checked Resident 8's medical record to determine what her Do Not Resuscitate (DNR) status was. LVN 16 stated she had not received any training on how to read the POLST form, she had just looked at the top of the form, read that the resident was a "DNR", and reported to LVN 1 at the resident's bedside. LVN 16 further stated no further interventions were done for the resident. On [DATE], at 4:35 p.m., LVN 1 stated she had not received any training on how to read the POLST form and was not familiar with what "limited interventions" involved. On [DATE], between 7:10 a.m. and 8 a.m., the RN supervisor, LVN 15 (night shift charge nurse), the MDS nurse, CNA 29, CNA 28, CNA 15, and the DSD, were interviewed and asked to go through randomly selected medical records and tell the surveyor what the resident's DNR status was. The MDS nurse was unable to locate a POLST form in seven medical records. LVN 15 went through a medical record for a total of 5 minutes before he was able to locate the resident's status. The RN supervisor stopped looking after 4 minutes, stating she was unable to locate DNR status of a resident. The MDS nurse located the POLST form within one minute and stated, "I know the form may be in the front of the chart, in the physician's orders [REDACTED]." On [DATE], at 2:30 p.m., the facility's administrator submitted a plan of correction in response to an immediate jeopardy outlining a plan to ensure all POLST forms are maintained in one location in the medical record and the pink form would be maintained on the current medical record instead of a copy.

Based on observation, interview, and record review, the facility's licensed staff failed to prevent the development of a pressure sore to the right ankle (area of skin that breaks down when positioned on an area too long) that progressed from a Stage II, on October 2, 2010, to a Stage III on October 6, 2010, and failed to implement interventions according to established plan of care by failing to: 1.provide the resident with pressure relieving device in bed. 2.provide heel protectors. 3.acted upon RD' s recommendation promptly. The RD had written recommendations on October 15, 2010, however, physician's orders [REDACTED]. This deficient practice resulted in an avoidable Stage III pressure sore for one of 13 sampled residents (Resident 8). See F325 for additional information regarding Resident 8. According to: www.npuap.org/pr2.htm a Stage III pressure sore is a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough (dead tissue) may be present but does not obscure the depth of tissue loss. Findings: On October 19, 2010 at 8:30 a.m., and 10:30 a.m., Resident 8 was observed on a semi right side position, right ankle and heels were positioned on the bed without any pressure relieving devices and no heel protectors. During a dressing change observation and interview, on October 19, 2010 at 10:45 a.m., with Licensed Vocational Nurse 2 (LVN 2) the resident's right ankle and heels did not have any pressure relieving device. The right ankle pressure sore appeared round and dark in color. LVN 2 stated the pressure sore to the resident's right ankle was a Stage IV. According to: www.npuap.org/pr2.htm Stage IV pressure sore is a full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dead tissue) may be present on some parts of the wound bed. Often include undermining and tunneling. After the treatment, LVN 2 placed pillows under the resident's heels. Another observation on October 20, 2010 at 9 a.m., and again at 1 p.m., Resident 8 right ankle and bilateral heels were in direct contact with the mattress and no support to relieve pressure. An interview with Certified Nursing Assistant 3 (CNA 3) on October 20, 2010 at 9:05 a.m., she stated the resident took the pillow from under his heels. However, an extra pillow was not observed on the bed or around the area. A review of the Wound/Skin Healing Record, dated October 4, 2010, indicated the onset of the Stage II pressure sore to the resident's right outer ankle on October 2, 2010, and measured 1.5 centimeter (cm) x 0 .8 cm., and had serosanguineous exudate (fluid composed of serum and blood from the blood vessels, can indicate inflammation). A review of the Treatment Record dated October 2, 2010, indicated the right ankle was cleansed with normal saline, applied santyl ointment (used to remove dead skin from wounds), and covered with dry dressing, every day for 30 days. Review of the physician's orders [REDACTED]. A review of the resident's plan of care for risk of skin breakdown, dated April 2, 2010, indicated the resident was to be turned and repositioned at least every two hours, and as needed, to provide pressure relieving devices, to provide adequate