Every finding on record at Palm Springs Healthcare & Rehabilitation Center

Based on observation, interview, and record review, the facility failed to maintain proper use of Low Air Low (LAL) Mattresses (A specialized air-filled mattress used to treat and prevent the development of pressure ulcers - skin damage caused by prolonged pressure to one area of the body), when the resident's LAL pump/air pressure was not maintained at the proper setting for four of 6 residents reviewed (Residents 1, 2, 3 and 4).This failure had the potential to contribute to the development and/or prolonged healing of pressure ulcer's (PUs). Findings: On February 11, 2026, at 1012 a.m., an interview was conducted with Registered Nurse (RN) 1, who stated a facility medical intervention to help residents avoid development and assist with healing of PU's includes the use of an LAL mattress. The RN stated the LAL mattress has a pump that fills it with air, which relieves prolonged pressure on the resident's skin. The RN further stated the amount of air/pressure of the LAL mattress is controlled by a dial on the pump which is set according to the resident's weight. RN 1 further stated the Subacute Unit's Coordinator (SAC) placed a yellow arrow on each resident's LAL pump, correlating with the resident's weight, indicating to staff where the dial should be set. On February 11, 2026, at 10:35 a.m., a concurrent observation of Resident 1's LAL pump and an interview with RN 1 was conducted. Resident 1's LAL pump had a yellow arrow placed between the numbers of 80 to 160 pounds (lbs.). The resident's LAL dial was set at 400 lbs. RN 1 verified the LAL pump was incorrectly set at 400 lbs., stating it should be set here, as RN turned the pump dial to line up with the yellow arrow between 80 to 160 lbs. A record review of Resident 1's weight, dated January 12, 2026, indicated the resident weighed 117 lbs. On February 11, 2026, at 10:40 a.m., an interview was conducted with the SAC. The SAC stated she placed yellow arrows on the resident's LAL pumps, indicating where staff should set the pump/air pressure, according to the resident's weight. The SAC stated it's important that the resident's LAL pump is set and customized according to the resident's weight because it relieves pressure on the resident's skin and minimizes the risk of developing PU's. On February 11, 2026, at 10:45 a.m., a concurrent observation of Resident 2's LAL pump, and interview with SAC was conducted. Resident 2's LAL pump had a yellow arrow placed between 100 and 150 lbs., and the dial was set at 350 lbs., stating Firm. The SAC stated, The (LAL pumps) dial is not set where it should be. The SAC verified Resident 2's LAL pump was set at 350 lbs., and the correct setting is between 100 and 150 lbs., correlating with Resident 2's weight. A record review of Resident 2's weight, dated January 12, 2026, indicated the resident weighed 144 lbs. On February 11, 2026, at 11:00 a.m., a concurrent observation of Resident 3's LAL pump, and an interview with the SAC was conducted. Resident 3's LAL pump had a yellow arrow placed between 80 to 160 lbs., and the resident's dial was set to 400 lbs., stating Max. The SAC verified Resident 3's pump was not set correctly, stating the dial should be lined up with the yellow arrow between 80 to 160 lbs., not at 400 lbs.A record review of Resident 3's weight, dated January 12, 2026, indicated the resident weighed 150 lbs. The SAC further stated it is her expectations for the resident's assigned Licensed Vocational Nurse (LVN) to check and verify the residents LAL pumps settings are correct at the beginning of their shifts. On February 11, 2026, at 11:05 a.m., an interview was conducted with LVN 1 who stated LAL mattresses are used as an intervention to prevent the development of PU's. LVN 1 stated LAL mattress pumps are set according to the resident's weight, and the dial should be lined up with the yellow arrow on the pump. LVN 1 stated when the pump is set correctly the air pressure is evenly distributed across the resident's body. The LVN stated he checks the correct setting of his assigned resident's LAL pump at the beginning and end of his shift, and after resident care has been provided. LVN 1 verified he was the assigned LVN for Resident 1. LVN 1 stated he did check Resident 1's LAL pump at the beginning of his shift and verified It was good (at the correct setting). LVN 1 verified Resident 1 later received a wound treatment. LVN 1 stated he did not re-check the setting on Resident 1's LAL pump after his treatment and he should have to ensure the resident's pump was at the correct setting. On February 11, 2026, at 11:25 a.m., a concurrent observation of Resident 4's LAL pump, and an interview with LVN 1 was conducted. Resident 4's LAL pump had a yellow arrow placed at 200 lbs., and the resident's pump was set to 285 lbs. LVN 1 verified Resident 4's pump was not set correctly, stating the resident's mattress was over inflated which can make the surface hard and may contribute to the development of PUs. LVN 1 further stated, I don't think I checked on (Resident 4's) mattress (setting) today and I should have. A record review of Resident 4's weight, dated January 12, 2026, indicated the resident weighed 183 lbs. On February 11, 2026, at 11:55 a.m., an interview was conducted with the Director of Nursing (DON) who verified the LAL pump settings correlate with the resident's weight, and she expects the LVN to check the LAL pump at the beginning of their shift and after resident care to ensure the setting is correct. A review of Resident 1's, Face Sheet indicated the resident was admitted to the facility on [DATE], with a diagnosis of traumatic subarachnoid hemorrhage (severe stroke-death to brain cells). A review of Resident 1's Brief Interview for Mental Status (BIMS-a cognitive assessment) indicated the resident had severe cognitive impairment. A review of Resident 1's Doctor's (Drs) Orders dated December 22, 2025, at 10:10 a.m., indicated, . LAL mattress LN (Licensed Nurse) to monitor function, proper set-up and placement .A review of Resident 2's Face Sheet indicated the resident was admitted to the facility on [DATE], with a diagnosis of traumatic subarachnoid hemorrhage. A review of Resident 2's BIMS indicated the resident had severe cognitive impairment. A review of Resident 2's Dr's Orders dated December 30, 2025, at 9:05 a.m., indicated, . LAL mattress LN to monitor function, proper set-up and placement . A review of Resident 3's Face Sheet indicated the resident was admitted to the facility on [DATE], with a diagnosis of anoxic brain damage (brain damage caused by oxygen deprivation). A review of Resident 3's BIMS score indicated the resident had severe cognitive impairment. A review of Resident 3's Dr's Orders dated, November 25, 2025, at 9:21 a.m., indicated, . LAL mattress LN to monitor function, proper set-up and placement . A record review of Resident 4's Face Sheet indicated resident was admitted to the facility on [DATE], with a diagnosis of acute and chronic respiratory failure.A review of Resident 4's BIMS score indicated the resident had severe cognitive impairment. A review of Resident 4's Dr's Orders dated, February 1, 2026, at 1:22 a.m., indicated, . LAL mattress LN to monitor function, proper set-up and placement .A review of the facility's policy and procedure titled, Low Air-Loss Therapy Bed, undated, indicated, Low-air-loss therapy beds inflate to specific pressures based on the height and weight of the patient .

Based on interview and record review, the facility failed to notify the resident's representative, for one of three residents reviewed (Resident 5), when Resident 5 experienced a fall. This failure resulted in the resident's representative not being aware of the resident's change of condition. Findings: A review of Resident 5's Face Sheet indicated the resident was admitted to the facility on [DATE], with a diagnosis of traumatic subarachnoid hemorrhage (stroke causing brain cell damage) following a motor vehicle accident. A review of Resident 5's Brief Interview for Mental Status (BIMS-A cognitive assessment) dated January 17, 2025, indicated Resident 5 had severe cognitive impairment. A review of Resident 5's Doctor's Orders dated February 5, 2025, indicated Resident 5 did not have the capacity to make his own decisions. On February 5, 2026, at 10:15 am, an interview was conducted with the Administrator who stated Resident 5's representative makes his healthcare decisions due to the resident's severe cognitive impairment. A review of Resident 5's SBAR (change of condition - COC) dated May 16, 2025, at 1:10 a.m., indicated Resident 5 had an unwitnessed fall and was found on the floor next to his bed. Further review indicated, . Notified MD (medical doctor) and calling (representative) in am . A review of Resident 5's Risk Meeting Notes dated May 16, 2025, at 9:23 a.m., attended by the Director of Nursing (DON), indicated, .Initial Risk Note: (Status post fall) with injury today at (1:10 a.m.).Resident Representative Notified: No. A review of Resident 5's progress notes following the resident's unwitnessed fall on May 16, 2025, indicated no documentation stating Resident 5's representative was notified of the resident's unwitnessed fall. On February 5, 2026, at 2:15 p.m., a concurrent record review of Resident 5's May 16, 2025, SBAR, Risk Meeting Notes, progress notes, and interview with the Subacute Coordinator (SAC) was conducted. The SAC stated notification to a resident's representative should be done at the time of the COC. The SAC verified Resident 5 had an unwitnessed fall on May 16, 2025, and the SBAR, Risk Meeting and progress notes did not indicate the resident's representative was notified of the fall. On February 11, 2026, at 12:57 p.m., a concurrent record review of Resident 5's May 16, 2025, SBAR, Risk Meeting, progress notes, and an interview with the DON was conducted. The DON stated when a resident has a COC, notification to the resident's representative should be made at the time of the COC and the nurse should document the date and time the notification was made on the resident's SBAR and concurrent progress notes. The DON verified Resident 5 had an unwitnessed fall on May 16, 2025, and the SBAR, Risk Meeting and progress notes did not indicate the resident's representative was notified of the fall. A facility policy and procedure titled, Changes in Resident Condition, undated, indicated, .Purpose .The.resident representative (if resident has no capacity to make health care decisions.) are notified when changes in condition .occur .Procedure .The resident.representative.are notified by the Licensed Nurse/Company Designee when there is .an accident involving the resident which results in injury and has the potential for requiring physician intervention .

