Every finding on record at Palms Care Center

Based on interview and record review, the facility failed to accurately and appropriately act on a significant change of condition on 7/7/26 for one of five residents (Resident 1) in accordance with professional standards of practice and facility's policy and procedure when Resident 1 was admitted to the facility on [DATE] for rehabilitation and on 7/6/26 Resident 1 was alert, cooperative, progressing with care goals, and was able to ambulate 25 feet. Resident 1 experienced an acute clinical decline the morning of 7/7/26 when staff noted Resident 1 was difficult to arouse from sleep, refused to get up and not able to ambulate, refused meals, and was found to have a high blood sugar. Nursing did not accurately provide the clinical decline assessment to the physician. Staff notified the physician about the elevated blood sugar but did not notify the physician of the extent of the clinical decline. On 7/7/26 the physician ordered the administration of insulin for the high blood sugar, for staff to re-check blood sugar after administering insulin, and monitor Resident 1. On the morning of 7/8/26, Resident 1 was found unresponsive with shallow breathing, low blood pressure, and low pulse and could not be aroused with vigorous sternal rub (A physical test used to determine if a person can wake up or feel pain. This is done by making a fist and firmly rubbing your knuckles up and down the chest bone for a few seconds). Certified Nursing Assistant (CNA) 1, who found Resident 1 to be unresponsive, twice requested Licensed Vocational Nurse (LVN) 4 to assess Resident 1's change in condition and LVN 4 did not assess Resident 1. When LVN 4 did not assess Resident 1, CNA 1 then called LVN 2, who ultimately assessed Resident 1 and initiated a transfer to the hospital for further evaluation. These failures resulted in not providing the expected level of quality of care and delayed treatment of Resident 1's clinical decline. Resident 1 was transported to the emergency department (ED) of the local hospital and admitted to the intensive care unit (ICU- (unit that specializes in close monitoring, and life support for people with severe, life-threatening illnesses or injuries) where he was admitted for eight days and intubated (a life-saving medical procedure where a tube is placed into the windpipe to assist with breathing using a machine) for respiratory failure(when lungs can't move oxygen in or out). Resident 1 was diagnosed with urosepsis (a life-threatening medical emergency caused when a urinary tract infection [UTI] spreads to the kidneys and causes a harmful body-wide response), acute kidney injury (kidneys suddenly lose their ability to filter waste from the blood), encephalopathy (damage or disease that affects the brain), pleural effusion (buildup of excess fluid between the layers of tissue that line the lungs and the chest), tachycardia (increased heart rate of more than 100 beats per minute at rest) and hypertension(high blood pressure). Resident 1 has been in the acute care hospital for 28 days and remains there currently.Findings:During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses of Heart failure (heart cannot pump blood well), Atrial Fibrillation (an irregular and fast heartbeat), Diabetes Mellitus (a condition that happens when your blood sugar, occurs when the pancreas does not produce enough insulin or the body cannot effectively use the insulin), muscle weakness, dysphagia (trouble swallowing), Benign prostatic hyperplasia with lower urinary tract symptoms (enlargement of the prostate gland that causes lower urinary tract symptoms like a weak urine stream, frequent urination, and trouble starting to urinate) Short term Rehabilitation (a temporary, therapy program to help patients recover from an acute illness, injury, or surgery with the primary goal of returning home or to independent living).During a review of Resident 1's Minimum Data Set [MDS, a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 7/8/26, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 0 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 had severe cognitive impairment.During a telephone call on 7/24/26 at 9:30 a.m. with family member (FM), FM stated Resident 1 had been admitted to the facility on [DATE] for short term rehabilitation to regain strength. FM stated that prior to entering the facility Resident 1 was in the hospital for 15 days for abdominal pain and was diagnosed with urinary retention. FM stated that upon discharge from the hospital Resident 1 was told to continue with the foley catheter (medical tube inserted into the bladder to drain urine) that was placed before admission, until he was seen by the physician and specialists. FM stated the facility staff removed Resident 1's catheter within 24 hours after admission to the facility. FM stated she informed facility staff of concerns regarding the removal of the catheter as FM was informed by the hospital staff that Resident 1 required the catheter to urinate effectively. FM stated that Resident 1 was in the facility for a few days and initially Resident 1 was progressing with physical therapy. FM stated that Resident 1 was observed walking with a walker with therapy during his stay. FM stated that Resident 1's prior level of functioning was independent with walking, dressing, toileting and bathing with supervision when walking. FM stated when Resident 1 arrived at the facility the goal was to complete physical therapy and discharge home. FM stated that on 7/7/26 in the afternoon Resident 1 was observed tired, grimacing as if he was in pain, refusing to eat and his arms were shaking as though he was shivering. FM stated that Resident 1's change in condition was so severe that Resident 1 had gone from standing with assistance to using a mechanical lift for transfers. FM stated that the concerns about Resident 1's condition and level of function were voiced to the facility staff, including the concern with Resident 1's urination without the catheter. FM stated the facility staff informed them that Resident 1 was in good condition and stable. FM stated that on 7/7/26 Resident 1's blood sugar levels were high, and he was administered insulin to stabilize his blood sugar. FM stated Resident was observed again on the afternoon of 7/7/26, where he appeared to look like he was in a coma. Resident 1 was not responsive to FM. FM stated that LVN 3 was made aware of FM's concern but LVN 3 informed FM that LVN 1 had called the physician the morning of 7/7/26 and informed the physician that Resident 1 had an elevated blood sugar. FM stated that LVN 3 informed them that Resident 1's vital signs were stable and if Resident 1's condition deteriorated throughout the night, then the physician would have been called again to transfer to the hospital. FM stated that the facility called FM on 7/8/26 to inform her that Resident 1 had been transferred to the hospital. FM stated the lack of staff attention toward Resident 1 had caused immense distress as he had been hospitalized on [DATE] with a severe infection. FM stated that the facility failed to listen to FM's concerns about Resident 1's health and FM felt as though the facility was negligent in assessing Resident 1 causing Resident 1 and his family unnecessary pain and suffering. FM stated that the facility staff could have done more for Resident 1 or identified the immediacy of the situation when FM voiced the concerns of Resident 1's health decline on 7/7/26. FM stated that Resident 1 was alert, awake and walking before this incident but now he was not.During review of Resident 1's hospital document titled, Physical Therapy, Occupational Therapy, Speech Therapy, dated 6/15/26, the document indicated, . [Resident 1] has good prognosis for discharge to skilled nursing facility(a special type of licensed medical facility that provides 24 hour nursing care, medical treatment, and physical therapy) for short term rehabilitation.During a review of the Resident 1's hospital records titled, Discharge Summary, dated 6/30/26, the records indicated, . Urology (a medical and surgical specialty focusing on the urinary tract) consulted and foley catheter placed. recommend continue foley catheter at time of discharge. diabetes and hypertension controlled. labs stable, hemodynamically stable (a person has a stable blood flow, normal blood pressure, and a steady heart rate that safely supply blood to all major organs), patient at clinical baseline (an initial measurement or health state recorded before a treatment or study begins) can be discharge to skilled nursing facility. The record indicated Resident 1 was discharged from the hospital on 6/30/26 to the facility, with no complications and a recommendation to continue with the foley catheter for urination.During a concurrent interview and record review on 7/24/26 at 10:17 a.m. with the Director of Nurses (DON), Resident 1's, Change of Condition (COC) Evaluation, dated 7/7/2026 and 7/8/2026, were reviewed. The COC dated 7/7/26 indicated, . List the other change, altered mental status with hyperglycemia (high blood sugar), this started on 7/7/26, Vital signs evaluation. Pulse 109 regular. sudden change in level of consciousness or responsiveness. needs more assistance with activities of daily living. Resident has altered mental status. elevated blood sugar 337 (normal range is 70-100 before eating and 70-140 after eating). The document indicated nursing staff did not document Resident 1's significant decline in alertness, refusal of meals, decline in activity and level of cooperation with care. DON stated that on 7/8/26, Resident 1 was transferred to the hospital after CNA 1 found him unresponsive. The DON stated CNA 1 had entered Resident 1's room for breakfast and attempted to wake Resident 1 and CNA 1 discovered Resident 1 was unresponsive. The DON stated CNA 1 immediately informed LVN 4 of her findings. The DON stated that due to LVN 4's lack of urgency and assessment of Resident 1 after repeated requests from CNA 1, the DON stated LVN 4 was terminated for not completing an assessment of Resident 1 on the morning of 7/8/26 when Resident 1 was unresponsive.During a concurrent interview and record review on 7/24/26 at 11:14 a.m. with the Director of Rehabilitation (DOR), Resident 1's, Physical Therapy Treatment Encounter Notes, dated 7/2/26-7/7/26 were reviewed. The notes indicated, . Date of Service 7/2/26, summary of daily skilled services. skilled interventions focused on bed mobility (functional movements a person makes to change and adjust their body position while lying in bed) training to increase functional skills, training in supine (back)/side lying to/from sitting edge of bed and training in safe sit to stand to sit mobility. The [Resident 1] performed bed mobility tasks with moderate assistance and sit to stand with maximal assistance. Date of service 7/3/26. Gait (walking) training with four wheeled walker for 25 feet with minimal assistance. skilled interventions focused on transfer training to increase functional task performance and strengthening activities. the [Resident 1] performed bed mobility tasks with moderate assistance and transfers with moderate assistance. Date of service 7/6/26, [Resident 1] performed therapeutic exercises in sitting using ankle weights to develop strength and facilitate independence. [Resident 1] performed exercises. with rest breaks. compliant with skilled interventions. Date of service 7/7/26. [Resident 1] performed transfers with maximal assistance with 2 staff. [Resident 1] had more difficulty following commands today. Communicated decline to nursing and DON. The DOR stated that upon Resident 1's arrival at the facility, Resident 1 was able to stand, pivot and transfer with therapy staff assistance without issue. The DOR stated that Resident 1 was observed on 7/6/26 smiling, laughing and had walked with therapy assistance and a walker for 25 feet. The DOR stated that on 7/7/26, Resident 1 was observed lying in bed with no strength to complete his physical therapy session. The DOR stated that Resident 1's decline was concerning and was a quick change from his usual self therefore she proceeded to notify LVN 1 of the observation.During