nutrition and hydration, and to refer to the physician and the registered dietician (RD) as needed. Another plan of care for alteration in skin integrity, dated October 2, 2010, for a right ankle pressure ulcer related to diabetes and poor appetite, (progressed from a Stage II to a Stage III on October 6, 2010). The Wound/Skin Healing Record, indicated on October 4, 2010, the right ankle pressure ulcer was a Stage II. The Nurses Progress Notes, dated October 6, 2010, indicated the resident's right ankle was reassessed and noted a 90% redness with 10% thin yellow and scant draining. A new physican's order was written for wound dressing, and to obtain a wound consult. The care plan was updated on October 6, 2010, indicating the pressure ulcer on the right ankle was a stage III, and to provide pressure relieving devices in the bed, provide heel protectors, turning and repositioning, and to refer to the weight variance committee for close monitoring of weight, as needed (PRN). A review of the Minimum Data Set (MDS), a standardized assessment and care screening tool, dated June 28, 2010, and another MDS dated [DATE], Section M. Skin Condition (5) was not checked for pressure relieving devices, turning and repositioning, or nutrition and hydration interventions, and was left blank. A quarterly Minimum Data Set (MDS), a standardized assessment and care screening tool, dated September 24, 2010, indicated the resident had short term memory problems, had modified independence in his cognitive skills for daily decision. The resident had the ability to understand others and make himself understood. The resident needed extensive assistance with activities of daily living including dressing, bed mobility, personal hygiene, bathing and supervision with meals. The resident did not have any behavioral problems. During an interview with the MDS Coordinator on October 21, 2010 at 3 p.m., he stated a mistake was made in the MDS Section for Resident 8 ' s Skin Treatment, and was not marked for turning and repositioning, and for a pressure relieving device. A plan of care was written on April 2, 2010, indicating the risk for skin breakdown and the need for pressure relieving devices. A review of the Admission Nursing Assessment, Risk for Pressure Ulcers, dated June 20, 2010, indicated the resident had a total score of 21, and on October 11, 2010, the total score was 13 (a total score of 16 or below indicated at risk for pressure sores). A review of the Braden Scale- For Predicting Pressure Sore Risk, dated June 15, 2010, had a score of 18, and on September 22, 2010, and October 11, 2010, indicated the resident had a score of 19 (represents a low risk). Total score of 12 or less represents high risk. A review of the Change in Condition Assessment, dated October 2, 2010, indicated the resident's right ankle had an open area measuring 1 cm x 0.8 cm. Physician orders [REDACTED]. A review of the Nurses Progress Notes, dated October 6, 2010 at 11 a.m., indicated a reassessment was done to the right ankle open area, 90 % red with 10 % thin yellow (not specified) and scant drainage. Another physician's orders [REDACTED]. A review of the Nurses Progress Notes, dated October 12, 2010, indicated the right ankle was dark, hard, and had eschar (a slough or dead tissue). A review of Resident 8's clinical records (face sheet) indicated he was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On October 7, 2010, the resident was transferred to the acute care hospital for poor appetite, and a change in level of consciousness. A review of the Resident Transfer and Referral Record, dated October 7, 2010, indicated the resident was transferred to the acute care hospital with a right ankle open wound. A review of the acute hospital Extended Care Patient Transfer Record, dated October 11, 2010, on readmission to the facility, indicated the pressure sore to the resident's right ankle was healing. A review of the Nutritional Assessment Screening, dated October 15, 2010, indicated the RD had written recommendations for Zinc Sulfate (ZnS04) 220 milligrams (mg), a mineral used for wound healing, to be given by mouth every Monday, Wednesday and Friday for 14 days, one extra egg at breakfast, 8 ounces mocha mix at all meals, 24 ounce citrus juice at lunch, and 250 mg of vitamin C orally, every day. Physician orders [REDACTED]. A review of the facility's policy and procedure titled Stage I, II, III and Stage IV, dated May 2010, indicated one of the measures to prevent a pressure sore was by relieving pressure. The goal of the treatment was to prevent further deterioration, risk assessment, and nutritional assessment. Dietary interventions listed were particular attention to vitamin C, and minerals (Zinc).