Based on interview and record review the facility failed to ensure a safe environment when: 1. Use of siderails were not implemented in accordance with the siderail evaluation conducted on May 24, 2025, for Resident 2. 2. A physician order was not obtained to implement siderails for one of three sampled residents (Resident 1). These failures had the potential to result in accidents or injury while in bed for Residents 1 and 2. Findings: On June 17, 2025, at 9:35 a.m., an unannounced visit was conducted to investigate a quality care issue. 1. On June 17, 2025, at 9:44 a.m., an interview was conducted with the Administrator (ADM), who stated Resident 2 had an unwitnessed fall out of bed. The ADM stated the following: a. The staff heard a Thump from resident's room, and found resident face down on the floor, next to her bed. b.The nursing staff called 911, and resident was sent to the General Acute Care Hospital (GACH) for evaluation. c. The resident had a history of seizures and was supposed to have siderails on her bed for safety. d. The Unit Manager (UM) assessed Resident 2's bed, after the fall, and stated there were no siderails. On June 17, 2025, at 2:30 p.m., an observation of Resident 2 was conducted. Resident 2 was observed resting in bed, connected to a ventilator, side rails noted on both sides of the bed. Resident 2 opened her eyes to the sound of this writer's voice, but unresponsive to questions. A review of Resident 2's admission record dated, June 18, 2025, indicated resident was admitted to the facility on [DATE], with diagnoses which included respiratory failure with dependance on a ventilator, and epilepsy (A brain disorder that causes seizures). Further review indicated, the resident was discharged from the facility on May 21, 2025, and re-admitted to the facility on [DATE]. A review of Resident 2's, Progress Notes, dated, June 2, 2025, at 3:47 a.m., edited at, 5:52 a.m., by Respiratory Therapist (RT), indicated, . (Resident 2) was found fallen out of bed onto face . Alerted all nearby staff . placed pillow under head as 911 was called. Gave report to (911) . hand off (of Resident 2) to (Emergency Medical Staff) . Further review of Resident 2's, Progress Notes, dated, June 2, 2025, at 5:46 a.m., by Registered Nurse (RN) 2, indicated, . RT heard loud thud . (RT) found (Resident 2) lying on right side next to bed on the floor. (RT) alerted staff and we assessed (resident), (resident) had a red right knee. (Resident 2) was still alert and appeared to have no change in mental status . (Resident in stable condition) . 911 was called at (4:50 a.m.). (Emergency Medical Staff) & (Fire Department) arrived at 4:58 (a.m.) . (Resident 2) was transferred to General Acute Care Hospital {GACH} at 05:07 (a.m.) . On June 17, 2025, at 2:55 p.m., an interview was conducted with Registered Nurse (RN) 1, who stated, residents with a history of seizures and required total care (total dependence on nursing staff for all care) have siderails for safety to help prevent falls out of bed. RN 1 stated, during the admission process, nursing staff would complete a siderail evaluation, and if the evaluation indicated resident required siderails for safety, the nurse would notify the physician, and upon receiving a physician order for siderails, siderails would be placed on the resident's bed. A review of Resident 2's re-admission progress note, dated, May 24, 2025, at 5:42 p.m., indicated, . re-admitted (Resident 2) at . 5:18 p.m., (May 24, 2025) from (GACH) . A review of Resident 2's Side Rail Evaluation, dated, May 24, 2025, at 10:20 p.m., indicated resident did require the use of siderails as a safety precaution. A review of Resident 2's physician dated, May 24, 2025, at 6:44 p.m., indicated resident had a physician order for, . Quarter side rails up . when in bed to minimize risk . On June 17, 2025, at 3:52 a.m., an interview was conducted with the Unit Manager (UM), who stated her expectations are for staff to keep residents safe. The UM further stated side rails were used to keep residents safe from falling out of bed. On June 17, 2025, at 5:35 p.m., an interview was conducted with Licensed Vocational Nurse (LVN) 1, who stated, she was working on (June 2, 2025), when Resident 2 was found on the floor. LVN stated the RT called out for staff to help, and she went to resident's room, she observed Resident 2 face down on the floor next to her bed, and the bed had no side rails. LVN 1 further stated, she was Resident 2's nurse that night, and she did not see physician orders for side rails. Further review of Resident 2's physician orders, indicated resident's side rail orders were discontinued on May 25, 2025, at 6:22 a.m., and not renewed, prior to Resident 2 falling out of bed on June 2, 2025. On June 18, 2025, at 11:58 a.m., a concurrent interview was conducted with the UM, and record review of Resident 2's side rail physician order. The UM verified Resident 2's physician order for the siderails was discontinued on May 25, 2025, and not renewed prior to resident falling out of bed on June 2, 2025. The UM stated, she was not sure why Resident 2's physician order for side rails was discontinued, but the order should have been renewed, as resident's side rail evaluation from May 24, 2025, indicated Resident 2 needed side rails for safety. The UM further stated, her expectations were for nursing staff to check the resident's previous side rail evaluation, physician orders, and should notify the physician if they think a resident is missing side rails on their bed. On June 18,2025, at 12:55 p.m., a concurrent interview with the Director of Nursing (DON), and record review of Resident 2's Side Rail evaluation completed on May 24, 2025, and physician orders was conducted. The DON verified, resident's Side Rail evaluation indicated, resident did require the use of siderails for Safety precaution. The DON further verified, Resident 2's physician order for side rails was discontinued on May 25, 2025, and not renewed, prior to resident's fall out of bed on June 2, 2025. The DON stated, her expectations were for nursing staff to check the last side rail evaluation to ensure residents have side rails if deemed necessary, make sure side rail physician orders were received following the evaluation, and should implement the side rails. A review of the facility policy and procedure( P & P) titled, Side Rails, undated, indicated, . An example of appropriate, medically necessary side rail use for a non-mobile resident might be protection from falls related to strong involuntary spasms or seizures . Nursing completes Side Rail Evaluation form . Obtain MD order, including diagnosis/medical necessity for use of restraint . A review of the facility P&P titled, Fall Management, undated, indicated, . Purpose: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to reduce the risk of the resident falling and to try to minimize complications from falling . The nursing staff, in conjunction with the attending physician . will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information . The nursing staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of fall . 2. A review of Resident 1's admission record dated June 19, 2025, indicated the resident was admitted to the facility on [DATE], with diagnoses which included chronic respiratory failure and dependence on a ventilator (a mechanical breathing device to assist with inadequate independent breathing). On June 17, 2025, at 2:55 p.m., during an interview, Registered Nurse (RN) 1 stated, residents with history of seizures and need total care (total dependence on nursing staff for all care) have siderails for safety to help prevent falls from bed. RN 1 stated, during the admission process, nursing staff would complete a siderail evaluation, and if the evaluation indicated resident would require siderails for safety, the nurse would notify the physician. RN 1 stated as soon as a physician order for siderails were obtained, then side rails would be implemented and placed on the resident's bed. A review of Resident 1's, Side Rail evaluation, dated, March 13, 2025, at 2:51 a.m., indicated, .Resident (1) require(s) the use of siderails(s) . A review of Resident 1's physician orders did not indicate an order for a side rail until April 8, 2025. On June 17, 2025, at 3:52 a.m., an interview was conducted with the Unit Manager (UM), who stated her expectations were for staff to keep residents safe. The UM further stated side rails are used to keep residents safe from falling out of bed. On June 18, 2025, at 11:58 a.m., during a concurrent interview with UM, and record review of Resident 1's siderail evaluation and physician orders. The UM verified, Resident 1's Side Rail evaluation, indicated resident required the use of siderails, and did not have a physician order for side rails, until April 8, 2025. The UM stated the nursing staff should have obtained a physician order for siderails after the siderail evaluation was completed on March 13, 2025. On June 18,2025, at 12:55 p.m., during a concurrent interview with the Director of Nursing (DON), and record review of Resident 1's siderail evaluation and physician order, the DON verified Resident 1 did require the use of siderails. The DON stated the nursing staff were expected to check the last siderails evaluation to ensure residents would have siderails if deemed necessary, and to make sure a physician order was obtained for the siderails and that it was carried. A review of the policy and procedure (P&P) titled, Side Rails, undated, indicated, . An example of appropriate, medically necessary side rail use for a non-mobile resident might be protection from falls related to strong involuntary spasms or seizures . Nursing completes Side Rail Evaluation form . Obtain MD order, including diagnosis/medical necessity for use of restraint .

Based on observation, interview, and record review, the facility failed to implement proper infection control precaution in accordance with the facility policy and procedure, when one of nine residents (Resident 1) was identified positive of carbapenem-resistant pseudomonas aeruginosa (CRPA - a type of bacteria resistant to a powerful class of antibiotics) on March 28, 2025. This failure had the potential to negatively impact the vulnerable residents in the subacute care (a level of care needed by a resident who does not require hospital acute care but who requires more intensive licensed skilled nursing care than is provided to the majority of patients in a skilled nursing facility) unit. Findings: A review of Resident 1's admission record indicated the resident was initially admitted in the facility on September 28, 2024, and re-admitted on [DATE], with diagnoses which included respiratory failure with tracheostomy (an opening surgically created through the neck into the windpipe to allow air to fill the lungs) and resistance to carbapenems (occurs when bacteria defeat the antibiotic designed to kill them). A review of Resident 1's Sputum Culture, Final Update Result, dated March 28, 2025, indicated there was heavy growth of CRPA. A review of the same document indicated that the medical doctor (MD) was notified and ordered no antibiotics and for the staff to monitor. On May 28, 2025, at 12:15 p.m., during observation, there was contact precaution (used to prevent the spread of infections transmitted through direct or indirect contact with a patient or environment) and droplet precaution (used to prevent the spread of diseases that are transmitted through respiratory droplets generated by an infected individual when coughing and sneezing) signs posted outside the door of Resident 1' s room. Resident 1 was lying in bed, turned to his left side, with tracheostomy connected to oxygen. On May 28, 2025, at 1:20 p.m., during an interview, Registered Nurse (RN) 1 stated on March 16, 2025, the resident had a fever and sputum culture was ordered and an antibiotic therapy was started. RN 1 stated the facility received the final sputum culture result on March 28, 2025, which indicated heavy growth of CRPA. RN 1 stated it was another RN who received the results. RN 1 stated there was no documentation in the progress notes that the RN notified the Infection Preventionist (IP) on Resident 1 ' s sputum culture result. RN 1 stated the IP should be notified when a resident ' s laboratory result indicated CRPA. On May 28, 2025, at 1:35 p.m., during an interview, the IP stated on April 22, 2025, RN 2 reported Resident 2 ' s sputum culture result which came out positive of CRPA on March 28, 2025. The IP stated she moved Resident 1 to a different room and placed the resident on contact and droplet precaution. The IP stated she did not receive any report that Resident 1 had CRPA before April 22, 2025. The IP stated Resident 1 should have been placed on contact isolation immediately on March 28, 2025. The IP stated contact isolation required for the staff to don PPE (Personal Protective Equipment) every time they would enter the residents ' room regardless of what they are going in for and residents have dedicated equipment such as blood pressure machine and stethoscope. The IP stated CRPA required contact isolation. On May 28, 2025, at 4:19 p.m., during an interview, the Director of Nursing (DON) stated the facility received Resident 1's sputum culture result but was not reviewed. The DON stated nothing was implemented until April 22, 2025. The DON stated the RN did not notify the IP when she received Resident 1's sputum culture. In addition, the DON stayed the RN should have reported the culture result to the IP and to the physician and document it. On May 29, 2025, at 11:25 a.m., during an interview, the IP stated Resident 1 was not on contact isolation for a month. A review of the undated facility policy and procedure titled, Carbapenem Resistant Pseudomonas Aeruginosa (CRPA), indicated, .The facility will adhere to the Centers for Disease Control and Prevention (CDC) guidelines for the surveillance, diagnosis, and treatment of Carbapenem-resistant Pseudomonas Aeruginosa (CRPA) . The facility will adhere to the CDC's recommendations to prevent CRPA transmission .Contact Precautions: Place CRPA colonized or infected residents on Contact Precautions (CP) .