a review of Resident 1's, Nurses Note, dated 7/7/26, the note indicated, (Resident 1) was noted to be declining from a reporting from therapy stating (Resident 1) had declined in participation and became a full assist and had an overall decline in performance from usual baseline. (Resident 1) was assessed and noted to be calm and cooperative and alert to baseline. No bladder distention (organ that holds urine is stretched or enlarged beyond its normal size because it cannot empty properly) or pain noted upon assessment. (Resident 1) stated he had no pain when palpated (touched) and that he was good no nonverbal indicators of pain noted. At approximately 2:00 p.m. (Resident 1) was observed to be less alert than he was from the morning's assessment. Vitals obtained and were stable and within normal limits for (Resident 1). (Resident 1) was difficult to arouse verbally but upon a sternal rub (a central painful stimulus used to check a patient's level of consciousness, check for brain responsiveness, and test motor reactions when milder cues fail) resident responded with open eyes and stated he was okay. The note indicated Resident 1 had a noticeable decline in health and had continued to decline during the day. The note indicated the decline in health was observed by the physical therapists and the nurse on the morning of 7/7/26.During an interview on 7/24/26 at 11:37 a.m. with LVN 1, LVN 1 stated she had taken care of Resident 1 and was familiar with his care. LVN 1 stated that Resident 1 was able to follow commands, took his medications without hesitation, had good upper body strength but was weak in the lower extremities, and was able to sit up in his wheelchair. LVN 1 stated that on 7/7/26, the DOR notified her that Resident 1 was not acting like himself. LVN 1 stated she proceeded to go to Resident 1's room and observed Resident 1 lying in bed. LVN 1 stated Resident 1 was not responding therefore LVN 1 proceeded to complete a sternal rub that woke Resident 1 and Resident 1 stated I am ok. LVN 1 stated that Resident 1's vital signs were stable but had an elevated blood sugar of 337. LVN 1 stated she called the physician to notify him that Resident 1 had altered mental status and was unresponsive with an elevated blood sugar of 337. LVN 1 stated the physician ordered insulin and blood sugar checks and labs to be collected. LVN 1 stated that at the time of the change, there was not a concern for infection as the symptoms of infection included temperature change, high pulse, high blood pressure, changes in blood sugar levels, pain, burning during urination. LVN 1 stated that Resident 1's change was drastic and a big difference as to how Resident 1 normally looked. LVN 1 stated that the initial change began toward the end of her scheduled shift and was unsure when Resident 1's condition was reassessed or when his blood sugar was rechecked after insulin administration. LVN 1 stated the facility's process for a change of condition was for the nurse to check the vital signs, assess the resident condition, call the physician and notify them of all findings, continue to monitor the resident, recheck blood sugar and identify if the condition had not improved and call the physician again, which was not done. LVN 1 stated it was important to follow physician orders and monitor the residents because their condition can get worse and the nurses should identify the change as soon as possible to ensure the residents are treated. LVN 1 stated it was important to assess a resident thoroughly when a change was identified to prevent a delay in care. LVN 1 stated a delay could have led to Resident 1 becoming fully unresponsive and could have led to the condition getting worse.During an interview on 7/24/26 at 12:06 p.m. with LVN 2, LVN 2 stated that on 7/8/26, she began her shift at around 6:00 a.m. that morning. LVN 2 stated that CNA 1 had approached her and asked LVN 2 to check on Resident 1 as he was not responding. LVN 2 stated she immediately went to Resident 1's room and observed Resident 1 lying in bed breathing but would not respond to verbal calls or to sternal rubbing. LVN 2 stated she took Resident 1's vital signs and noticed Resident 1's blood pressure and pulse were extremely low. LVN 2 stated that CNA 1 called 911. LVN 2 stated she was not the nurse assigned to Resident 1 on 7/8/26 and LVN 4 was assigned to care for Resident 1. LVN 2 stated that CNA 1 had reported that she had attempted to alert LVN 4 of Resident 1's condition first but LVN 4 had not responded to CNA 1's urgency to have a nurse assess Resident 1's condition. LVN 2 stated that since CNA 1 could not get LVN 4 to go to Resident 1's room, CNA 1 requested LVN 2 assist Resident 1. LVN 2 stated she transferred Resident 1's care to the emergency services and proceeded to alert the DON of LVN 4's negligence and failure to respond to Resident 1's emergent condition. LVN 2 stated that Resident 1's condition was so critical that her first instinct was to call emergency services. LVN 2 stated it was important to complete resident assessments to ensure residents get the care they need regardless of the severity of the condition. LVN 2 stated if Resident 1's condition would have been assessed sooner; Resident 1 could have received treatment sooner to improve outcome.During a telephone interview on 7/24/26 at 12:28 p.m. with LVN 3, LVN 3 stated that on 7/7/26 she was the nurse caring for Resident 1 during the afternoon shift. LVN 3 stated that on 7/7/26 she had received report from LVN 1 regarding Resident 1's altered mental status that began that morning. LVN 3 stated she had observed Resident 1's family members in the room with LVN 1. LVN 3 stated that at the time of the observation she was under the impression that Resident 1 was going to be transferred to the hospital due to his altered mental status and high blood sugar. LVN 3 stated that LVN 1 informed her that Resident 1 was not going to be transferred to the hospital and instead would remain in the facility for monitoring high blood sugar. LVN 3 stated that on 7/7/26 Resident 1 was observed lying in bed, had visibly declined in mobility and was not eating when staff attempted to assist him with dinner. LVN 3 stated there was a concern for Resident 1 to potentially aspirate or choke with dinner due to his decline in health. LVN 3 stated she was approached by FM asking what was going to happen with Resident 1 and if he would be sent to the hospital due to his decline in health. LVN 3 stated she had informed Resident 1's FM that LVN 1 had notified the physician of Resident 1's condition and relayed the physician's orders to FM. LVN 3 stated that she had informed FM if Resident 1's condition continued to decline, Resident 1 would have been transferred to the hospital. LVN 3 stated that during the shift Resident 1's condition did not decline further or require a hospital transfer. LVN 3 stated the facility process was to assess the resident's condition when there was a change to ensure the change is identified and treated immediately. LVN 3 stated if the change in condition is not identified, the condition can get worse.During a review of Resident 1's, Nurses note, dated 7/7/26 9:35 p.m., the note indicated, (Resident 1) is on alert charting (staff tag or flag a resident's chart to track acute changes in condition) for altered mental status and hyperglycemia. (Resident 1) did not eat dinner and was asleep most of the shift. (Resident 1) BS (blood sugar) went down to 186 after insulin was administered. The note indicated that LVN 3 had identified a continued decline in Resident 1's condition when Resident 1 had refused his meal and was sleeping most of the shift consisting of eight hours. The note indicated Resident 1 was administered insulin medication that would have lowered blood sugar levels, but Resident 1 had not consumed any meals on 7/7/26.During a telephone interview on 7/24/26 at 1:00 p.m. with LVN 4, LVN 4 stated she was the nurse for Resident 1 on the night of 7/7/26 into the morning of 7/8/26. LVN 4 stated when she arrived for her shift the night of 7/7/26, she was not informed by LVN 3 that Resident 1 had a change in condition or that he had declined in health. LVN 4 stated throughout the night there was no change in Resident 1 that had been reported to her. LVN 4 stated that on the morning of 7/8/26, before 7:00 a.m., CNA 1 had approached LVN 4 and informed her that Resident 1 was hard to arouse and CNA 1 was unable to wake him. LVN 4 stated she went to Resident 1's room and observed him but did not conduct a thorough assessment. LVN 4 stated that based on her observation she knew Resident 1 needed to be transferred to the hospital, therefore she proceeded to exit the room and went to gather paperwork needed for the hospital transfer. LVN 4 stated that LVN 2 and CNA 1 were with Resident 1 during this time. LVN 4 stated that after observing Resident 1, there was a visible decline from his normal baseline. LVN 4 stated she assessed Resident 1's condition by visualization only, and believed she was able to identify the change in Resident 1 with only an observation. LVN 4 stated she had been terminated and accused of neglecting to assess Resident 1, but she disagreed with the outcome as the previous nurses before her should have identified Resident 1's condition as well.During a telephone interview on 7/24/26 at 1:24 p.m. with CNA 1, CNA 1 stated she was the CNA assigned to Resident 1 on 7/8/26. CNA 1 stated the morning of 7/8/26, she received report from the night shift for the residents she was responsible for which included Resident 1. CNA 1 stated there were no changes reported during the exchange for Resident 1 from the night shift staff. CNA 1 stated she had entered Resident 1's room before 7:00 a.m. to obtain vitals and assist him with breakfast. CNA 1 stated Resident 1 was not responsive when attempting to wake him. CNA 1 stated she immediately went to LVN 4 who was standing outside the hall next to Resident 1's room. CNA 1 stated she informed LVN 4 that Resident 1 was unresponsive, but LVN 4 did not reply. CNA 1 stated she proceeded to inform LVN 4 again that Resident 1 was not responding but LVN 4 did not reply or act on the information provided. CNA 1 stated she was concerned about Resident 1's health and proceeded to call LVN 2, and informed LVN 2 that Resident 1 was not responding and needed help. CNA 1 stated that LVN 2 entered Resident 1's room within seconds and immediately assessed Resident 1's condition. CNA 1 stated she had observed LVN 2 performing a sternal rub on Resident 1 but he was not responding. CNA 1 stated she had assisted with obtaining Resident 1's vital signs and observed Resident 1's blood pressure and heart rate were low. CNA 1 stated emergency services were called and arrived within minutes. CNA 1 stated Resident 1 was breathing during the time of LVN 2's assessment. CNA 1 stated she had worked with Resident 1 in the past and was able to identify that there was something wrong with Resident 1 when he was not responding or moving. CNA 1 stated that prior to 7/8/26 Resident 1 would sit up in his wheelchair, had arm and leg mobility and was talkative.During a telephone interview on 7/27/26 at 1:42 p.m. with Resident 1's physician, the physician confirmed that the facility had called to inform him that Resident 1 had a change in condition that involved an elevated blood sugar. The physician stated he recalled giving an order for blood work to be completed, blood sugar checks and an order for insulin as Resident 1 had a diagnosis of Diabetes. The physician stated he did not recall being made aware that Resident 1 was not consuming meals, hard to awaken, had a decline in mobility and alertness that was observed by physical therapy, staff and Resident 1's family members. The physician stated that if the facility had made him aware of the whole situation, the orders given to the facility would have been different. The physician stated he felt the orders that were given to the facility were standard orders and protocol for any resident who was experiencing an episode of high blood sugar and had a history of diabetes. The physician stated he had completed an in-person physical examination of Resident 