Based on interview and record review, the facility failed to maintain an accurate reconciliation of the controlled medication that had been administered for two of three sampled residents (Residents 2 and 3). This failure increased the risk for medication error, which could negatively impact the residents' health condition. Findings: A review of Resident 2's admission Record, indicated the resident was admitted to the facility on [DATE], with diagnoses which included fracture (break in the bone) of right humerus (upper arm bone). A review of Resident 2 ' s Physician Order Report, for May 2025, indicated, oxycodone (narcotic medication) - Schedule II tablet; 5 mg (milligram-unit of measurement); amt (amount): 1 tab; oral Special Instructions: Dx (diagnosis) Moderate pain 5-6 (pain level), Severe pain 7-10 (pain level) Every 4 (four) Hours - PRN . Further review of the physician order report indicated the medication was ordered on May 2, 2025. On May 29, 2025, at 10:20 a.m., during an interview, Licensed Vocational Nurse (LVN) 1 stated when administering narcotics, the nurses are expected to sign on the narcotic sheet that they removed the medication and then sign the Medication Administration Record (MAR) after administering the medication. During a concurrent review of Resident 2' s narcotic sheet and electronic MAR for May 2025, LVN 1 stated Resident 2' s Oxycodone was removed from the medication cart on the following dates and times: a. May 6, 2025, at 8:39 a.m., and 8:45 p.m.; b. May 7, 2025, at 6:50 a.m. and 11:30 a.m.; c. May 8, 2025, at 9:34 a.m.; and d. May 11, 2025, at 11:54 p.m. LVN 1 stated oxycodone was not documented in the MAR as administered on May 6, May 7, May 8, and May 11, 2025. LVN 1 stated the licensed nurses should sign the MAR that they administered the medication. A review of Resident 3's admission record, indicated the resident was initially admitted to the facility on [DATE], and was re-admitted on [DATE], with diagnoses which included urinary tract infection. A review of Resident 3's Physician Order Report, for May 2025, indicated, acetaminophen-hydrocodone (Norco - narcotic) 325-5 mg tablet; 5/325 MG; amt: 1 tab; oral Special Instructions: PRN Moderate pain (SCALE 5-6) OR Severe pain (SCALE 7-10) .Every 4 Hours - PRN . The physician order report indicated the medication was ordered on April 9, 2025. On May 29, 2025, at 11:07 a.m., during an interview and record review of Resident 3 ' s narcotic sheet and electronic MAR for May 2025, the Infection Preventionist (IP) stated, Resident 3 ' s Norco was removed from the medication cart on May 1, 2025, at 4:35 p.m., on May 13, 2025, at 12:47 p.m., and May 14, 2025, at 8:57 a.m., but was not documented on the MAR as administered. The IP stated the practice was when narcotics were given, the licensed nurses should be signing the MAR. On May 29, 2025, at 2:15 p.m. during an interview, the Director of Nursing (DON) stated the licensed nurses should sign the narcotic sheet and the MAR when they administer narcotic medications. The DON stated the facility policy for Controlled Substances should be followed. On May 29, 2025 at 3:40 p.m., during a concurrent interview with LVN 2 and a record review of Residents 2 and 3's narcotic sheet and MAR, LVN 2 stated he would document narcotics administration on the narcotic sheet and on the MAR. LVN 2 stated he administered Resident 3's Norco on May 1, 2025 and Resident 2's oxycodone on May 6, 2025, but he did not document on the MAR. LVN 2 stated he probably got busy and he should have documented on Residents 2 and 3's MAR. A review of the facility policy and procedure titled, Controlled Substances, dated November 2017, indicated .Controlled Medications are . medications are subject to special handling, storage, disposal, and record keeping at the nursing care center, in accordance with federal and state laws and regulations . When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record when removing dose from controlled storage .Date and time of administration .Amount administered .Signature of the nurse administering the dose .Administer the controlled medication and document dose administration on the MAR .

Based on observation, interview, and record review, the facility failed to ensure for 12 of 14 residents, Residents 2, 3, 4, 5, 6, 8, 9, 10, 11, 12, 13 and 14, infection control practices where in place when multiple respiratory equipment was not changed and dated according to the facility ' s policy and procedure. Findings: On February 26, 2025, an unannounced visit was conducted at the facility. On February 26, 2025, at 8:36 a.m., during an interview, Respiratory Therapist (RT) 1 stated respiratory equipment was changed routinely and as needed (PRN). RT 1 stated they have a schedule to follow. RT 1 stated ventilator circuits, bacterial viral filters (BVF) are changed monthly and PRN; the heat moisture exchangers (HME - a miniature artificial nose that warms and moisten the air a person breathes through their tracheostomy) are changed every Monday, Wednesday and Friday; the [NAME] suction catheters (a medical device that allows to safely suction (remove mucus) from a patient's airway (like through a tracheostomy tube) while they are still on a ventilator, without disrupting their ventilation) are changed every Tuesday. The HHNs are changed every Saturday. The oxygen tubing is changed every Thursday. On February 26, 2025, at 9:03 a.m., during a concurrent observation of Resident 2 and interview with RT 1, Resident 2 was in her room awake, alert and sitting in bed, with a tracheostomy tube (trach tube - a tube inserted through a surgically created opening in the neck, directly into the windpipe to help a person breathe when their mouth and nose are obstructed or not working properly) connected to a ventilator (vent -a medical device that helps a patient breathe). RT 1 stated the oxygen tubing was dated January 30, 2025, and should have been changed. On February 26, 2025, at 9:08 a.m., during a concurrent observation of Resident 3 and an interview with RT 1, Resident 3 was in her room, lying in bed with eyes closed, with a trach tube connected to a vent. RT 1 stated the BVF filter was dated January 21, 2025, and should have been changed on February 21, 2025. On February 26, 2025, at 9:12 a.m., during a concurrent observation of Resident 4 and an interview with RT 1, Resident 4 was in his room, lying in bed with eyes closed, with a trach tube connected to a vent. RT 1 stated the HHN and suction tip were undated and should have been dated when changed. On February 26, 2025, at 9:20 a.m., during a concurrent observation of Resident 8 and an interview with RT 1, Resident 8 was in his room, lying in bed with eyes closed, with a trach tube connected to a vent. RT 1 stated the BVF was undated and should have been dated when changed. On February 26, 2025, at 9:22 a.m., during a concurrent observation of Resident 9 and an interview with RT 1, Resident 9 was in her room, lying in bed with eyes closed, with a trach tube connected to a vent. RT 1 stated the BVF and oxygen tubing were undated and should have been dated when changed. On February 26, 2025, at 9:24 a.m., during a concurrent observation of Resident 5 and an interview with RT 1, Resident 5 was in his room, awake, alert, lying in bed, watching television, with a trach tube connected to a vent. RT 1 stated the BVF was dated March 5, 2025. RT 1 stated the RT who changed the BVF may have dated it for when it needs to be change. RT 1 stated the RT should have dated the BVF on the date it was changed. On February 26, 2025, at 9:30 a.m., during a concurrent observation of Resident 6 and an interview with RT 1, Resident 6 was in her room, lying in bed with eyes closed, with a trach tube connected to a vent. RT 1 stated the HHN was undated and should have been dated when changed; the BVF was dated December 6, 2024, and should have been changed on January 6, 2025; the oxygen tubing was dated January 30, 2025, and should have been changed on February 20, 2025. On February 26, 2025, at 9:33 a.m., during a concurrent observation of Resident 10 and an interview with RT 1, Resident 10 was in her room, lying in bed with eyes closed, with a trach tube connected to a vent. RT 1 stated the HHN was not dated and should have been dated when changed; the BVF filter was dated January 9, 2025, and should have been changed on February 9, 2025. On February 26, 2025, at 9:37 a.m., during a concurrent observation of Resident 11, and an interview with RT 1, Resident 11 was in his room, lying in bed with eyes closed, with a trach tube connected to a vent. RT 1 stated the HHN and BVF were not dated and should have been dated when changed. On February 26, 2025, at 9:39 a.m., during a concurrent observation of Resident 12, and an interview with RT 1, Resident 12 was in his room, lying in bed with eyes closed, with a trach tube connected to a vent. RT 1 stated the HHN and BVF were not dated and should have been dated when changed. On February 26, 2025, at 9:43 a.m., during a concurrent observation of Resident 13, and an interview with RT 1, Resident 13 was in his room, lying in bed with eyes closed, with trach connected to a vent. RT 1 stated the BVF was undated and should have been dated when changed; the oxygen tubing was dated January 30, 2025, and should have been changed on February 20, 2025. On February 26, 2025, at 9:46 a.m., during a concurrent observation of Resident 14, and an interview with RT 1, Resident 14 was in his room, lying in bed, alert and awake, with a trach tube connected to an oxygen concentrator (a medical device that gives you extra oxygen). RT 1 stated the oxygen tubing was dated January 30, 2025, and it should have been changed on February 20, 2025. On February 26, 2025, at 10:59 a.m., during an interview, RT 1 stated the RTs should date respiratory equipment when changing it to ensure they follow routine equipment changes as scheduled, prevent the use of outdated respiratory equipment on residents and maintain infection control standards. On February 26, 2025, at 4:15 p.m., during an interview, Registered Nurse (RN) 1, who was also the Sub-acute Coordinator, stated the night shift (6:30 p.m. - 6:30 a.m.) RTs were responsible for changing respiratory equipment and they should be dating and documenting when equipment is changed. RN 1 further stated it was important to date and change respiratory equipment to keep track of when it was changed and to maintain infection control practices. A review of the undated facility document titled, RESPIRATORY EQUIPMENT CHANGE SCHEDULE indicated .NIGHT SHIFT .TUESDAY .BALLARDS . THURSDAY .O2 (OXYGEN) TUBING .SATURDAY .HHNS .CHANGE EQUIPMENT PRN IF NEEDED .VENT CIRCUITS & BAC FILTERS (BVF) ARE TO BE CHANGED EVERY 5TH OF THE MONTH .DATE EQUIPMENT NEATLY AND VISIBLY WITH DAY, MONTH AND YEAR . A review of the facility ' s undated policy and procedure titled, .Changing Disposable Equipment indicated .Disposable equipment is for single patient use only and be change (sic) as regularly scheduled and on a PRN basis .Disposable equipment must be labeled with the patient ' s name and date. Equipment such as (i.e. yankers (sic), suction tubing and HHN) must be bagged individually and label (sic) properly .

Based on observation, interview, and record review, the facility failed to ensure that the ventilators (vent -a medical device that helps a patient breathe), for eight of 12 residents, Residents 1, 2, 3, 4, 5, 6, 7, and 8, were serviced by the due dates indicated on the label at the back of the vents and according to the manufacturer ' s recommendation. This failure had the potential to result in Residents 1, 2, 3, 4, 5, 6, 7, and 8 ' s increased risk for infection and improper ventilation. Findings: On February 26, 2025, an unannounced visit was conducted at the facility. On February 26, 2025, at 8:36 a.m., during a concurrent observation of Resident 1 with Respiratory Therapist (RT) 1, Resident 1 was lying in bed with eyes closed, with a tracheostomy tube (trach tube - a tube inserted through a surgically created opening in the neck, directly into the windpipe to help a person breathe when their mouth and nose are obstructed or not working properly) connected to a vent. RT 1 stated Resident 1 ' s vent had a label indicating a service due date of March 2, 2024. The RT checked the vent settings and stated the vent had 22,864 blower hours (BH - cumulative runtime of the vent ' s blower or turbine, which is responsible for generating airflow and pressure for patient ventilation). On February 26, 2025, at 9:03 a.m., during a concurrent observation of Resident 2 and an interview with RT 1, Resident 2 was in her room awake, alert and sitting in bed, with a trach tube connected to a vent. RT 1 stated Resident 2 ' s vent had a service due date of March 22, 2024, and had 25,042 BH. On February 26, 2025, at 9:08 a.m., during a concurrent observation of Resident 3 and an interview with RT 1, Resident 3 was in her room, lying in bed with eyes closed, with a trach tube connected to a vent. RT 1 stated Resident 3 ' s vent had a service due date of December 6, 2024, and had 11,645 BH. On February 26, 2025, at 9:12 a.m., during a concurrent observation of Resident 4 and an interview with RT 1, Resident 4 was in his room, lying in bed with eyes closed, with a trach tube connected to a vent. RT 1 stated Resident 4 ' s vent had a service due date of December 6, 2024, and had 7,938 BH. On February 26, 2025, at 9:24 a.m., during a concurrent observation of Resident 5 and an interview with RT 1, Resident 5 was in his room, , awake, alert, lying in bed, watching television, with a trach tube connected to a vent. RT 1 stated Resident 5 ' s vent had a servcice due date of December 6, 2024, and had 10,861 BH. On February 26, 2025, at 9:30 a.m., during a concurrent observation of Resident 6 and an interview with RT 1, Resident 6 was in her room, lying in bed with eyes closed, with a trach tube connected to a vent. RT 1 stated Resident 6 ' s vent had a service due date of July 5, 2023, and had 18,298 BH. On February 26, 2025, at 9:43 a.m., during a concurrent observation of Resident 7 and interview with RT 1, Resident 7 was in his room, lying in bed with eyes closed, with a trach tube connected to a vent. RT 1 stated Resident 7 ' s vent had a service due date of December 6, 2024, and had 13,234 BH. A review of Resident 1 ' s medical record indicated she was admitted to the facility on [DATE], with diagnoses which indicated anoxic brain damage (damage to the brain caused by a complete lack of oxygen), respiratory failure (a serious condition that occurs when your lungs can't get enough oxygen into your blood) with tracheostomy and dependence on vent. A review of Resident 2 ' s medical record indicated she was admitted readmitted to the facility on [DATE], with diagnoses which indicated respiratory failure with tracheostomy and dependence on vent. A review of Resident 3 ' s medical record indicated she was admitted to the facility on [DATE], with diagnoses which included anoxic brain damage (a condition when the brain is completely deprived of oxygen) and respiratory failure with tracheostomy and dependence on vent. A review of Resident 4 ' s medical record indicated he was readmitted to the facility on [DATE], with diagnoses which included nontraumatic intracerebral hemorrhage (bleeding within the brain tissue without any head injury) and respiratory failure with tracheostomy and dependence on vent. A review of Resident 5 ' s medical record indicated he was readmitted to the facility on [DATE], with diagnoses which included respiratory failure with tracheostomy and dependence on vent. A review of Resident 6 ' s medical record indicated she was readmitted to the facility on [DATE], with diagnoses which included respiratory failure with tracheostomy and dependence on vent. A review of Resident 7 ' s medical record indicated he was readmitted to the facility on [DATE], with diagnoses which included stroke (a condition when blood flow to the brain is interrupted) with right sided weakness, respiratory failure with tracheostomy and dependence on vent. On February 26, 2025, at 10:59 a.m., during an interview, RT 1 stated the vents should undergo preventative maintenance (PM) yearly, based on the due dates indicated on the labels, to ensure that the vents were functioning properly and for residents ' safety. RT 1 stated he was instructed to focus on the vents ' BH instead. RT 1 stated if the vent had not reached 30,000 BH, it was considered safe to use. RT 1 stated it was his responsibility to ensure that the vents undergo PM, and he requested for the PM of the vents last week to his Supervisor and the owner of (name of respiratory company) over the phone. RT 1 stated once he made the request, it was beyond his control. On February 26, 2025, at 4:45 p.m., during an interview, the ADM stated the RN Sub-acute Coordinator and RT 1 should ensure that all vents are functioning and had undergone PM. The ADM stated she was unaware that the vents had not undergone PM. The ADM stated the vents for Residents 1, 2, 3, 4, 5, 6, 7, and 8 should have undergone PM on the due dates indicated on the label of each vent. A record review of the undated operating manual of the vents titled [NAME] 50 Operating Manual indicated .Regular maintenance inspections and controls shall be carried out at least every 12 months .

Based on interview and record review, the facility failed to timely (within three months) complete the quarterly MDS (Minimum Data Set - an assessment tool used to evaluate the health status of nursing home residents) assessment for six of 81 residents still in the facility (Residents 57, 14, 38, 28, 30 and 35). This failure had the potential to negatively impact the residents' quality of care and had the potential for staff to not be aware of the residents' care needs and provide appropriate treatment. Findings: On December 11, 2024, at 10:05 a.m., an interview and concurrent record review was conducted with the MDS nurse. The MDS nurse stated Resident 57's MDS quarterly assessment was over three months old. The MDS quarterly assessment was reviewed for all 81 residents in the facility. Five other residents did not have the MDS quarterly assessment completed within three months from the last assessment on August 4, 2024: Resident 14, Resident 38, Resident 28, Resident 30, and Resident 35. The MDS nurse stated the MDS assessments for Residents 57, 14, 38, 28, 30, and 35 should have been completed by November 4, 2024, within three months from the last quarterly assessment, which was August 4, 2024. On December 11, 2024, at 11:54 am, an interview and concurrent record review was conducted with the Director of Nursing (DON). The DON confirmed the quarterly MDS assessments for Residents 57, 14, 38, 28, 30, and 35 was not completed timely, and it should have been done within three months (92 days) from the last quarterly assessment. The facility policy and procedure titled, .Submission and Correction of the MDS Assessments ., revised October 2023, was reviewed. The policy indicated, .Nursing homes are required to submit Omnibus Budget Reconciliation Act (OBRA) required Minimum Data Set (MDS) records for all residents in Medicare- or Medicaid-certified beds regardless of the payer source .An OBRA assessment (comprehensive or Quarterly) is due every quarter unless the resident is no longer in the facility .

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1a. One half gallon carton of Mocha Mix in the number two reach-in refrigerator did not have a use-by-date and was readily available for use; 1b. One Ziploc bag containing shredded carrots in the number three reach-in refrigerator did not have a use-by-date; and 2. One four ounce orange sherbet container and black residue were observed on the floor behind the freezer racks of the walk-in freezer. These failures had the potential to cause foodborne illness (illness caused by food contaminated with bacteria, viruses, parasites, and toxins) in vulnerable and medically compromised residents. Findings: 1a. On December 9, 2024, at 9:59 a.m. a concurrent observation and interview was conducted with the Food Service Assistant (FSA) in front of the number two reach-in refrigerator. One half gallon carton of Mocha Mix was labeled opened on 11-29-24. The Mocha Mix did not have a use-by-date label. The FSA stated the Mocha Mix should have a use-by-date label. She stated the kitchen staff who opened the Mocha Mix should have placed the use-by-date label. 1b. On December 9, 2024, at 10:20 a.m., a concurrent observation and interview was conducted with the FSA in front of the number three reach-in refrigerator. A Ziploc bag containing shredded carrots was dated 12/7/24. The Ziploc bag containing the shredded carrots did not have a use-by-date label. The FSA stated the date on the Ziploc bag was when the shredded carrots were prepared and stored. She stated there should be a use-by-date label for the shredded carrots. 2. On December 9, 2024, at 10:16 a.m., a concurrent observation and interview was conducted with the FSA inside the walk-in freezer. One small cup of sherbet was observed on the floor and black residue covered the floor and lower part of the wall behind the freezer rack. The FSA stated the cup of sherbet should not be on the floor and the black residue should have been cleaned behind the freezer racks. She stated she was responsible for cleaning the walk-in freezer twice a month. On December 9, 2024, at 11:01 a.m. an interview was conducted with the Food Service Director (FSD). The FSD stated the Mocha Mix and the Ziploc bag containing the shredded carrots should have the name of the food item, the date prepared/stored, and the use-by-date. He stated it was not safe without the use-by-date. He stated there should be a daily visualization of the the floor and cleanliness of the walk-in freezer. A review of the facility's undated policy and procedure titled, FOOD RECEIVING AND STORAGE OF COLD FOODS, indicated, .All perishable food items purchased by the department of food and dining services will be stored properly. Perishable food will be kept refrigerated .All open food items will have an open date and use-by-date per manufacturer's guidelines . A review of the facility's undated policy and procedure titled, SANITATION AND INFECTION CONTROL, indicated, .The Dining Service Director will develop comprehensive cleaning schedules that staff will follow in order to maintain a sanitary department, prevent cross contamination, and meet state/federal requirements .The Director of Food and Nutrition Services should routinely check cleaning schedules and cleanliness of the kitchen .