1 since admission but could not recall the date. Following the interview, multiple attempts were made to retrieve the documentation to support the physician's statement that an examination was completed in the facility for Resident 1, but the facility failed to provide the documentation, indicating the physical examination by the physician was not completed for Resident 1.During a telephone interview on 7/27/26 at 2:42 p.m. with the DON, the DON stated the facility process for a change in condition was for the nurse to complete an assessment, notify the physician, resident representative, follow physician orders and continue to monitor the resident. The DON stated if the resident's condition changed or declined, the process was to complete an assessment and notify the physician of the findings again. The DON stated this process applied to any change in conditions identified for all residents. The DON stated after reviewing Resident 1's documents and sequence of events leading to his hospital transfer, she believed that the nurses caring for Resident 1 on 7/7/26, followed the facility process and notified the physician. The DON stated she believed the failure occurred the morning of 7/8/26, when LVN 4 failed to respond to CNA 1's request for assessment when CNA 1 found Resident 1 unresponsive.During a telephone interview on 7/27/26 at 3:53 p.m. with the registered nurse (RN), the RN stated she had admitted Resident 1 to the facility and had reviewed the hospital discharge records prior to arrival to the facility. The RN stated that upon Resident 1's arrival to the facility, Resident 1 already had a foley catheter in place for urine retention. The RN stated she had obtained a physician order to remove the catheter for a 24-hour trial and monitoring to see if Resident 1 was able to urinate without the catheter. The RN stated, Resident 1 was incontinent (lack of voluntary control over urination) and using a brief therefore the nurses were able to observe Resident 1's briefs were wet with urine and determined that Resident 1 was able to urinate on his own without the catheter. The RN stated that on the morning of 7/7/26, she was called by LVN 1 due to Resident 1's change in condition regarding high blood sugar. The RN stated Resident 1 was assessed by LVN 1 and the physician was notified of Resident 1's change in blood sugar levels. The RN stated at the time of Resident 1's change in health, based on the assessment completed by LVN 1, it was believed that his condition had changed due to elevated blood sugar. The RN stated knowing the outcome of the change in condition, there were other factors that should have been assessed such as the refusal of meals and change in alertness. The RN stated that there were no indications that Resident 1 was experiencing urine retention at the time of the assessment and showed no signs of infection. During a review of Resident 1, Emergency Department (ED) Notes, dated 7/8/26, the notes indicated, . Chief complaint altered mental status, respiratory distress. brought Emergency department from [facility name] for altered mental status. Emergency medical services [EMS] reports staff at facility reported [Resident 1] was not behaving like his normal self however they were unable to tell what his baseline is. In route [Resident 1] blood pressure was 279 systolic (part of the measure of blood pressure that measures the force of blood against your artery walls when your heart beats, this is typically under 140) and he was tachycardic (fast heart beat). History unobtainable from [Resident 1] secondary to severity of condition. Physical Exam, first vital signs: blood pressure, 92/54 (normal is around 120/80), heart rate 172 ( how many times your heart beats per minute-normal is 60-100), respiratory rate 50 (how many times you breath per minute-normal is 12-20), oxygen saturation 97 % oxygen method bagging (manual artificial ventilation using a bag and mask to push air into a person's lungs when they are unable to breathe on their own). cardiovascular: rapid irregular rate, shallow diminished bilateral breath (person is barely breathing). Diagnosis this visit: Atrial Fibrillation, poorly controlled Diabetes mellitus, shingles (painful blistering viral infection caused by the same pathogen that causes chicken pox), hypertension, benign prostatic hyperplasia with urinary obstruction (occurs when an enlarged prostate gland squeezes the urethra [tube that carries urine out of your body], causing trouble starting a urine stream, and weak flow and incomplete bladder emptying), acute kidney injury, sepsis (a life threatening medical emergency that happens when the body has an extreme, harmful reaction to an infection), altered mental status, urinary tract infection. Intent to admit Intensive care unit (unit that specializes in close monitoring, and life support for people with severe, life-threatening illnesses or injuries) . The note indicated Resident 1 was admitted to the emergency department in critical condition with multiple areas of health decline including assistance with breathing and severe infection.During a review of the facility's Lesson Plan titled, Change of Condition, undated, the lesson plan indicated, . Recognizing and responding to a change of condition of residents. A change of condition is any decline or improvement in a resident's physical, mental, emotional, or functional status that differs from their normal baseline. Early recognition prevents complications, reduces hospitalizations, improves resident outcomes, meets regulatory requirements, promotes resident safety. know each resident's baseline, recognize subtle changes early, assess promptly. early interventions improve resident outcomes.During a review of the facility's policy and procedure (P&P) titled, Notification of Changes, dated 2025, the P&P indicated, The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Circumstances requiring notification include. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: Life-threatening conditions, or Clinical complications.During a review of a professional reference (PR) titled, National Library of Medicine- Chapter 4 Nursing Process, dated 2021, the PR indicated, . Nurses make decisions while providing patient care by using critical thinking and clinical reasoning. Using critical thinking means that nurses take extra steps to maintain patient safety and don't just follow orders. It also means the accuracy of patient information is validated and plans for caring for patients are based on their needs, current clinical practice, and research. The nursing process is a critical thinking model based on a systematic approach to patient-centered care. Nurses use the nursing process to perform clinical reasoning and make clinical judgments when providing patient care.

Based on observation, interview and record review, the facility failed to ensure daily nurse staffing information contained all required information when the total number of hours and actual hours worked by Registered Nurse (RN)s, Licensed Vocational Nurse (LVN) s, Licensed Practical Nurse (LPN)s, and Certified Nursing Assistant (CNA)s were not separated, and was not posted in a prominent readily accessible location to 60 out of 60 residents and visitors. This failure resulted in restricted public access to posted nurse staffing information for 60 out of 60 residents admitted within the facility which had the potential to result in residents not knowing how many direct care hours were provided daily. Findings: During a concurrent interview and record review on 4/3/25 at 1:54 p.m. with the Director of Staff Development (DSD), the facility's document titled Daily Nurse Staffing , dated 4/3/25 was reviewed. The facility's daily nurse staffing document indicated, .Total Hands on PPD (Per Patient Day) . 3.7 [hours] .Total Hours 222 [hours] .Divided by total census 60 . The DSD could not state or locate the total number and actual hours worked by RNs, LVNs/LPNs, or CNAs on the daily nurse staffing document. The DSD stated she was responsible to calculate unlicensed nursing staff total number and actual hours worked by CNAs. The DSD stated the Director of Nursing (DON) was responsible to calculate licensed nursing staff total number and actual hours worked by the LVNs or LPNs and RNs. The DSD stated she was responsible to post daily nurse staffing information with all required information. During a concurrent observation and interview on 4/3/25 at 2:15 p.m. with the DSD at the nursing station, the facility's daily nurse staffing document was observed posted behind the nursing station to the right of the facility's sink. At the entrance of the nursing station a sign indicated, Staff members only beyond this point. Thank you. The DSD stated residents and visitors were not allowed behind the nursing station. The DSD stated residents and visitors could not readily access or view the daily nurse staffing information behind the nursing station. The DSD stated residents and visitors had to ask for the daily nurse staffing information. The DSD stated the daily nurse staffing information should be posted in a location easily accessed and viewable to all 60 residents and visitors. The DSD stated unlicensed and licensed nursing staff hours should be separated. The DSD stated residents and visitors had a right to view and access the posted nurse staffing information without assistance. The DSD stated residents and visitors had a right to know which staff members were working and how many direct care hours were provided for each resident every day. During a concurrent interview and record review on 4/3/25 at 4:32 p.m. with the DON, the facility's document titled Daily Nurse Staffing (DNS), dated 4/3/25 was reviewed. The DON could not state or locate the total number and actual hours worked by RNs, LVNs/LPNs, or CNAs on the DNS document. The DON stated the facility's DNS document was posted behind the nursing station. The DON stated the facility's DNS document was not readily accessible to all residents and visitors. The DON stated it was important to have the total number and actual hours worked by RNs, LVNs/LPNs, and CNAs. The DON stated it was important residents and visitors had access to the facility's daily nurse staffing document with all required information so they could view what staff was on shift, how many staff were available and how many licensed/ unlicensed direct care hours were provided to care for each resident on daily basis. During a concurrent interview and record review on 4/3/25 at 4:57 p.m. with the Administrator (ADM), the facility's document titled DNS, dated 4/3/25 was reviewed. The ADM could not state or locate the total number and actual hours worked by RNs, LVNs/LPNs, or CNAs on the DNS document. The ADM stated, 99% of the time it [the facility's DNS document] is posted behind the nursing station. The ADM stated the document was not easily accessible to all residents or visitors when the document was behind the nursing station. The ADM stated residents and visitors had a right to view and know nurse staffing information with all required information. The ADM stated the facility did not have a policy or procedure for posted daily nurse staffing information or requirements. The ADM stated he expected the facility to follow state regulations for posted nurse staffing information. During a review of the facility's document titled DNS, dated 3/27/25, 3/28/25, 3/29/25, 3/30/25, 3/31/25, 4/1/25, 4/2/25, and 4/3/25 the documents were not separated by the total number and actual hours worked by RNs, LVNs/LPNs and CNAs. The document combined all unlicensed and licensed nursing hands on care provided to residents into, Total Hands on PPD. During a review of the facility's job description document titled, Director of Nursing, undated, the job description indicated, .Oversees nursing schedules to ensure resident needs, regulatory and budget standards are met . During a review of the facility's job description document titled, Administrator, undated, the job description indicated, Establishes a culture of compliance by adhering to all facility policies and procedures. Complies with standards of business conduct, and state/federal regulations and guidelines .