Based on observation, interview, and record review, the facility failed to ensure the accountability of controlled medications (those with high potential for abuse and addiction) and the appropriate use of pain medications when: 1. The Controlled Drug Records (accountability records, an inventory sheet that keeps records of the usage of controlled medications) for five of six residents reviewed (Residents 7, 53, 54, 68, and 70) did not reconcile with the Medication Administration Records (MAR). This failure resulted in inaccurate accountability and the potential for abuse and diversion of controlled medications; and 2. Nursing staff failed to administer one medication as ordered by the prescriber for one of five residents reviewed (Resident 70). This failure resulted in Resident 70 receiving a dose of pain medication without the appropriate indication. Findings: 1a. Resident 7 had a physician order, dated November 20, 2024, for oxycodone (a controlled medication for pain) 5 milligrams (mg), one tablet by mouth every four hours as needed for moderate pain. During a concurrent interview and record review on December 10, 2024, at 11:19 a.m., with Licensed Vocational Nurse (LVN) 1, Resident 7's oxycodone 5 mg Controlled Drug Record (CDR) and November 2024 MAR were reviewed. LVN 1 confirmed the CDR indicated the nursing staff signed out one tablet on the following dates and times but did not document the administration on the MAR (total of two doses) on November 22, 2024, at 8:36 a.m. and November 27, 2024, at 6 p.m. Resident 7 had an additional physician order, dated November 22, 2024, for oxycodone 10 mg, one tablet by mouth every four hours as needed for severe pain. During a concurrent interview and record review on December 10, 2024, at 11:19 a.m., with LVN 1, Resident 7's oxycodone 10 mg CDR and December 2024 MAR were reviewed. LVN 1 confirmed the CDR indicated the nursing staff signed out one tablet on the following dates and times but did not document the administration on the MAR (total of two doses) on December 4, 2024, at 12 a.m. and December 9, 2024, at 6:35 a.m. 1b. Resident 54 had a physician order, dated December 3, 2024, for hydrocodone with acetaminophen (a controlled medication for pain, generic for Norco) 5-325 mg, one tablet by mouth every six hours as needed for moderate and severe pain. During a concurrent interview and record review on December 10, 2024, at 11:40 a.m., with LVN 1, Resident 54's Norco 5-325 mg CDR and December 2024 MAR were reviewed. LVN 1 confirmed the CDR indicated the nursing staff signed out one tablet on the following date and time but did not document the administration on the MAR (total of one dose) on December 10, 2024, at 2 a.m. 1c. Resident 53 had a physician order, dated March 4, 2024, for oxycodone with acetaminophen (a controlled medication for pain, generic for Percocet) 10-325 mg, one tablet by mouth every four hours as needed for severe pain. Resident 53 had an additional physician order, dated May 29, 2024, for Percocet 10-325 mg, one tablet by mouth every six hours routinely for pain. During a concurrent interview and record review on December 10, 2024, at 12:21 p.m., with the Director of Nursing (DON), Resident 53's Percocet 10-325 mg CDR and December 2024 MAR were reviewed. The DON verified there was only one CDR for the two Percocet 10-325 mg orders. The DON confirmed the CDR indicated the nursing staff signed out one tablet on the following dates and times but did not document the administration on the MAR (total of two doses) on December 8, 2024, at 11 p.m., and December 9, 2024, at 11 p.m. 1d. Resident 70 had a physician order, dated August 13, 2024, for Norco 10-325 mg, one tablet by mouth every six hours as needed for moderate to severe right hand/wrist pain. During a concurrent interview and record review on December 10, 2024, at 12:48 p.m., with the DON, Resident 70's Norco 10-325 mg CDR and December 2024 MAR were reviewed. The DON confirmed the CDR indicated the nursing staff signed out one tablet on the following dates and times but did not document the administration on the MAR (total of four doses): - December 8, 2024, at 4 p.m.; - December 8, 2024, at 11:30 p.m.; - December 9, 2024, at 6 p.m.; and - December 9, 2024, at 11:45 p.m. 1e. Resident 68 had a physician order, dated May 2, 2024, for oxycodone 5 mg, one tablet by gastric tube (a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach) every eight hours as needed for moderate to severe pain, discontinued on December 2, 2024. Resident 68 had an additional physician order, dated December 2, 2024, for oxycodone 5 mg, one tablet by gastric tube every eight hours as needed for moderate to severe pain. During a concurrent interview and record review on December 10, 2024, at 3:58 p.m., with the Medical Records Director (MRD), Resident 68's oxycodone 5 mg CDR, November 2024 MAR, and December 2024 MAR were reviewed. The MRD confirmed the CDR indicated the nursing staff signed out one tablet on the following dates and times but did not document the administration on the MAR (total of seven doses): - November 13, 2024, at 12 a.m.; - November 20, 2024, at 1 a.m.; - December 1, 2024, at 5:20 p.m.; - December 3, 2024, at 4:15 a.m.; - December 4, 2024, at 12 a.m.; - December 4, 2024, at 5:25 p.m.; and - December 10, 2024, at 6 a.m. During a concurrent interview and record review on December 11, 2024, at 10:01 a.m., with the DON, the CDR and MAR for Residents 7, 53, 54, 68, and 70 were reviewed. The DON verified the controlled drug discrepancies for the five residents. The DON stated the expectation is for the CDR and the MAR to match. The DON stated timely documentation of medication administration in the MAR is important for resident safety to prevent accidental double dosing of medication. The DON stated the nurse needs to document the administration of the medication at the time it was given. During a phone interview on December 12, 2024, at 1:46 p.m., the Consultant Pharmacist (CP) stated controlled medication administration needs to be documented in the MAR if the resident got the medication. During a review of the facility's policy and procedure (P&P) titled, Medication Administration: Controlled Substances, dated November 2017, the policy indicated, .Administer the controlled medication and document dose administration on the MAR . 2. During a medication pass observation on December 9, 2024, at 12:12 p.m., LVN 2 was observed preparing and administering one medication, Norco 10-325 mg, to Resident 70. Resident 70 stated his pain level was an eight out of 10 and the pain was in his back, neck, and hips. A review of Resident 70's electronic medical record indicated a physician order, dated August 13, 2024, for Norco 10-325 mg, take one tablet by mouth every six hours as needed for RIGHT HAND /WRIST MODERATE PAIN (4-6 SCALE) - SEVERE PAIN ( 7-10 SCALE). During a concurrent interview and record review on December 9, 2024, at 2:53 p.m., with LVN 2, Resident 70's medical record was reviewed. LVN 2 stated she gave Resident 70 the Norco pain medication because Resident 70 said he had lower back pain, neck pain, and lower leg pain. LVN 2 verified the Norco orders indicated to give for right wrist or hand pain. LVN 2 stated Resident 70 did not have an active physician order for generalized moderate or severe pain. During a concurrent interview and record review on December 11, 2024, at 10:41 a.m., with the DON, Resident 70's medical record was reviewed. The DON verified Resident 70's Norco was indicated for right hand and wrist pain. The DON stated the medication needs to be given as indicated in the order. The DON verified Resident 70's Norco should only be given for right hand or wrist pain, not for other types of pain. The DON stated nursing needed to request updated orders to address Resident 70's pain management needs. During a phone interview on December 12, 2024, at 1:46 p.m., the CP stated the Norco order needed to have the correct indication. During a review of the facility's P&P titled, . Pain Management, undated, the policy indicated, .Administer a therapeutic intervention for pain - non-drug interventions or pain medication as ordered by the physician . During a review of the facility's P&P titled, .Medication Pass Guidelines, undated, the policy indicated, .Medications are administered in accordance with written orders of the attending physician .

Based on observation, interview, and record review, the facility failed to ensure a resident with post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event) was identified timely and the trauma informed practices and care plan were implemented for one of one resident reviewed (Resident 70). This failure resulted in Resident 70's verbalization of feeling sad and resulted in his mental and psychosocial needs not being met by the facility. Findings: On December 9, 2024, at 4 p.m., Resident 70 was observed sitting upright in his bed awake, alert, and able to verbalize his needs. Resident 70 verbalized the past history of trauma in his life. He was asking to talk to someone in regards to his feelings and about his PTSD. On December 10, 2024, Resident 70's record was reviewed. Resident 70 was admitted to the facility on [DATE], with diagnoses which included Chronic Obstructive Pulmonary Disease(COPD- lung disease). The history and physical dated April 20, 2024, indicated Resident 70 had the capacity to make health care decisions. The Minimum Data Set (MDS- an assessment tool) dated October 27, 2024, indicated Resident 70's Brief Interview for Mental Status (BIMS - an assessment tool to screen for cognitive impairment) a score of 13, being cognitively intact. The physician's orders dated April 19, 2024, indicated .May have Psychiatry and Psychology consult as needed . The (name of behavioral group) document dated June 5, 2024, indicated Resident 70 was visited by a psychologist (a mental health professional). The psychologist notes indicated Resident 70 .verbalized sadness, nervousness and depression .a traumatic life-history living with alcoholic mother and seven different abusive step fathers .placed in the foster care system at a young age .described his life as all trauma .heavy tobacco dependence, substance abuse including alcohol .abused by his partner .lost his finances .had severe automobile accident in his early 20's . There was no documented evidence Resident 70's pertinent psychosocial history and evaluation of the psychologist were discussed by the Interdisciplinary Team (IDT - a group of healthcare professionals from different disciplines who coordinates and deliver care to patients). There was no documented evidence a trauma informed care plan for Resident 70's was developed since June 5, 2024, after Resident 70 was evaluated by the psychologist. The document titled,Psychiatric Visit Progress Report, dated December 10, 2024, indicated, .Resident 70 wanted to ask about mental health, had PTSD and wanted therapy .severe depression . The physician's order dated December 10, 2024, indicated Resident 70 was started on Remeron (a medication used for depression) 15 milligram (mg - a unit of measurement) nightly for depression. On December 11, 2024, at 3:59 p.m., a concurrent interview and record review was conducted with the Social Service Director (SSD). The SSD stated Resident 70 did not verbalize any traumatic life history to her when he was admitted . She acknowledged she made a referral to the psychologist on June 5, 2024, when the staff told her Resident 70 was feeling sad and wanted to talk to someone. She stated she should have discussed the result of the psychologist's evaluation on April 5, 2024, with the IDT. She stated a care plan was not developed for Resident 70's PTSD. The facility's undated policy and procedure, titled, Trauma Informed Care, indicated, .To guide staff in appropriate and compassionate care specific to individuals who have experienced trauma .Trauma-informed care is culturally sensitive and person-centered .Caregivers are taught strategies to help eliminate, mitigate or sensitively address a resident's triggers .

Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. Certified Nursing Assistant (CNA) 1 did not wear personal protective equipment (PPE - equipment used to protect against infection or illness) when taking care of a resident (Resident 43) on enhanced barrier precautions (EBP - an infection control intervention designed to reduce transmission of multidrug resistant organisms in nursing homes); 2. The facility failed to place a resident (Resident 50) on EBP who had an indwelling urinary catheter (a tube placed in the body to drain and collect urine from the bladder); and 3. The facility failed to place a resident (Resident 248) on EBP who had a gastrostomy tube (a feeding tube through the skin and the stomach wall). These failures had the potential to increase the spread of multidrug resistant organisms and infections from staff to residents which could lead to illness or death. Findings: 1. On December 9, 2024, at 11:13 a.m., during an observation of the facility, Resident 43's room had a sign posted outside the door that indicated Enhanced Barrier Precuations .Providers and Staff Must .Wear gloves and a gown for the following high-contact resident care activities .any skin opening requiring a dressing . CNA 1 was observed not wearing PPE when providing care to Resident 43. During an interview on December 9, 2024, at 11:33 a.m. CNA 1 stated he forgot to wear PPE. CNA 1 agreed that Resident 43 was on EBP and further stated he should have worn PPE while providing care to prevent the spread of germs and protect the residents from infection. On December 9, 2024, at 12:15 p.m., an interview was conducted with LVN 3. LVN 3 stated that PPE must be worn when providing care to residents who have a gastrostomy tube, tracheostomy (a surgically created hole in the windpipe) or any type of catheter. LVN 3 further stated wearing PPE is important because it is for the resident's protection and staff's protection from micro-organisms, bacteria and secretions. On December 11, 2024, at 12:35 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated it is expected that staff adhere to PPE procedures to prevent spread of multiple organisms such as MRSA (Methicillin Resistant Staphylococcus Aureus - a germ that is resistant to some antibiotics), and other communicable diseases. On December 12, 2024, at 4:27 p.m., a review of Resident 43's admission record indicated he was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Resident 43's diagnosis included chronic respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in your body), urinary tract infection and MRSA. A review of Resident 43's History and Physical, dated September 9, 2024, indicated Resident 43 had the capacity to make decisions. A review of Resident 43's Physician Order Report, dated December 12, 2024, indicated, .Enhanced Barrier Precautions .for d/t (due to) indwelling catheter, feeding tube and tracheostomy . A review of the undated facility's policy and procedure (P&P) titled, Personal Protective Equipment Guidelines, the P&P indicated, .All employees using PPE are expected to observe .precautions . 44173 2. On December 9, 2024, at 3:09 p.m., Resident 248 was observed lying in bed. Resident 248 was observed to have a urinary catheter attached to a drainage bag. In a concurrent interview with Resident 248, he stated he came in to the facility with the urinary catheter. On December 11, 2024, Resident 248's record was reviewed. Resident 248 was admitted to the facility on [DATE], with diagnoses which included obstructive and reflux uropathy (a condition where the urine flow is hindered due to a blockage in the urinary tract, with a backflow of urine). 3. On December 9, 2024, at 4:02 p.m., Resident 50 was observed lying in bed. Resident 50 was observed to raise his shirt to show his gastrostomy tube located above the navel (belly button). In a concurrent interview with Resident 50, he stated he was being fed through the tube. He also stated the staff did not use gloves or a gown when they fed him. On December 11, 2024, Resident 50's record was reviewed. Resident 50 was admitted to the facility on [DATE], with diagnoses which included dysphagia (difficulty swallowing foods or liquids). There were no EBP signs posted on the doors of Residents 248 and 50, and no isolation carts with PPE available outside of their rooms. On December 9, 2024, at 3:33 p.m., during an interview with CNA 2, CNA 2 stated the use of PPE (gloves and gowns) is a must when emptying a urinary catheter or rendering care to residents on EBP. She stated there were no EBP signs posted on the door and isolation carts with PPE were not available outside the rooms for Residents 248 and 50. She stated there should have been an EBP sign posted on the doors and an isolation cart outside the rooms of Residents 248 and 50. On December 9, 2024, at 3:49 p.m., during an observation with CNA 3, CNA 3 entered the rooms of Residents 248 and 50. CNA 3 was observed to use alcohol based hand rub but did not use any PPE. In a concurrent interview with CNA 3, she stated she was not sure if an EBP sign should be posted for residents with indwelling catheter and gastrostomy tube. CNA 3 asked another staff member and verified an EBP sign should be posted on the door and an isolation cart with PPE should be available when a resident has a foley catheter or a gastrostomy tube. On December 9, 2024, at 4:01 p.m., during an interview with LVN 4, she stated residents with an indwelling urinary catheter, gastrostomy tube, and IV (intravenous - a thin, flexible tube inserted into a vein to deliver fluids, medications, blood products, or nutrition directly into the bloodstream) should be placed on EBP. She stated Resident 248, who had an indwelling urinary catheter and Resident 50, who had a gastrostomy tube should have an EBP sign posted on the door and an isolation cart with PPE available for use. LVN 4 also stated other staff like the CNAs would not be aware of the precautons if there was no EBP sign posted on the door. On December 10, 2024, at 11:13 a.m., during an interview with the Infection Prevention (IP) nurse, she stated residents with an IV, gastrostomy tube, indwelling urinary catheter, wounds, and ostomies (a surgically created opening in the body) should be placed on EBP. She stated there should be an EBP sign posted on the door and an isolation cart with PPE available outside the room. A review of the undated facility's P&P titled, Enhanced Barrier Precautions (EBP), the P&P indicated, .Infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) by employing targeted gown and glove use during high-contact resident care activities .EBP shall be used in conjunction with standard precautions and expand the use of personal protective equipment (PPE) to donning of gown and gloves during high-contact resident care activities that may result in transfer of MDROs to staff hands and clothing .EBP are indicated for residents with any of the following .Wounds and/or indwelling medical devices even if the resident is not known to ne infected or colonized with an MDRO .