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (CP - a detailed approach to care customized to an individual resident's needs) for three of 14 sampled residents (Resident 28, 37, 41) when: 1. Resident 37's CP did not address Resident 37's preference to maintain an ileostomy (is a surgical procedure where the end of the small intestine (ileum is brought through an opening in the abdomen (stoma) to allow waste to exit the body through a bag instead of the anus) and to manage the associated risk. This failure placed Resident 37 at risk for stoma complications and not to honor residents' choice while ensuring proper care. 2. Resident 41's CP was not developed to address the ongoing medication refusal. This failure had the potential for resident 41 to experience severe and serious medical complications. 3. Resident 28 did not have an individualized care plan for self-harm indicated by pulling dried skin and scabs off her wounds (picking) on her right and left arms and right shoulder causing bleeding and unhealing wounds. This failure placed Resident 28 at an increased risk for wound infection, pain and discomfort. 4. Resident 28's CP was not implemented to provide a toileting schedule (a schedule that instructed Certified Nursing Assistants (CNA)s to assist Residents to the toilet every 2 hours) and adequate supervision and assistance to prevent falls. This Failure resulted in Resident 28 attaining an unwitnessed fall and put Resident 28 at risk for further falls. Findings: 1. During a review of Resident 37's Admission Record (AR- a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 4/4/25, the AR indicated, Resident 37 was admitted to the facility on [DATE] with a diagnosis of Protein-calorie Malnutrition (is the state of inadequate intake of food), Supraventricular Tachycardia (a rapid heart rhythm problem where the heart beats too fast), Anxiety (emotion characterized by feelings of unease, worry, or fear), and Ileostomy . During a review of Resident 37's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function assessment, dated 3/8/25, the MDS assessment indicated Resident 37's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment assessment score was 15 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 37 was cognitively intact. During a concurrent observation and interview on 4/1/25 at 10:08 a.m. with Resident 37, in Resident 37's room, Resident 37 was observed to have a stoma (surgical opening in the abdomen to allow fecal waste to exit the body into a bag) on the right side of the abdomen, and was uncover. Resident 37 was observed cleaning the stoma with a white washcloth. Resident 37 was observed having a clear large plastic bag filled with white washcloths to the left-hand side on the bed. Resident 37 stated she had an ileostomy. Resident 37 stated the bag over the stoma bothered the stoma area and rather keep the bag off the stoma. Resident 37 stated the nurses could not get the bag to stick on correctly, causing the bag to leak. Resident 37 stated when the bag got too full it bothered her. Resident 37 stated the plastic bag next to her had clean towels inside, her family brought back to the facility after washing the towels. Resident 37 stated she would clean and took care of the stoma using the washcloths to manage the fecal waste coming out of the stoma. During a review of Resident 37's Physician Order (PO), dated 3/1/25, the PO indicated, . Order date: 3/1/25 . Communication Method: Prescriber written . Order Summary: Ileostomy care .every shift . During a review of Resident 37's Electronic Medical Record (EMR), on 4/2/25, the EMR indicated no CP was developed for Resident 37's preferred ileostomy care. During an interview on 4/2/25 at 10:22 a.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated Resident 37 did not like to have the ileostomy bag over the stoma. CNA 2 stated Resident 37 would care for the stoma and the fecal waste with towels her family brought to her. CNA 2 stated Resident 37 did not like the ileostomy bag on because it bothered her, and the bag would get too full too quick. During a review of Resident 37's Hospice Notes (notes created by an individual who is providing care and comfort support to a person terminal ill), on 4/3/25, the Hospice notes indicated, . Reports her ileostomy bag fills very rapidly when she eats anything .she does not want to empty the bag in the middle of a meal .loosing her appetite when she sees her bag fill up During a concurrent interview and record review on 4/2/25 at 2:49 p.m. with Licensed Vocational Nurses (LVN) 3, LVN 3 stated Resident 37 did not have a person centered CP in place for stoma care. LVN 3 stated the CP should be in place indicating resident 37 choice to keep the stoma uncovered. LVN 3 stated the CP was important because it insured everyone who provide care for Resident 37 had the appropriate information needed to provide person centered care. During an interview on 4/3/25 at 11:05 a.m. with the Director of Nursing (DON), the DON stated CP were important for all residents. DON stated her expectation was for the CP to be created on time and updated as needed. During a review of the facility's Policy and Procedure P&P titled, Comprehensive CP, dated 2025, the P&P indicated, .It is the policy of this facility to develop . the comprehensive person-centered CP for each resident . focus on the resident as the locus of control and support the resident .Resident specific interventions that reflect the residents needs and preferences .Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions .and when changes are made . 2. During a review of Resident 41's AR, dated 4/3/25, the AR indicated, Resident 41 was admitted to the facility on [DATE] with a diagnosis of Epilepsy [a chronic brain disorder characterized by recurrent seizures(uncontrolled jerking body movements)], Atrial Fibrillation (heart beat irregularly and rapidly), Transient Ischemic Attack (TIA- a medical condition where blood flow to the brain is briefly blocked), and Hypertension (a condition where the force of blood pushing against the artery [A blood vessel that carries blood from the heart to tissues and organs in the body] walls is consistently too high, meaning the heart has to work harder to pump blood. That can lead to serious health problems, such as heart disease, stroke, and kidney failure.) During a review of Resident 41's MDS dated [DATE], the MDS assessment indicated Resident 41's BIMS assessment score was 13 out of 15. The BIMS assessment indicated Resident 41 was cognitively intact. During an interview on 4/1/25 at 4:07 p.m. with Resident 41's Responsible Party (RP), RP stated she was the person of contact for Resident 41. RP stated Resident 41 was admitted into the facility 1/7/25. RP stated Resident had a stroke in the past and began to care for her at home and can no long care for her. RP stated she has not been contacted by the facility to inform her of any changes to Resident 4's condition. During a review of Resident 41's Medication administration Record (MAR- a standardized record that organizes essential information about a patient and their prescribed medications), dated 3/2025, the MAR indicated, .Apixaban (a type of medicine helps prevent harmful blood clots from forming] Oral (by mouth) Tablet 5 milligrams- (MG-a unit of measurement used to measure the dosage of medication] give 1 tablet by mouth two times a day for [for stroke prevention] related atrial fibrillation .start date 1/8/25. The MAR indicated Resident 41 refused the medication twice a day for 24 days out of 31 days. During a review of Resident 41's MAR dated 3/2025, the MAR indicated, Levtiracetam (medication for seizures) 500 MG give two tablets two times a day for seizures .start date 1/8/25. The MAR indicated Resident 41 refused medication twice a day for 24 days out of 31 days in March. During a review of Resident 41's MAR dated 3/2025, the MAR indicated Metoprolol Succiate (medication to lower blood pressure and heartrate) 50 MG 1 tablet by mouth one time a day for high blood pressure .start date 1/8/25, was refused by Resident 41, 27 days out of 31 days in March. During a review of Resident 41's MAR dated 3/2025, the MAR indicated Lisinopril (medication used to lower blood pressure.) .start date 1/8/25 ., 5 MG 1 tablet by mouth one time a day for high blood pressure, was refused by resident 41, 27 days out of 31 days in March. During a concurrent interview and record review on 4/3/25 at 10:21 a.m. with LVN 2 , Resident 41's MAR and CP was review. LVN 2 stated Resident 41's CP for medication refusal and interventions was not created. LVN 2 stated nurses were expected to care plan residents' refusal with person centered interventions. LVN 2 stated after every refusal, the RP and medical doctor should be notified and document the responses. LVN 2 stated a CP should have been created for Resident 41. LVN 2 stated Resident 41 was at risk for health decline refusing medications. During a concurrent interview and record review on 4/3/25 at 11:05 a.m. with the DON, Resident 41's CP and progress (a record of how the residents respond to treatment or services) notes were reviewed. The DON stated she expected the refusal of medication to be documented with Resident 41's reason of refusals, what person-centered education information was provided, with the Residents 47' s' response and to notify the RP, and medical doctor. The [NAME] stated it was important documentation reflected education provided to Resident 41 to ensure she received accurate and ongoing education. The DON stated it was important resident 41's refusals were care planned to ensure interventions were in place to ensure ongoing education of medication importance. During an interview on 4/3/25 at 4:33 p.m. with Medical Doctor (MD), the MD stated he expected nursing staff to provide education on risk and benefits of not taking medication as ordered. The MD stated he expected the nursing staff to contact and inform Resident 41's RP of every refusal. The MD stated he expected nursing staff to document risks and benefit as provided to Resident 41. The MD stated it was important to document the risks and benefits that were explained to Resident 41 to ensure she received education . During a review of the facility's P&P titled, Comprehensive CP, dated 2025, the P&P indicated, .It is the policy of this facility to develop . the comprehensive person-centered CP for each resident . focus on the resident as the locus of control and support the resident .Resident specific interventions that reflect the residents needs and preferences .Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions .and when changes are made . During a review of the facility's P&P titled, Refusal of Treatment/Medication, dated 8/11, the P&P indicated, .Resident refuses treatment .the charge nurse, or DON will interview them to determine what and why they refuse . detailed information relating to the refusal must be entered into the resident's medical record . Documentation .shall include . medication or treatment refused; .response and reason(s) for refusal; . resident was informed to the extent of their ability to understand of the purpose of the treatment and the consequences of not receiving the medication/or treatment . Date and time the physician was notified as well as physicians response . 3. During a concurrent observation and interview on 4/01/25 at 11:22 a.m. in Resident 28's room, Resident 28 was observed dressed, lying in bed with uncovered wounds on her right and left arms and right shoulder. Resident 28 was observed pulling dried skin and scabs off from her shoulder. Resident 28 stated she picked at her wounds because they itched. Resident 28 stated she was not getting medication for the itching. During a review of Resident 28's AR , dated 4/3/25, the AR indicated Resident 28 was admitted to the facility from an acute care hospital on 12/9/24 with diagnoses of type 2 Diabetes Mellitus (when the blood sugar levels in the body are too high), depression (persistent feelings of sadness, despair, loss of energy, and difficulty dealing with normal daily life), muscle weakness, and abnormalities of gait (an unusual walking pattern). During a review of Resident 28's MDS - , dated 2/6/25, the MDS section C indicated Resident 28 had a BIMS score of 11 out of 15 , which suggested Resident 28 was moderately impaired. During an interview on 4/02/25 at 2:33 p.m. with CNA 1, CNA 1 stated Resident 28 picked at her wounds because she was anxious. CNA 1 stated this was a behavior of Resident 28. CNA 1 stated she did not know if Resident 28 was given medication for her wounds. CNA 1 stated she reported Resident 28's behavior and wounds to the nurse. CNA 1 stated Resident 28 had picked at the same wounds, and they were not healing, During a concurrent interview and record review on 4/03/25 at 10:40 a.m. with LVN 1, Resident 28's CP, undated was reviewed. The CP indicated there was no care plan developed and implemented regarding Resident 28 harming herself by picking at her wounds, and no interventions for the care of her wounds. LVN 1 stated Resident 28 was non-compliant with picking at her wounds. LVN 1 stated Resident 28 should have had a CP for her wound care and behavior and should have been put on alert charting for monitoring. LVN 1 stated CPs were important so nurses and CNAs would have continued follow up on resident's goals and would have known if assistance was needed when caring for residents. LVN 1 stated the CPs helped make sure resident's goals and objectives were complete. LVN 1 stated if there was no CP in place, the resident's level of care may not have been met. During a concurrent interview and record review on 4/03/25 at 4:56 p.m. with the Director of Nursing (DON), Resident 28's CP, undated was reviewed. The DON stated there was no care plan in place regarding Resident 28 picking at her wounds. The DON stated she was notified yesterday of Resident 28 picking at her arms and shoulder. The DON stated Resident 28 should have had a care plan for picking at her wounds so staff would have known Resident 28's plan of care and , what interventions were in place to care for Resident 28's wounds. The DON stated the CP helped staff deliver a personalized plan of care and informed staff how to take care of each resident. The DON stated Resident 28's wounds could have gotten worse and had put Resident 28 at risk for infection. 