Based on interview and record review, the facility failed to ensure one of five residents reviewed (Resident 196) was free of unnecessary medications when pain assessments were not documented with the administration of pain medications. This failure had the potential for unnecessary or ineffective pain management for Resident 196. Findings: Resident 196 had a physician order, dated December 6, 2024, for hydrocodone with acetaminophen (Norco, a controlled medication for pain) 5-325 milligrams (mg), one tablet by mouth every four hours as needed for Moderate pain 4-6 Severe pain 7-10. A review of Resident 196's December 2024 Medication Administration Record (MAR) indicated Resident 196 received a dose of Norco 5-325 mg on the following dates and times: - December 7, 2024, at 10:12 a.m.; - December 8, 2024, at 10:03 p.m.; - December 10, 2024, at 8:54 p.m.; and - December 11, 2024, at 8:27 a.m. The record did not indicate the pain rating scale (pain score, numerical value between zero and 10, where zero means no pain and 10 means severe pain) and pain assessment before or after the Norco administration. During an interview on December 9, 2024, at 2:53 p.m., Licensed Vocational Nurse (LVN) 2 stated the nurse needs to document the pain assessment, including pain score and pain location, when documenting the administration of the pain medication in the MAR. During an interview on December 11, 2024, at 10:36 a.m., the Director of Nursing (DON) stated the nurse needs to perform a pain assessment before and after administering a pain medication to the resident. The DON stated the nurse needs to correctly document the pain assessment before and after administering pain medication. The DON stated documentation of the pain assessment is important to assess effectiveness of the medication. The DON stated if the pain assessment is not documented, the facility will not know if the resident's pain was managed, improved, or got worse. During a concurrent interview and record review on December 12, 2024, at 11:10 a.m., with the DON, Resident 196's medical record was reviewed. The DON verified Resident 196 received Norco 5-325 mg without documentation of any pain assessment before and after medication administration. The DON stated the pain score before and after the Norco was given should have been documented. During a review of the facility's P&P titled, .Pain Management, undated, the policy indicated, .Document the resident's response to pain management in the Pain Management Flow Sheet .Record pain assessment results .Document in the electronic health records system .

Based on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was assessed timely following an unwitnessed fall. The facility also failed to provide notification to the physician following an unwitnessed fall. This failure had the potential for Resident 1 to experience a delay in the provision of care and complications such as, pain, bruising, scratches, lacerations (a deep cut or tear in skin), and fractures (a complete or partial break in a bone). Findings: On September 4, 2024, at 8:45 a.m., an unannounced visit was conducted at the facility to investigate a facility reported incident. Resident 1 was unavailable for an interview or observation due to being transferred out of the facility to a general acute care hospital (GACH) on August 18, 2024. A review of Resident 1's facility medical record indicated she was admitted to the facility on [DATE], with diagnoses that included osteoporosis (causes bones to become weak and brittle), cerebral infarction (stroke) and contracture of muscles (a shortening of muscles, tendons, or skin). On September 4, 2024, at 12:59 p.m., an interview was conducted with the facility's Respiratory Therapist (RTT). The RTT stated on August 15, 2024, at approximately 7:30 p.m., he overheard someone calling out for help. The RTT stated he went to Resident 1's room to investigate and found two Certified Nurse Assistants (CNAs) holding her at ground level attempting to get her back in bed. The RTT stated he entered Resident 1's room to assist the two CNAs. The RTT stated he informed the Licensed Vocational Nurse (LVN) Charge Nurse that there was an incident in Resident 1's room. The RTT stated he was informed by the two CNAs that the resident slid out of bed. The RTT stated he informed the LVN Charge Nurse the area where Resident 1 was located and what happened. On September 4, 2024, at 1:29 p.m., a telephone interview was conducted with CNA 2. CNA 2 stated she did work at the facility on Thursday, August 15, 2024, and was assigned to take care of Resident 1. CNA 2 stated she was providing care to another resident when she heard screaming coming from Resident 1's room. CNA 2 stated she when to Resident 1's room to investigate and found that half of Resident 1's body was on the floor and her head and chest were still on the bed. CNA 2 stated another CNA (CNA 3) came into the room to assist her. CNA 2 stated when the other CNA came in to help, she ran out of the room and told the Licensed Vocational Nurse (LVN) Charge Nurse what she found. CNA 2 stated she heard CNA 3 state to the LVN charge nurse that it was important that she come and see Resident 1. CNA 2 stated it was her understanding that the nurse should come to the room to check the patient if something like that happened. CNA 2 stated that she never saw the nurse enter Resident 1's room. CNA 2 stated the resident did not complain of pain but expressed that she was scared. On September 4, 2024, at 1:41 p.m., a telephone interview was conducted with the LVN Charge Nurse (LVN 2). LVN 2 stated she worked at the facility for approximately one month. LVN 2 stated she received training on resident rights and resident safety upon hire at the facility. LVN 2 further stated she was no longer employed at the facility. LVN 2 stated she was assigned to provide care for Resident 1 on August 15, 2024. LVN 2 stated there was no incident that occurred that was out of the ordinary and there were no incidents that were reported to her on August 15, 2024. LVN 2 denied being told that there were any changes with Resident 1. On September 4, 2024, at 1:41 p.m., a telephone interview was conducted with CNA 3. CNA 3 stated she did work at the facility on August 15, 2024, but was not assigned to take care of Resident 1 that day. CNA 3 stated on August 15, 2024, she was picking up all the trays from dinner and heard the sound of screaming. CNA 3 stated CNA 2 was in Resident 1's room trying to help Resident 1 back in bed. CNA 3 stated she began helping CNA 2, when the RTT entered the room and began to help. CNA 3 stated they called the nurse and informed her of what happened. CNA 3 stated she was not aware if the nurse went to see that resident but the LVN Charge Nurse was told about the incident. On September 4, 2024, at 2:54 p.m., an interview was conducted with Registered Nurse (RN) 2. RN 2 stated she did work at the facility on Thursday, August 15, 2024. RN 2 stated if a CNA or other facility staff reports a fall or unusual occurrence to the LVN charge nurse, an assessment of the resident should be completed immediately. RN 2 further stated that it is the expectation that the LVN charge nurse notify the Nursing Supervisor immediately. RN 2 further stated the risk associated with failing to immediately assess the resident is that an injury or change in the resident's condition could be missed. RN 2 also stated that the physician and resident's family should have been notified when the fall occurred. On September 4, 2024, at 3:11 p.m., an interview was conducted with the facility Administrator (ADM). The ADM stated it is the expectation that the LVN charge nurse complete an assessment and notify the Nursing Supervisor if there is any reported fall or change in the resident's condition. The ADM further stated that Resident 1's physician and family should have been notified of the incident. On September 5, 2024, at 11:08 a.m., a telephone interview was conducted with the facility's Medical Director (MD) who stated he did not receive any notice of Resident 1's fall on August 15, 2024. A review of Resident 1's facility medical record did not indicate any documentation of the incident or notification to the physician on August 15, 2024. A review of the facility's policy and procedure titled Changes in Resident Condition, undated, was reviewed. The policy indicated .the resident, attending Physician and resident representative .are notified when changes in condition or certain events occur. Communication with the interdisciplinary team and direct care staff is also important to ensure that consistency and continuity of care are maintained. The policy and procedure also indicated .The Licensed Nurse will contact the Physician based on the urgency of the situation . The facility policy further indicated .Changes in condition will be documented in the Change of Condition form or Nurses' Progress notes every shift .

Based on observation, interview, and record review, the facility failed to accommodate the needs for one of three sampled residents (Resident 2), when the call light button was observed not within reach. This failure had the potential for Resident 2 not to be able to call staff for assistance which could result in unmet resident's needs. Findings: On September 4, 2024, at 9:45 a.m., during an observation and concurrent interview with Resident 2, the resident's call light button was observed hanging on the wall behind the resident's bed. Resident 2 stated he was not sure where the call light was. On September 4, 2024, at 10:02 a.m., an observation and concurrent interview was conducted with Certified Nursing Assistant (CNA) 1, CNA 1 agreed the resident (Resident 34) was not able to reach the call light, and the call light should be within reach. CNA 1 stated that the call light should not be hanging on the wall behind the bed. CNA 1 further stated Resident 2 can fall or not be able to get assistance and he (Resident 2) would need to use the call light to let us know what he needs. On September 4, 2024, at 10:05 a.m., an observation and concurrent interview was conducted with Licensed Vocational Nurse (LVN) 1, LVN 1 acknowledged that call light should not be hanging on the back of the bed and was not in reach of the resident. LVN 1 stated the risk associated with Resident 2's call light not being within reach increases his risk of fall and injuries. LVN 1 further stated Resident 2 could hurt is arm reaching for it and if there was an emergency, it would take longer for him to get help. Resident 2's record was reviewed. Resident 2 was admitted to the facility on [DATE], with diagnoses that included fracture (a complete or partial break in a bone) of the pelvis and age-related osteoporosis (when bones become weak and brittle). An undated facility policy and procedure, titled Call Lights-Answering Of, undated, indicated .Facility staff will provide an environment that helps meet the Resident's needs. The policy and procedure further indicated .ensure that the call light is placed within the Resident's reach .

Based on interview and record review, the facility failed to provide resident with an alternative meal, consistent with resident's identified food allergies, for 1 out of 5 residents (Resident 1). This failure could have negatively impacted Resident 1's health by consuming a food item they had an allergy to. Findings: On May 7, 2024, at 7:55 a.m., an unannounced visit was made to the facility to investigate a quality-of-care issue. On May 7, 2024, at 8:20 a.m., an interview was conducted with Resident 1, who stated, her food allergies are peanuts and tomatoes. Resident further stated, she requested a tuna sandwich from nursing staff, and nursing staff brought her a tuna sandwich with tomatoes on it. Resident 1 informed nursing staff she was allergic to tomatoes, and she could not eat it. Nursing staff returned resident's sandwich and brought her a new tuna sandwich with no tomatoes on it. A review of Resident 1's face sheet, indicated, resident was admitted to the facility on [DATE], with a diagnosis of Pneumonitis (inflammation in the lungs) due to inhalation of food and vomit. Further review, indicated, Resident 1 had food allergies to peanuts and tomatoes. A review of Resident 1's Brief Interview for Mental Status ({BIMS} - an assessment tool used to identify cognitive conditions) indicated a score of 12 (moderate cognitive impairment). On May 7, 2024, at 11:10 a.m., an interview was conducted with Certified Nursing Assistant (CNA) 1, who stated, when a resident requests an alternative food item, such as a sandwich, the CNA will take resident's Diet Card (a card on residents meal trays that contains individualized diet information, including food allergies) off resident's meal tray, check resident's allergies and diet against their food request, give dietary staff residents diet card and food request, dietary staff checks resident's food allergy on diet card, then will give nursing staff resident's food item, if available per diet/food allergies. On May 7, 2024, at 1:00 p.m., an interview was conducted with facility Cook 1, who stated, when a resident requests an alternative food item, nursing staff provides resident diet card to dietary staff, dietary staff will check resident's diet card against resident's food allergies and request, if diet card is not available, Cook 1 will ask nursing staff to verify residents allergies from their medical records. On May 7, 2024, at 1:23 p.m., and interview was conducted with the facility's Registered Dietician (RD), who stated, when a resident requests an alternative food item, dietary staff will ask nursing staff for the resident's diet card to check the resident's allergies and prescribed diet. If nursing staff is unable to provide the resident's diet card, dietary staff is to call the Dietary Supervisor (DS) to check resident's allergies/prescribed diet. If DS is not available, dietary staff will ask nursing staff to check resident's medical record to verify their allergies. On May 7, 2024, at 1:41 p.m., an interview was conducted with DS, who verified, Resident 1 did receive a tuna sandwich with a tomato in it, although resident is allergic to tomatoes. DS stated, her expectations are for nursing staff to bring the resident's diet card to the kitchen with resident's food request; Dietary staff are to ask for the resident's diet card, and check resident allergies, prior to giving out an alternative meal. If resident's diet card is not available, dietary staff are to contact DS/or nursing staff, to verify resident allergies, prior to providing an alternative meal. A facility Policy & Procedure, titled, Diet (Tray) Card, OP3 0213.02, undated, indicated, .Purpose: The diet cards purpose is to inform the dietary staff how to assemble the resident's meal tray and to provide caregivers with mealtime information . Background: The diet (tray) card contains the resident's name . allergy information . Procedure: 2. Ensure that food items served are consistent with tray card information .

Based on observation, interview, and record review, the facility failed to document ventilator alarm checks every 4 hours, on the ventilator flow sheets, as specified in the facility ' s policy and procedure, Mechanical Ventilation, for 3 out of 3 residents. This failure could have resulted in facility staff to be unaware of a ventilated resident ' s respiratory decline or faulty ventilator setting. Findings: On [DATE], at 12:00 p.m., an unannounced visit was made to the facility for a Quality-of-Care issue. 1) A review of Resident 1 ' s SBAR (Situation, Backround, Assessment, Recommendations), dated, [DATE], at 11:34, by RN 1, stated, . LN (Licensed Nurse) reported to RN (Registered Nurse) that (Resident 1) is unresponsive. Upon assessment, (Resident 1) was unresponsive, blue color, no pulse. Code blue called and CPR (Cardio-Pulmonary Resuscitation, life saving measures) was initiated and called 911 . Review of Resident1 ' s face sheet, indicated, resident was admitted to the facility on [DATE], with a diagnosis of Acute and chronic respiratory failure with hypoxia (Impairment of oxygen exchange between the lungs and blood, causing a decreased amount of oxygen in the blood); Tracheostomy (An opening made in the wind pipe to help air and oxygen reach the lungs); Dependance on respirator [Ventilator] (A machine that can be connected to a tracheostomy to move air in and out of the lungs). Further review of Resident1 ' s medical records indicated, resident could not breath independently, and required the constant assistance of a ventilator machine, connected to his tracheostomy, to breath. On [DATE], at 1:36 p.m., an interview was conducted with RN 1. RN 1 stated, She was giving report to the oncoming nurse at nursing station; rounds were being done by additional staff, and a staff called from (Resident 1 ' s) room that the resident was unreponsive. RN1 was in the nursing station just across from (Resident 1 ' s) room, and she did not remember a ventilator alarm going off at the time of being notified resident was unresponsive. RN1 further stated, the ventilator alarms are Really loud, and they alarm at the nurse ' s station, light up above the resident ' s room, and shows what room the ventilator is alarming down the hall on the screen. On [DATE], at 5:12 p.m., an interview was conducted with RN2, who stated, she was Just coming on to shift, during report, she heard RN1. RN1 stated (Resident1) was unresponsive and called for help, RN2 Called the code blue, (A medical emergency, where a resident requires immediate medical attention, most often the results of a respiratory or heart heart failure) went into (Resident1 ' s) room, she observed RT1 (Respiratory Therapist) Started CPR. RN2 further stated, she was across the hall from Resident1 ' s room, when the Code Blue was called, and Didn ' t hear the ventilator alarm go off, stating, No ventillator Alarms were going off. On [DATE], at 3:10 p.m., an interview was conducted with Respiratory Therapist (RT1), who stated, Resident1 was on full ventilator support (Requires the ventilator to breath). Nursing staff found (Resident1) unresponsive and called a code blue, and RT responded to the code. I was down the hall. The ventilator was not alarming on the monitor or in the room. RT1 Helped with CPR by doing compressions, until (First responders) showed up. RT1 further stated, At the beginning of the RT ' s shifts they do a vent check which includes checking the setting on the alarms, this check is done every 6 hours, and documented in the resident ' s progress notes (Medical records). On [DATE], at 12:55 p.m., an interview was conducted with the facilities Lead RT (LRT). The LRT stated, The (ventilator) alarm link is attatched to the side of the ventilator. I do a check (on ventilator alarms) every Monday for corporate, making sure everthing is plugged in, working properly, etc. Every RT comes on shift and checks their (Resident ' s ventilator) alarms by (visually) checking the parameters of the alarm, then (RT) begins their tracheostomy care, and when the resident is suctioned, the alarm will go off. The alarms are very loud. Ventilator alarm checks are done at the beginnning of shift and every 4 hours. (Alarm check documentation) is on Matrix under progress notes, and pop-ups (Flow sheets). A review of the facility ' s Policy & Procedure, titled, Mechanical Ventilation, undated, reference, RC2 0528.00, indicated, .Producedure . 3. The ventilator flowsheet will be maintained every four hours . 10. Check the ventilator alarms to be sure they are poroperly set before leaving the room and with every vent (ventilator) check (every four hours) . Documentation: On Ventilator Flow Sheet: Record ventilator checks, minimally every four hours . Review of Resident1 ' s RT progress notes, dated [DATE], (The date of the code blue) at 3:51 a.m., indicated, . Received patient . (Ventilator) alarms connected and audible . Review of Resident 1 ' s, Ventilator Flow Sheet, titled, Respiratory Therapy Minutes, dated [DATE], at 2:41 p.m., indicated, no documented ventilation alarm checks, every 4 hours. 2) On [DATE], at 1:45 p.m., an observation of Sub-Acute Unit, and ventilator alarms was conducted with SAC. Observed nursing staff monitoring ventilated residents from their bedside, visually checking their ventilator settings, and assisting residents with tracheostomy care. A ventillator was observed alarming in Resident 2s room. The Alarm was loud, a light lite up above resident ' s doorway, and Resident 2 ' s room number (3) was observed on a screen down in the hallway. SAC responded to the alarm immediately by suctioning resident (Clearing the airway of secretions or mucus), ventilator alarm continued to alert during suctioning, and reset by SAC, after care was performed. A review of Resident 2 ' s clinical records, face sheet was conducted, and indicated, Resident 2 was admitted to the facility on [DATE], with a diagnosis of Acute and chronic respiratory failure; Tracheostomy; On a Ventilator. Review of Resident 2 ' s RT progress notes, dated [DATE], indicated, . Patient received . Vent alarms are connected and audible . A review of Resident 2 ' s, ventilator flow sheet, titled, Respiratory Therapy Minutes, dated, [DATE], at 2:52, indicated, no documented ventilator alarm checks, every 4 hours, on the ventilator flow sheet. A review of the facility ' s Policy & Procedure, titled, Mechanical Ventilation, undated, reference, RC2 0528.00, indicated, .Producedure . 3. The ventilator flowsheet will be maintained every four hours . 10. Check the ventilator alarms to be sure they are poroperly set before leaving the room and with every vent (ventilator) check (every four hours) . Documentation: On Ventilator Flow Sheet: Record ventilator checks, minimally every four hours . 3) On [DATE], at 2:25 p.m., an observation of Resident 3 conducted, which indicated, resident sleeping in bed, with a ventilator connected to his tracheostomy, resident ' s chest observed rising and falling with ventilator assistance. A review of Resident 3 ' s clinical records, face sheet was conduceted, and indicated, Resident 3 was admitted to the facility on [DATE], with a diagnosis of Acute respiratory failure; Dependance on ventilator. Review of Resident 3 ' s RT progress notes, dated, [DATE], at 2:31 a.m., indicated, Patient received . (Plus)5 alarms on and audible . A review of Resident 3 ' s, ventilator flow sheet, titled, Respiratory Therapy Minutes, dated [DATE], at 2:42 p.m., indicated, no documented ventilator alarm checks, every 4 hours. On [DATE], at 10:43 a.m., an interview was conducted with the facility ' s Administrator (Admin). Admin stated, she verified with the Sub-Acute Coordinator (SAC) that visual ventilator alarm checks are being performed by RT ' s every 4 hours, for every resident on a ventilator. Admin further verified, she had Reviewed the (RTs) progress notes, and ventilator alarm checks have been documented at the start of RTs shift, when they receive the residents care, but the alarm ventilator Checks are not being documented consistently (Every 4 hours), per facility policy and procedure (Mechanical Ventilation). A review of the facility ' s Policy & Procedure, titled, Mechanical Ventilation, undated, reference, RC2 0528.00, indicated, .Producedure . 3. The ventilator flowsheet will be maintained every four hours . 10. Check the ventilator alarms to be sure they are poroperly set before leaving the room and with every vent (ventilator) check (every four hours) . Documentation: On Ventilator Flow Sheet: Record ventilator checks, minimally every four hours .