4. During a concurrent observation and interview on 4/01/25 at 11:22 a.m. with Resident 28 in Resident 28's room, Resident 28 was observed dressed, lying in bed. Resident 28 stated she did not know how she was doing. Resident 28 stated she had been at the facility for four to five weeks. Observed fall mats on the right side of Resident 28's bed. Resident 28 stated she had fallen while she had been at the facility. Stated she did not know when she fell . Resident 28 stated her right leg did not work. Resident 28 stated she had gone to the hospital, but did not know if she went to the hospital because of her fall. Resident 28 observed changing position to sit up in bed and move her legs over the side of her bed to attempt to get out of bed. Resident 28 stated she needed to use the restroom. Resident 28 stated she needed help to get to her wheelchair. Observed wheelchair at foot of Resident 28's bed out of reach. During an interview on 4/2/25 at 2:33 p.m. with CNA 1, CNA 1 stated CNAs should have been going to resident rooms every two hours to check on residents and made rounds regularly by going up and down the hallway. CNA 1 stated Resident 28 had a couple of falls. CNA 1 stated she did not know why Resident 28 fell . During a concurrent interview and record review on 4/02/25 at 3:03 p.m. with the Social Services Director (SSD), Resident 28's Interdisciplinary Post Event Note, dated 3/14/25 was reviewed. The Interdisciplinary Post Event Note indicated, . Root cause is she (Resident 28) often calls out for help because she doesn't understand how to use the call light because she is confused . The SSD stated the therapy department was to follow up with Resident 28 to educate on her environmental awareness and use of her call light. During an interview on 4/03/25 at 10:40 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the nurse was responsible for assessing residents for falls. LVN 1 stated if the resident had a fall, the nurse would have assessed the resident after the fall to be sure there were no injuries that would have put the resident at immediate risk. LVN 1 stated the nurse would have assisted the resident to a proper position to be sure the resident was safe, checked the resident's orientation level, called the resident's physician and Responsible Party (RP). LVN 1 stated the nurse would have performed an assessment for a Change of Condition (COC) in the resident's status, and if the resident hit their head, the nurse would have performed neurological (relating to the nervous system) checks for the first two hours. LVN 1 stated neurological checks would have also been performed if the resident's fall was unwitnessed. LVN 1 stated nurses would have put the resident on alert charting after a fall, inform the resident's family, and monitor the resident throughout their shift. The nurse revised the resident's care plan, and the DON sent the reporting to the appropriate facilities. During a concurrent interview and record review on 4/03/25 at 4:56 p.m. with the DON, the DON stated Resident 28 had a fall on 3/14/25 which resulted in no injuries. The DON stated after a resident had a fall, the IDT would review the fall note in the system and go over the root cause of the fall. The DON stated the IDT would come up with therapy or activity recommendations for the resident. During a concurrent interview and record review on 4/04/25 at 3:24 p.m. with the Director of Staff Development (DSD), Resident 28's Fall Risk Assessment, dated 1/30/25 was reviewed. The Fall Risk Assessment indicated Resident 28 had a fall risk score of 11.0, which was considered a high risk for falls. The DSD stated Resident 28 was a high fall risk resident and staff should have been checking on Resident 28 at least every two hours. Resident 28's CP, undated was reviewed. The CP indicated, . Date Initiated 01/31/25 . Revision on: 02/3/25 . Interventions . anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance . Date Initiated: 01/31/25 . resident to be on a toileting schedule . Date Initiated: 02/03/25 . The DSD stated staff should have checked Resident 28 every two hours for toileting needs. The DSD stated checking residents more frequently than every two hours was important as it provided closer monitoring for residents who were at a higher risk for falls. During a review of the facility's policy and procedure (P&P) titled Comprehensive Care Plans, dated 2025, indicated, . It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs .and meet professional standards of quality . [care and all services are provided according to accepted standards of clinical practice] . resident specific interventions that reflect the resident's needs . 48739

Based on observation, interview, and record review the facility failed to ensure an infection prevention and control program was maintained for 7 of 14 sampled residents (Resident 4, 9, 10, 22, 48, 50, and 261), when: 1. Licensed Vocational Nurse (LVN) 1 and LVN 2 did not perform hand hygiene [cleaning hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based rub (ABHR)] between Resident 10, 22, 48, 50, and 261 during medication administration. This failure had increased risk of cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effects) and the spread of infection. 2. Resident 4's oxygen nasal cannula (O2 NC- a tube that directs oxygen into the nose) tubing was observed not in a protective bag on top of the oxygen concentrator (medical device that supplies oxygen-enriched air to help people breathe easier). This failure placed Resident 4 at risk for cross contamination which could result in infection and illness. 3. Certified Nursing Assistant (CNA) 4 did not perform hand hygiene after leaving a resident room and before entering and exiting Resident 9's room. This failure had the potential to cause cross contamination and the spread of harmful pathogens (tiny germs like bacteria or viruses) from one resident 's environment to another, leading to potential infections. Findings: 1. During an observation of medication administration on 4/2/25 at 11:31 a.m. LVN 1 and LVN 2 were observed administering afternoon medications to Resident 10, 22, 48, 50, and 261. LVN 1 and LVN 2 did not perform hand hygiene between administering the medications to residents. During a review of Resident 10's Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive[mental processes], physical functional level assessment), dated 12/18/24, the MDS section C indicated Resident 10's Brief Interview for Mental Status (BIMS- a test given by medical professionals to determine cognitive(involving the process of thinking, learning and understanding) understanding on a scale of 1-15) score was 15 out of 15 (0-6 severe cognitive impairment, 7-12 moderately impaired, 13-15 cognitively intact) which indicated Resident 10 was cognitively intact. During a review of Resident 22's MDS assessment dated [DATE], the MDS assessment indicated Resident 22's BIMS assessment score was 12 out of 15 which indicated Resident 22 had moderately impaired. During a review of Resident 48's MDS assessment dated [DATE], the MDS assessment indicated Resident 48's BIMS assessment score was 00 out of 15 which indicated Resident 22 had severe cognitive impairment. During a review of Resident 50's MDS assessment dated [DATE], the MDS assessment indicated Resident 50's BIMS assessment score was 13 out of 15 which indicated Resident 22 was cognitively intact. During a review of Resident 261's MDS assessment dated [DATE], the MDS assessment indicated Resident 261's BIMS assessment score was 15 out of 15 which indicated Resident 22 was cognitively intact. During a concurrent observation and interview on 4/2/25 at 11:31 a.m. with Licensed Vocational Nurse (LVN) 1 in the south hall, during afternoon medication administration. LVN 1 was observed administering medications to Resident 10, 22 and 261 without performing hand hygiene. LVN 1 stated hand sanitizer should have used before and after entering the residents' rooms. LVN 1 stated it was important to wash hands between residents during medication pass to reduce the risk of infection for other residents. During an observation on 4/2/25 at 11:57 a.m. LVN 2, was observed in the East Hall exiting Resident 48's room and entering Resident 50's room without performing hand hygiene during afternoon medication administration. During an interview on 4/2/25 at 11:57 a.m. with LVN 2, LVN 2 stated that hand washing should be done after three to four residents. LVN 2 stated she did not perform hand washing because the sink was far. The LVN stated the hand hygiene was important for residents because it places them at risk for cross contamination. During an interview on 4/4/25 at 11:22 p.m. with Infection Preventionist (IP-professionals who make sure healthcare workers and health facilities are doing all the things they should to prevent infections from spreading), the IP stated her expectation was to perform hand hygiene before entering the residents' rooms, coming out of the residents' rooms, before and after resident care and between residents during medication administration. The IP stated staff was expected to wash hands with soap and water after care for residents who are on Enhanced Barrier Precaution (EBP- an infection control intervention to reduce transmission of infections). The IP stated hand hygiene was important to prevent cross contamination and the spread of infections. During a review of facility's policy and procedure (P&P) titled, Medication Administration, dated 4/2024, the P&P indicated, . Wash hands prior to administering medication . During a review of facility's policy and procedure (P&P) titled, Hand Hygiene, dated 5/2024, the P&P indicated, .All staff will perform proper hand hygiene procedures to prevent the spread of infection . 2. During an observation on 4/1/25 at 10:08 a.m. in Resident 16's room, Resident 16's oxygen NC tubing was observed not in a protective bag on top of the oxygen concentrator and in direct contact with the wall. During a review of Resident 16's AR, the AR indicated, Resident 16 was admitted to the facility on [DATE] with a diagnosis which included Chronic Obstructive Pulmonary Disease (COPD- a common lung disease that makes it difficult to breathe) and acute respiratory failure with hypoxia (lungs are suddenly not able to get enough oxygen into their blood, causing a lack of oxygen throughout their body). During a review of Resident 16's Order Summary Report (OSR), dated 4/4/25, the OSR indicated, . [Resident 16] . Order Summary: Oxygen- At 2 liters (unit of measurement) per/minute via Nasal cannula Every Shift . Order status: Active .Start Date/By: 2/25/25 . During an interview on 4/2/25 at 2:50 p.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated the oxygen NC should not have been left out on top of the oxygen concentrator touching the wall. LVN 3 stated tubing needed to be replaced and put into the protective bag when the resident was not using it. LVN 3 stated cross contamination could have occurred with the NC not in the protective bag when not in use. During an interview on 4/4/25 at 11:22 a.m., with the IP, the IP stated the oxygen nasal cannula touching the wall on top of the concentrator was unacceptable. The IP stated the potential outcome for a resident could be an infection, compromising the health of Resident 16. The IP stated cross contamination for Resident 16 could have occurred. The IP stated staff did not follow the facility policy and procedure for Oxygen Administration. During a review of facility's policy and procedure (P&P) titled, Oxygen Administration, dated 2/2023, the P&P indicated, . Keep delivery devices covered in plastic bag when not in use . 51271 During an observation on 4/3/25 at 9:22 a.m. CNA 4 exited a resident room without performing hand hygiene, entered Resident 9's room without performing hand hygiene, assisted Resident 9 with their out-of-reach call light, and left the room without performing hand hygiene out. During the review of Resident 9's Admission Record, dated 4/3/25, the AR indicated Resident 9 was admitted on [DATE] with the diagnosis of: dementia (a progressive state of decline in mental abilities), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) and muscle weakness (decreased strength in muscles). During a review of Resident 9's MDS, dated [DATE], the MDS BIMS- , which indicated Resident 4 had severe cognitive impairment. During an Interview with CNA 4 on 4/3/25 at 9:41 a.m. CNA 4 stated the importance of performing hand hygiene while going in and out of resident rooms was to prevent cross contamination. During an interview with Licensed Vocational Nurse (LVN) 1 on 4/3/25 at 11:49 a.m. LVN 1 stated we are to perform hand hygiene in and out of resident rooms. LVN 1 stated this was important because they did not want to spread germs (living things that can be found everywhere) to other residents. LVN 1 stated ensuring proper hand hygiene helped reduce the risk of infection. During an interview with the Director of Nursing (DON) on 4/3/25 at 4:56p.m. the DON stated that her expectation of staff was to perform hand hygiene when entering and exiting resident rooms. The DON stated CNA 4 should have performed hand hygiene when she entered and exited Resident 9's room. The DON stated her expectation of staff was to perform hand hygiene upon entering and exiting resident rooms, even if they were not touching anything, as it ensured germs were not carried from room to room. During a review of facility's policy and procedure (P&P) titled, Hand Hygiene, dated 5/2024, the P&P indicated, .All staff will perform proper hand hygiene procedures to prevent the spread of infection .staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice .

Based on observation, interview, and record review, the facility failed to meet professional standards of practice for two of 11 sampled residents (Resident 28 and Resident 57) when: 1. Resident 28 sustained wounds due to continued itching and picking (pulling off dried skin and scabs) from her wounds on her right, left arms and right shoulder and Licensed Vocational Nurses (LVN)s did not notify the physician. This failure resulted in Resident 28 having open, bleeding and unhealing wounds which put Resident 28 at risk for infection and continued discomfort. 2. Resident 57's oxygen therapy (a colorless, odorless, tasteless gas essential to living organisms) was not administered per the physician order. This failure resulted in Resident 57 not receiving his oxygen therapy as ordered which had the potential to result in nasal dryness, shortness of breath, oxygen toxicity, and serious medical condition. Findings: 1. During a review of Resident 28's Admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 4/3/25, the AR indicated Resident 28 was admitted to the facility from an acute care hospital on 12/9/24 with diagnoses of type 2 Diabetes Mellitus (when the blood sugar levels in the body are too high), depression (persistent feelings of sadness, despair, loss of energy, and difficulty dealing with normal daily life), muscle weakness, and abnormalities of gait (an unusual walking pattern). During a review of Resident 28's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 2/6/25, the MDS section C indicated Resident 28 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of 11 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 28 was moderately impaired. During a concurrent interview and record review on 4/03/25 at 10:40 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 28's Progress Notes dated 3/14/25 and 3/21/25 were reviewed. The Progress Note, dated 3/14/25 indicated, . The client was picking at their skin, resulting in open areas with minor bleeding. Bloody tissues were left on their dinner tray . LVN 1 stated there was no documentation of physician notification for Resident 28's continued picking of her wounds. LVN 1 stated the physician should have been notified so he could determine the proper care for Resident 28's wounds and behavior. LVN 1 stated Resident 28 was at risk of infection due to her open wounds. LVN 1 stated the Certified Nursing Assistant (CNA)s should have documented Resident 28's wounds during skin checks and should have notified the nurse of Resident 28 picking at her wounds. During a concurrent interview and record review on 4/03/25 at 4:37 p.m. with the Pharmacist Consultant (PC), Resident 28's Order Summary Report, dated 4/3/25 was reviewed. The PC stated some pain medications could have caused itching, but he did not recall being notified Resident 28 had itching. The PC stated he did not evaluate residents but looked at nurses' notes when he did his monthly review. The PC stated he relied on nurses to let him know if there was anything significant going on with a resident. During an interview on 4/04/25 at 3:24 p.m. with the Director of Staff Development (DSD), the DSD stated staff should have checked Resident 28's skin every time they did skin care and during Resident 28's shower. The DSD stated her expectation was staff should have reported any wounds immediately to the charge nurse, so they could have notified the physician and received a treatment plan for Resident 28's wounds and prevented further skin breakdown. The DSD stated it was not okay for CNAs to have observed Resident 28 picking at her wounds and not report it to the charge nurse. During an interview on 4/04/25 at 4:14 p.m. with LVN 1, LVN 1 stated there were no paper log sheets for resident's bathing or showering skin checks. LVN 1 stated CNAs should have let the nurse know if there were any wounds and the nurse would have assessed the resident with the CNA. During a review of the facility policy and procedure (P&P) titled, Wound Treatment Management, dated 2024, indicated . To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders . wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change . in the absence of treatment orders the licensed nurse will notify physician to obtain treatment orders . the effectiveness of treatments will be monitored through ongoing assessment of the wound . During a review of the facility's job description document titled, Licensed Vocational Nurse, undated, the document indicated . Observes for changes in residents' status, notifying the physician . performs wound treatments as per physicians' orders, observes for changes and documents accordingly . performs rounds to ensure resident needs are being met . During a review of the facility's job description document titled, Certified Nursing Assistant, undated, the document indicated . Assists with tracking the condition of the resident's skin. Reports any presence of pressure areas, skin breakdown or skin tears to nurse and supervisor . During a professional reference review obtained from https://www.jamda.com/article/S1525-8610(04)70066-3/abstract titled, Improving Communication Among Attending Physicians, Long-Term Care Facilities, Residents, and Residents' Families, dated March - April 2024, the professional reference review indicated, . effective bidirectional communication (data exchange between two parties) between attending physicians and long-term care facilities is of critical importance to ensure timely, appropriate, and high-quality care that is responsive to resident's needs . 2. During a review of Resident 57's AR, dated 4/3/25, the AR indicated, Resident 57 was admitted in the facility on 3/12/25, with diagnosis which included .Chronic respiratory failure with hypoxia (occurs when the lungs cannot adequately provide oxygen to the blood, leading to a chronic low oxygen level), heart failure (occurs when the heart can't pump enough blood to meet the body's needs), and pneumonia (a lung infection that inflames the air sacs and can lead to fluid buildup, making it difficult to breathe) . During a review of Resident 57's MDS assessment, dated 3/18/25, the MDS assessment indicated Resident 57's BIMS- assessment score was 9 out of 15 which indicated Resident 57 had moderate cognitive impairment. During a concurrent observation and interview on 4/2/25 at 11:01 a.m. with LVN 1 in Resident 57's room, Resident 57 was observed lying in bed, eyes closed with his nasal cannula (a thin, flexible tube with two prongs that fit into the nostrils and deliver oxygen) in his nose. LVN 1 stated Resident 57 had an order for oxygen therapy 2 LPM (liter per minute- a unit of measurement for the flow rate of oxygen) continuously through the nasal cannula. Resident 57's nasal cannula was observed connected to the oxygen concentrator (medical device that helps residents' breath). LVN 1 stated he observed Resident 57's oxygen concentrator on the right side of the bed turned on at 5 LPM. LVN 1 stated Resident 57 had not received oxygen at 2 LPM. LVN 1 stated he was Resident 57's nurse and could not state how long Resident 57 received 5 LPM of oxygen therapy. LVN 1 could not state who increased Resident 57's oxygen therapy. During a concurrent interview and record review on 4/2/25 at 11:05 a.m. with LVN 1, Resident 57's Order Summary Report, dated 4/2/25 was reviewed. LVN 1 stated Resident 57 had an active order for, .Oxygen at 2 LPM via nasal cannula every shift . LVN 1 stated Resident 57 had not received oxygen at 2 LPM. LVN 1 stated Resident 57 had not received oxygen therapy as per the physician order. LVN 1 stated it was important to follow all physician orders as prescribed. LVN 1 stated Resident 57 was at risk for nasal dryness and increased need for oxygen therapy requirements. During a concurrent interview and record review on 4/2/25 at 11:09 a.m. with Respiratory Therapist (RT) 1, outside of Resident 57's room, RT 1 stated Resident 57 had chronic respiratory failure and required continuous oxygen therapy at 2 LPM . RT 1 stated Resident 57 was not in any respiratory distress and his oxygen therapy should not have been increased. RT 1 stated oxygen was a medication, and all medication orders were expected to be followed. RT 1 stated Resident 57 had not received his oxygen therapy as prescribed by the physician. RT 1 stated she was Resident 57's RT and could not state how long Resident 57 received 5 LPM of oxygen therapy. RT 1 could not state who increased Resident 57's oxygen therapy. During a concurrent interview and record review on 4/3/25 at 4:32 p.m. with the Director of Nursing (DON), the DON stated oxygen therapy was a physician's order and was considered a medication. The DON stated all physician orders and medications must be administered as prescribed. The DON stated Resident 57's oxygen therapy was not administered as prescribed. The DON stated only physician's, Registered Nurses (RN), LVN's, and RT's were allowed to adjust the oxygen concentrator. The DON stated Resident 57 was at risk for shortness or breath with increased oxygen administration and oxygen toxicity. During a review of Resident 57's Order Summary Report, dated 4/3/25, the Order Summary Report indicated, Resident 57 had an active order for oxygen .at 2 Liters/Min via nasal cannula every shift . During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, undated, the P&P indicated, .Oxygen is administered to residents who need it, consistent with professional standards of practice .oxygen is administered under orders of a physician .personnel authorized to initiate oxygen therapy include physicians, RNs, LPNs, and respiratory therapists . During a review of the facility's P&P titled, Medication Administration, undated, the P&P indicated, .Ensure that the six rights of medication administration are followed .right drug .right dosage . During a review of the facility's job description document titled, Licensed Vocational Nurse, undated, the document indicated, .Transcribes physician orders .and carries out orders as written .prepares and administers medications as per physicians' orders . During a review of the facility's job description document titled, Respiratory Therapist, undated, the document indicated, .Plans, develops, organizes, implements, evaluates, and directs the execution of respiratory care services in accordance with physician's orders . During a professional reference review retrieved from https://pubmed.ncbi.nlm.nih.gov/19377391/ titled, The use of medical orders in acute care oxygen therapy, dated 2009, the professional reference review indicated, . Oxygen is considered to be a drug requiring a medical prescription and is subject to any law that covers its use and prescription . authorized by a physician following legal written instruction to a qualified nurse . 51059 2. During a review of Resident 57's AR, dated 4/3/25, the AR indicated, Resident 57 was admitted in the facility on 3/12/25, with diagnosis which included .Chronic respiratory failure with hypoxia (occurs when the lungs cannot adequately provide oxygen to the blood, leading to a chronic low oxygen level), heart failure (occurs when the heart can't pump enough blood to meet the body's needs), and pneumonia (a lung infection that inflames the air sacs and can lead to fluid buildup, making it difficult to breathe) . During a review of Resident 57's MDS assessment, dated 3/18/25, the MDS assessment indicated Resident 57's BIMS- assessment score was 9 out of 15 which indicated Resident 57 had moderate cognitive impairment. During a concurrent observation and interview on 4/2/25 at 11:01 a.m. with LVN 1 in Resident 57's room, Resident 57 was observed lying in bed, eyes closed with his nasal cannula (a thin, flexible tube with two prongs that fit into the nostrils and deliver oxygen) in his nose. LVN 1 stated Resident 57 had an order for oxygen therapy 2 LPM (liter per minute- a unit of measurement for the flow rate of oxygen) continuously through the nasal cannula. Resident 57's nasal cannula was observed connected to the oxygen concentrator (medical device that helps residents' breath). LVN 1 stated he observed Resident 57's oxygen concentrator on the right side of the bed turned on at 5 LPM . LVN 1 stated Resident 57 had not received oxygen at 2 LPM. LVN 1 stated he was Resident 57's nurse and could not state how long Resident 57 received 5 LPM of oxygen therapy. LVN 1 could not state who increased Resident 57's oxygen therapy. During a concurrent interview and record review on 4/2/25 at 11:05 a.m. with LVN 1, Resident 57's Order Summary Report, dated 4/2/25 was reviewed. LVN 1 stated Resident 57 had an active order for, .Oxygen at 2 LPM via nasal cannula every shift . LVN 1 stated Resident 57 had not received oxygen at 2 LPM. LVN 1 stated Resident 57 had not received oxygen therapy as per the physician order. LVN 1 stated it was important to follow all physician orders as prescribed. LVN 1 