Based on observation, interview, and record review, the facility failed to ensure two residents were treated with dignity and respect, when Certified Nursing Assistant (CNA) 1 made disrespectful comments and gestures towards Resident 1 and 2. This failure resulted in not ensuring residents' rights to be treated with dignity and respect and could potentially result in negative psychosocial outcomes, such as changes in mood and/or behavior. Findings: 1. On July 20, 2023, at 10:40 a.m., during an interview, Resident 3 stated she heard the conversation between CNA 1 and Resident 1 on July 11, 2023, while CNA 1 was providing care to Resident 1. Resident 3 stated CNA 1 said look at that fat, referring to her roommates body. Resident 3 stated CNA 1's comments made her uncomfortable. On July 20, 2023, at 12:12 p.m., an interview with CNA 2 was conducted. CNA 2 stated Resident 1 told him CNA 1 made her feel uncomfortable, by making statements that she was too fat. Resident 1 said to CNA 2 that CNA 1 made her feel uncomfortable and insulted her of being fat. CNA 2 stated no facility staff was allowed to make inappropriate comments to any residents and every resident has the right to be treated with dignity and respect by the staff. On July 20, 2023, at 1 p.m., an interview and observation with Resident 1 was conducted. Resident 1 was observed in bed, in her room. Resident 1 was alert and oriented. Resident 1 stated in the morning of July 11, 2023, CNA 1 provided care for her prior to her going to dialysis (a treatment to remove blood toxins when the kidneys are not able to). Resident 1 stated CNA 1 touched her abdomen, pointing a finger to it, and said look at that fat. Resident 1 stated her roommate (Resident 3) was in the room and overheard the conversation between her and CNA 1. Resident 1 stated CNA 1's comment and gesture was disrespectful and made her feel uncomfortable. Resident 1's record was reviewed. Resident 1 was readmitted to the facility on [DATE], with diagnoses which included end stage renal (kidney) disease, dependence on renal dialysis, diabetes, morbid (severe) obesity, and anxiety disorder. 2. On July 20, 2023, at 11:12 a.m., an interview and observation was conducted with Resident 2. Resident 2 was in the activities room. Resident 2 was alert and oriented. Resident 2 stated CNA 1 provided care for him on July 11, 2023. Resident 2 stated CNA 1 said [NAME] (brother in Spanish) and [NAME]. Resident 2 stated CNA 1 kept repeating [NAME] to confuse him. Resident 2 stated he did not like it and said shut up to CNA 1. Then CNA 1 showed Resident 2 the middle finger (obscene gesture). Resident 2 stated he felt disrespected by the comments and the gesture of CNA 1 towards him. Resident 2's record was reviewed. Resident 2 was admitted to the facility on [DATE], with diagnoses which included cognitive communication deficit and aphasia (difficulty expressing speech) following cerebral infarction (stroke). On July 20, 2023, at 12:28 p.m., in an interview with the Registered Nurse Supervisor (RNS), the RNS stated the facility staff is not allowed to be disrespectful to any resident and all staff must be professional and treat all residents with dignity and respect. On July 20, 2023, at 1:40 p.m., an interview with the Administrator was conducted. The Administrator stated all residents must treated with dignity and respect by the facility staff. The Administrator stated the facility's own investigation validated CNA 1 did not treat Resident 1 and Resident 2 with dignity and respect. The Administrator stated CNA 1 was suspended and will be terminated. On August 18, 2023, at 11:38 a.m., in a phone interview, the Administrator stated CNA 1 was terminated due to his conduct. A review of the policy and procedure titled, Resident Dignity and Personal Privacy, undated, indicated, .The Company provides care for residents in a manner that respects and enhances each resident's dignity, individuality, and right to personal privacy . Dignity means that when interacting with residents, staff carries out activities that assist the resident in maintaining and enhancing his or her self-esteem and self-worth .

Based on observation, interview, and record review, for three (Resident 1, 4, and 5)) of five residents, the facility failed to ensure Resident 1, 4, 5 ' s medical records were accurate when services provided for Physical Therapy (PT) were not documented as they were provided. Furthermore, the facility ' s failure to document on a timely basis limits and delay providers access to the resident ' s records. Findings: On July 7, 2023, at 10:00 a.m., an unannounced visit was conducted on behalf of the facility residents to investigate allegation of inaccurate records. On July 7, 2023, Resident 1, 4, and 5 ' s PT records were reviewed. The PT records indicated late entries were made for services provided as follows: For Resident 1, date of service September 23, 2022, was electronically signed for as completed on September 26, 2022 by Physical Therapist Assistant 1 (PTA); date of service September 22, 2022, was electronically signed for as completed by PTA 1 on September 24, 2022, and revised on September 26, 2022; date of service September 24, 2022, was electronically signed for as completed on September 26, 2022, by PTA 1; date of service September 22, 2022, was electronically signed for as completed on September 24, 2022, by PTA 1; date of service September 21, 2022, was electronically signed for as completed on September 22, 2022, by PTA 1; and date of service September 19, 2022, was electronically signed for as completed on September 20, 2022, by PTA 1; For Resident 4, date of service provided on July 6, 2023, was electronically signed for as completed on July 7, 2023, by PTA 2/Rehab Director (RD); date of service July 5, 2023, was electronically signed for as completed on July 7, 2023, by PTA 2/RD; and date of service July 1, 2023, was electronically signed for as completed on July 3, 2023, by PTA 2/RD; and For Resident 5, date of service provided on July 3, 2023, was electronically signed for as completed on July 5, 2023, by PTA 2/RD; date of service provided on July 7, 2023, was electronically signed for as completed on July 3, 2023, by PTA 2/RD; date of service June 30, 2023, was electronically signed for as completed on July 3, 2023, by PTA 2/RD; date of service June 18, 2023, was electronically signed for as completed on June 19, 2023, by PTA 2/RD; and date of service June 15, 2023, was electronically signed for as completed on June 16, 2023, by PTA 2/RD. On July 7, 2023, at 12:04 p.m., a concurrent record review and interview was conducted with PTA 2/RD. Reviewed with PTA 2/RD resident ' s record for assessments/Evaluation and daily progress for Resident 1, 4, and 5. The record indicated a delay in the daily charting for services provided. Reviewed with PTA 2/RD their medical record policy that stated documentation had to be made in a timely manner for accuracy and completeness. PTA 2/RD verified the late entries made and stated moving forward, he will be documenting right after services were completed in case the physician or other department need to access the record. PTA 2/RD stated recording had to be timely to be accurate. On July 7, 2023, at 12:40 p.m., a concurrent interview and record review was conducted with PT 1. PT 1 was made aware of purpose of visit and reviewed with PT 1 documentations of staff for late entries made for PT services for Resident 1, 4, and 5. PT 1 stated he is a PT and working on his nursing degree and as a nurse, he knows the importance of documenting after services were provided. PT 1 stated it was hard to keep track but stated he had given the PTA 1 (former traveler) the orientation and reminders the best he could. PT 1 stated documentation had to be timely. Document while it is still fresh, accurate recording is timely recording. On July 7, 2023, at 1:35 p.m., a concurrent interview and record review was conducted with the Regional Director of Clinical Operation (RDCO). The RDCO stated he was covering for the absence of the administrator while she was on vacation. Documentations made by staff were reviewed with RDCO. The record indicated they were not documenting a soon as services were provided. Staff were documenting a day or two later and was not immediately accessible by the physician or other departments. RDCO stated documentation should be on time to be considered accurate and complete. A review of the undated facility policy titled, Medical Record Management, indicated, PURPOSE. The company must maintain medical records on each resident, in accordance with accepted professional standards and practice and state and federal law. Medical records must be complete, accurately documented, readily accessible, systematically organized, and maintained in a safe and secure environment .PROCEDURE .6. The HIM/Medical Records practitioner will periodically conduct an in-depth record audit to determine if the record: is written in a timely manner .accurately documents the course and results of services rendered .

Based on interview and record review, for one (Resident 1) of five residents, the facility failed to release Resident 1 medical record when requested on November 28, 2022 The facility failure had the potential to delay the requesting party to obtain the records in a timely manner and violating the requesting parties rights. Findings: On July 7, 2023, at 10:00 a.m., an unannounced visit was conducted on behalf of Resident 1 to investigate an allegation of request for medical record copy was not acted on. On July 7, 2023, at 1:22 p.m., Resident 1 ' s Authorization Form for Release of Information, was reviewed and a concurrent interview was conducted with the Medical Record Director (MRD). The record indicated the request for copies of Resident 1 ' s medical record was made on November 28, 2022. MRD stated that they did not provide the copies when it was initially requested. MRD stated she was instructed not to release the copy by their legal office because the Resident Representative ' s (RR) Power of Attorney (POA) no longer apply when the resident passed away. MRD was unable to provide for documented evidence of a facility policy indicating the RR was no longer able to represent the resident after her demise. MRD indicated the RR came back on January 3, 2023, and had supplied the requested death certificate to be able to get a copy of Resident 1 ' s medical record. No record was provided on his second visit. MRD was unable to provide for written documentation when they had eventually released the resident ' s medical record but had verbally indicated it was in part released to RR on January 18, 2023, and the second part of the copy was given on June 23, 2023. Reviewed with MRD their policy for releasing medical record when requested by resident and responsible party. MRD stated the record should have been provided over the 2 days acceptable time frame where record had to be provided to the patient and responsible party. MRD stated, if medical records were released late when requested, the resident or responsible party may not be able to use the records for whatever purposes they intend to when they initially requested for it. On July 7, 2023, at 1:35 p.m., the Regional Director of Clinical Operations (RDCO) was interviewed regarding their policy for Release of Medical Record. The RDCO stated he was covering for the absence of the Administrator and he was not sure about the delay of release of medical record. RCDO stated this was from their privacy officer and their policy should have been followed. A review of the undated facility policy titled, Resident Access to Protected Health Information, indicated, PROCEDURE: 1. Medicare regulations for nursing facilities provide that a current residents or their legal representatives may access the resident ' s designated record set upon written or oral request within 24 hours (excluding holidays and weekends). After receipt of the records for inspection, resident may purchase copies of the records, or any portion of them, at a cost not to exceed the community standard, upon 2 working days notice .