stated Resident 57 was at risk for nasal dryness and increased need for oxygen therapy requirements. During a concurrent interview and record review on 4/2/25 at 11:09 a.m. with Respiratory Therapist (RT) 1, outside of Resident 57's room, a picture of Resident 57's oxygen concentrator taken by the surveyor, dated 4/2/25 was reviewed. RT 1 stated the picture of the oxygen concentrator was Resident 57's RT 1 stated Resident 57's oxygen concentrator was on 5 LPM. RT 1 stated Resident 57 had chronic respiratory failure and required continuous oxygen therapy at 2 LPM . RT 1 stated she observed Resident 57 from the door way, outside Resident 57's room. RT 1 stated Resident 57 was not in respiratory distress and his oxygen therapy should not have been increased. RT 1 stated oxygen was a medication, and all medication orders were expected to be followed. RT 1 stated Resident 57 had not received his oxygen therapy as prescribed by the physician. RT 1 stated she was Resident 57's RT and could not state how long Resident 57 received 5 LPM of oxygen therapy. RT 1 could not state who increased Resident 57's oxygen therapy. During a concurrent interview and record review on 4/3/25 at 4:32 p.m. with the Director of Nursing (DON), a picture of Resident 57's oxygen concentrator taken by the surveyor, dated 4/2/25 was reviewed. The DON stated Resident 57's oxygen concentrator was turned on to 5 LPM and not the ordered 2 LPM. The DON stated oxygen therapy was a physician's order and was considered a medication. The DON stated all physician orders and medications must be administered as prescribed. The DON stated Resident 57's oxygen therapy was not administered as prescribed. The DON stated only physician's, Registered Nurses (RN), LVN's, and RT's were allowed to adjust the oxygen concentrator. The DON stated Resident 57 was at risk for shortness or breath with increased oxygen administration and oxygen toxicity. During a review of Resident 57's Order Summary Report, dated 4/3/25, the Order Summary Report indicated, Resident 57 had an active order for oxygen .at 2 Liters/Min via nasal cannula every shift . During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, undated, the P&P indicated, .Oxygen is administered to residents who need it, consistent with professional standards of practice .oxygen is administered under orders of a physician .personnel authorized to initiate oxygen therapy include physicians, RNs, LPNs, and respiratory therapists . During a review of the facility's P&P titled, Medication Administration, undated, the P&P indicated, .Ensure that the six rights of medication administration are followed .right drug .right dosage . During a review of the facility's job description document titled, Licensed Vocational Nurse, undated, the document indicated, .Transcribes physician orders .and carries out orders as written .prepares and administers medications as per physicians' orders . During a review of the facility's job description document titled, Respiratory Therapist, undated, the document indicated, .Plans, develops, organizes, implements, evaluates, and directs the execution of respiratory care services in accordance with physician's orders . During a professional reference review retrieved from https://pubmed.ncbi.nlm.nih.gov/19377391/ titled, The use of medical orders in acute care oxygen therapy, dated 2009, the professional reference review indicated, . Oxygen is considered to be a drug requiring a medical prescription and is subject to any law that covers its use and prescription . authorized by a physician following legal written instruction to a qualified nurse .

Based on observation, interview and record review the facility failed to ensure the Registered Dietitian (RD) offered adequate consultation to support food and nutrition services, residents' assessments and the development of individualized care plans for one of six sampled residents (Resident 39), when RD did not follow up with weight changes for Resident 39. This failure had the potential to cause reduced quality of life and risk of weight loss, dehydration and delayed wound healing. Findings: During an interview on 4/1/25 at 9:22 a.m. with the Certified Dietary Manager (CDM), the CDM stated the Registered Dietitian (RD) was not onsite. CDM stated RD typically worked on Saturdays. During an interview on 4/2/25 at 9:11 a.m. with Kitchen Staff (KS) 1, KS 1 stated the RD did not do staff training; it was done by the CDM. During an interview on 4/2/25 at 2:51p.m. with the CDM, the CDM stated she was responsible for the day -to-day operations, ordering, and tray line audits. The CDM stated the RD conducted sanitation audits. The CDM stated for new admissions, she interviewed the residents and completed the nutritional screening, resident preferences, tray cards and verified supplements. The CDM stated the RD's working hours were not consistent, as he worked at another facility. During an interview on 4/2/25 at 3:01 p.m. with the RD, the RD stated he worked around five to seven hours a week and did not have set scheduled days. The RD stated he came in after he finished work at his other job. The RD stated he was responsible for overseeing the kitchen, completing the administrator checklist, checking temperature logs and monitoring weight changes and assessments. The RD stated he did not provide any trainings or in-services; all in-services were done by the CDM. The RD stated he did not typically encounter the kitchen staff since his hours varied so much. During an interview on 4/3/25 at 9:29 a.m. with the CDM, the CDM stated the Director of Nursing (DON) would email her and the RD a list of residents triggered for weight changes. The CDM stated they had weekly Interdisciplinary Team (IDT) meetings with the DON, activities, social services and therapy. The CDM stated the RD did not attend those meetings. During an interview on 4/3/25 at 4:18 p.m. with the Administrator (ADM), the ADM stated the expectation for the dietitian was to be at the facility six to eight hours a week. The ADM stated he was expected to complete the sanitation reports and oversee the CDM. The ADM stated the RD was supposed to communicate with the DON about clinical issues related to resident weights. The ADM stated he wanted RD to work more hours to fulfill his job duties. During a concurrent interview and record review on 4/3/25 at 4:56 p.m. with the DON, progress note dated 3/17/25 was reviewed. The progress note indicated, Resident 39 had a five-pound weight loss in a week. The DON stated she did not know if RD was made aware of the weight loss for Resident 39. The DON stated the RD came in on Saturdays. The DON stated the RD only wrote one note in Resident 39's chart since January and no follow up notes since then. The DON stated the RD was not involved nor present in IDT meetings. The DON stated the RD probably should be involved in residents nutritional needs, because he was the one the facility turned to for guidance to ensure the residents received adequate calories. The DON stated they relied on the RD for all recommendations. The DON stated it would be nice to have the RD at the facility more often. The DON stated she emailed the RD and CDM the weekly weights that were triggered for weight gain or loss. The DON stated the RD was to send his recommendation. The DON stated it was his job to oversee the resident's weights. The DON stated in February and March the RD did not complete the Dietitian Nutritional Recommendations for Resident 39 even though Resident 39 was still triggered for weight change. The DON stated the Dietitian Nutritional Recommendations should have been done weekly until the resident was no longer triggered for weight changes. The DON stated she did not know if the RD was aware of Resident 39's weight fluctuation. The DON stated she did not know if the RD was able to fulfill his job duties due to the time spent at the facility. The DON stated she believed RD could have been seeing more residents and providing more dietary recommendations, if he come to the facility more often. The DON stated the RD did not create care plan for residents. The DON stated there were gaps in the recommendations he sent for February and March. During a review of the Offer Letter-Registered Dietitian dated 10/20/23, indicated the RD accepted the position as the Registered Dietitian. During a review of Dietitian Job Description dated 2023, indicated, the RD .The RD assessed and monitored the resident's nutritional status and provided recommendations to clinical/medical staff . Developed and updated nutritional care plans as needed .observed resident meal service to ensure diets were correct and modifications were followed .worked with other members of the interdisciplinary team to ensure that modified texture or therapeutic diets were in compliance with the residents medical condition .Conducted audits of relevant nutritional care on a routine basis .monitored residents for weight changes, nutrition support, and skin breakdown and made recommendations as needed . During a review of Employee Timecards dated 10/2024 through 3/2025 the RD worked these many hours per month: October 2024- 18.7 hours November 2024- 8 hours December 2024- 11 hours January 2025- 34.5 hours February 2025- 9.8 hours March 2025- 16.5 hours During a review of the State requirements professional reference titled, Title 22 California Code of Regulations (CCR) Section S72351 Dietic Service Staff,, indicated, . (a) A registered dietitian shall be employed on a full-time, part-time or consulting basis. Part-time or consultant services shall be provided on the premises at appropriate times on a regularly scheduled basis and of sufficient duration and frequency to provide continuing liaison with medical and nursing staffs, advice to the administrator, patient counseling, guidance to the supervisor and staff of the dietetic service, approval of all menus and participation in development or revision of dietetic policies and procedures and in planning and conducting in-service education programs. During the review of Resident 39's Admission Record (AR- a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 6/15/23, the AR indicated Resident 39 was admitted to the facility on [DATE] with the diagnosis of: hemiplegia (total loss of movement of the arm, leg and trunk on the same side of the body), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and cerebrovascular accident (CVA-stroke, loss of blood flow to part of the brain). During a review of Resident 39's Minimum Data Set (MDS-a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 1/20/25, the MDS section C indicated Resident 39 had a Brief Interview for Mental Status (BIMS- a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on scale of 1-15) score of 3 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 39 had severe cognitive impairment. During a review of Care Plan Report dated 1/24/25, indicated of all Resident 39's active care plans, none of them were created by the RD. During a review of Dietitian Nutritional Recommendations dated 1/9/25, indicated Resident 39 was flagged for having a five percent change in their weight. The RD reviewed the case and recommended a decrease in the formula (is a diet designed to meet the needs of patients who require full or partial tube feeding). During a review of a Progress Note dated 1/12/25, indicated the RD made a formula change to address Resident 39's weight gain of sixteen pounds over six months. The RD recommended decreasing the Resident 39's formula from eight cans to seven per day. During a review of the Revised 2024 Scope and Standards of Practice for Registered Dietitian Nutritionist (RDN) from the Commission on Dietetic Registration the credentialing agency for the Academy of Nutrition and Dietetics, indicated, RDNs (RDs) are the most qualified to provide Medical Nutrition Therapy (MNT), a cost-effective, essential component of comprehensive nutrition care. It indicated RDs in clinical practice provide person centered nutrition care and MNT use the Nutrition Care Process (NCP- is a systematic problem-solving method that credentialed nutrition and dietetics practitioners use to critically think and make decisions when providing MNT or to address nutrition-related problems and provide safe and effective quality nutrition care. The NCP consists of four distinct, interrelated steps: Nutrition Assessment and Reassessment, Nutrition Diagnosis, Nutrition Intervention, and Nutrition Monitoring and Evaluation). It indicated in Standard 7 (seven) providing person-/population-centered nutrition care, the registered dietitian nutritionist (RDN) conducts nutrition care process and workflow elements to identify and address nutrition-related problems which a RDN is responsible for treating. It indicated the RD: .7.2 Conducts nutrition assessment . 7.2.5 Obtains and assesses findings from nutrition-focused physical exam (NFPE) .

Based on interview and record review, the facility failed to ensure accurate and complete medical records in accordance with professional standards of practices were maintained for one of seven sampled residents (Resident 28), when the Physician Orders for Life-Sustaining Treatment (POLST- a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) was not accurate and complete. This failure had the potential for Resident 28's decisions regarding treatment options and end of life wishes to not be honored. Findings: During a concurrent observation and interview on [DATE] at 11:22 a.m. with Resident 28 in Resident 28's room, Resident 28 was observed dressed in bed. Resident 28 could not state how she was doing. Resident 28 stated she had been at the facility for four to five weeks. During a review of Resident 28's Admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated [DATE], the AR indicated Resident 28 was admitted to the facility from an acute care hospital on [DATE] with diagnoses of type 2 Diabetes Mellitus (when the blood sugar levels in the body are too high), depression (persistent feelings of sadness, despair, loss of energy, and difficulty dealing with normal daily life), muscle weakness, and abnormalities of gait (an unusual walking pattern). During a review of Resident 28's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated [DATE], the MDS section C indicated Resident 28 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of ,d+[DATE] ) score of 11 (a score of ,d+[DATE] suggests severe cognitive impairment, ,d+[DATE] suggests moderately impaired, ,d+[DATE] suggests cognitively intact), which suggested Resident 28 was moderately impaired. During a concurrent interview and record review on [DATE] at 10:40 a.m. with Licensed Vocational Nurse (LVN) 1 Resident 28's POLST undated was reviewed. The POLST indicated, the section for date the form prepared was undated, signature of patient or legally recognized decisionmaker which included: name, signature, mailing address, phone number, relationship, and date were not filled in, signed, or dated. LVN 1 stated the resident or responsible party (RP)'s signature section was not completed. LVN 1 stated Resident 28's POLST was not complete. LVN 1 stated Resident 28, or her RP should have signed and dated the POLST form. LVN 1 stated the resident's signature verified the POLST was discussed with the resident, and she agreed with the POLST orders. LVN 1 stated the Medical Records department was responsible for making sure resident's forms were complete before they were scanned into the resident's records. During a concurrent interview and record review on [DATE] at 4:56 p.m. with the Director of Nursing (DON), Resident 28's POLST undated was reviewed. The POLST indicated sections of the Date Prepared and Signature of Patient or Legally Recognized Decisionmaker were not filled in. The DON stated the resident or RP's signature should have been completed. The DON stated her expectation was for residents' POLSTs to be completed on admission. The DON stated the POLST was considered a physician order, and the physician should sign and date the POLST form. DON stated the nurse would have followed up with the incomplete POLST since it had the physician's signature. The DON stated Resident 28's POLST was not complete due to no resident or RP signature. The DON stated before the POLST was scanned into Resident 28's chart, Medical Records Clerk should have made sure it was complete. The DON stated if Resident 28's POLST was not complete, they should have given it back to the Social Services Director (SSD) to have it signed by Resident 28 or her RP. The DON stated the POLST was important so staff would know what to do if there was a change in the resident's condition, or if the resident needed a higher level of care and needed to be transferred to the hospital. The DON stated if a resident had no pulse, the POLST let staff know what emergency care they could do such as give cardiopulmonary resuscitation (CPR - an emergency lifesaving procedure performed when the heart stops beating) or place a G-tube (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach for people with swallowing problems). The DON stated if the resident's POLST was not complete, there was a risk for the resident's end-of-life wishes for treatment of not being met. During a review of the facility job description document titled, Medical Records Clerk, undated, the document indicated, . Ensures incomplete records/charts are returned to appropriate department or personnel for corrections . ensures resident records are properly completed, assembled, coded, etc., before filing . During a review of the facility job description document titled, Social Services Director, undated, the document indicated, . The Social Services Director will oversee the process of Advance Care Planning for each resident upon admission . The Director will ensure that staff members are made aware of the resident's code status and end-of-life wishes and will assist with informing and educating residents and their representatives about health care options and ramifications . Policy and Procedure for Medical Records/Accuracy of Resident Records was requested multiple times and not receives.

Based on observation, interview and record review the facility failed to ensure call lights were within reach for two of six sampled residents (Resident 4 and 9) when call lights were observed on the floor and tucked in bedside drawers out of resident reach. These failures had the potential for Resident 4 and 9 to have delayed medical attention, increased risk of falls, prolonged discomfort or pain, feelings of isolation and anxiety (feeling of worry or nervousness), and in severe cases, life-threatening situations. Findings: During a review of Resident 4's Admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes) dated 5/23/24, the AR indicated, Resident 4 was readmitted on [DATE] with the diagnosis of: congestive heart failure (CHF- a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), diabetes mellitus ( DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition and inactivity). During a review of Resident 4's Minimum Data Set (MDS- resident assessment tool which indicated physical and cognitive (the way we think and learn) abilities), dated 2/27/25, the MDS indicated, a Brief Interview for Metal Status (BIMS- an assessment of cognitive function) score of 15 out of 15 total score (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), which indicated Resident 4 had no cognitive impairment. During a concurrent observation and interview on 4/1/25 at 12:33 p.m. in Resident 4's room, Resident 4 was observed lying in bed with no call light. The call light was observed on the floor and out of reach. Resident 4 stated he could not get a hold of staff when the call light was on the floor. During the review of Resident 9's Admission Record, dated 4/3/25, the AR indicated Resident 9 was admitted on [DATE] with the diagnosis of: dementia (a progressive state of decline in mental abilities), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) and muscle weakness (decreased strength in muscles). During a review of Resident 9's MDS, dated [DATE], the MDS indicated a BIMS score of four, which indicated Resident 4 had severe cognitive impairment. During a concurrent observation and interview on 4/3/25 at 9:22 a.m. in Resident 9's room, Resident 9 was observed to hit the wall of her room to get staff attention because her call light was out of reach. Resident 9 stated it was difficult to get staff's attention without a call light, as she was supposed to call for help. During an interview with Certified Nursing Assistant (CNA) 4 on 4/3/25 at 9:41 a.m., CNA 4 stated the residents needed to have their call lights within reach so they could get help. CNA 4 stated if the call light was not accessible, the resident would not have been able to call for help, which could have led to a fall and potential injury. During an interview with Licensed Vocational Nurse (LVN) 1 on 4/3/25 at 11:49 a.m., LVN 1 stated, Call lights were supposed to be within the resident's reach, not on the floor or stuffed in a drawer. LVN 1 stated residents would be at risk for falling if they got out of bed on their own because they could not find their call light. During an interview with the Director of Nursing (DON) on 4/3/25 at 4:56 p.m. the DON stated it was her expectation for staff to ensure call lights be within Residents' reach. The DON stated, Call lights should not be on the floor or stuffed in a drawer. The DON stated the risk to the resident was that if they needed help, they could not get a hold of staff, and the resident could potentially fall while getting up unassisted. During a review of the facilities policy and procedure (P & P) titled Call lights: Accessibility and Timely Response, dated 8/2024, the P&P indicated, .Staff will ensure the call light is within reach of the resident .will be accessible to the resident while in bed .

Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 261) was provided activities that met his preferences and interests to support mental and psychosocial well-being when Resident 261's developed activities did not match his interests or preference to write, draw or color. This failure had the potential for Resident 261 to result in isolation and decreased engagement in activities. Findings: During a review of Resident 261's Admission Record (AR- a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 4/3/25, the AR indicated, Resident 261 was admitted to the facility on [DATE], with diagnosis which included, .Convulsions (rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement) .hypertension (high blood pressure) and muscle weakness . During a review of Resident 261's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment) assessment, dated 2/20/25, the MDS assessment indicated Resident 261's Brief Interview for Mental Status (BIMS- a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15) score of 11 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact) assessment score was 15 out of 15 which indicated Resident 261 had no cognitive impairment. During a review of Resident 261's Activities- Initial Review, dated 8/19/24, the Activities- Initial Review indicated, .likes .writing . During an interview on 4/1/25 at 10:00 a.m. with Resident 261, Resident 261 stated he did not participate in activities. Resident 261 stated the activities at the facility did not interest him. Resident 261 stated he liked to draw, color and write. Resident 261 stated he would enjoy participating in group activities if the facility had more drawing, writing and coloring activities. During a concurrent interview and record review on 4/3/25 at 11:46 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 261's Care Plan, dated 4/3/25 was reviewed. LVN 1 stated he was familiar with Resident 261. LVN 1 stated Resident 261 enjoyed drawing and coloring activities. LVN 1 stated Resident 261 was often observed coloring and drawing in his room. LVN 1 stated Resident 261's care plan did not reflect his preference and interest to draw, color or write. LVN 1 could not locate any progress activities notes in Resident 261's medical chart to reflect participation in coloring, drawing or writing in his room. LVN 1 stated Resident 261's care plan should have been updated to reflect his preferences and interests. LVN 1 stated he would expect activity progress notes to reflect Resident 261's participation or refusal to participate in activities independently. During a concurrent interview and record review on 4/3/25 at 11:56 a.m. with the Activities Director (AD) 2, Resident 261's care plan, dated 4/3/25 was reviewed. AD 2 stated she was responsible to ensure activities met resident interests and preferences. AD 2 stated she was responsible to provide activities to residents within their room if they did not want to participate in the activity room. AD 2 stated she was responsible to update, review and revise all care plan and notes for resident participation in activities. AD 2 stated Resident 261's care plan did not reflect his preference and interest to draw, color or write. AD 2 stated it was important Resident 261's care plan and notes reflected his preferences and interests so all staff members could implement his choice of activities. AD 2 stated she participated in resident council on 2/19/25 and there was a request in the resident council meeting for more painting and coloring activities. AD 2 stated she did not add painting or coloring activities to the March calendar in response to resident council. AD 2 stated she added Residents Choice every Friday to the March activity calendar in response to resident council. AD 2 stated Resident Choice allowed each resident to choose which activity they wanted to participate in. AD 2 stated residents would need to ask for coloring, drawing or writing material if they chose those activities on Resident Choice days. During an interview on 4/3/25 at 4:32 p.m. with the Director of Nursing (DON), the DON stated she expected all preferences and interests to be reflected and implemented in care plans. The DON stated she expected all suggested activities in resident council to be implemented by the activities department. The DON stated it was important to implement activities that interested each resident to promote engagement. The DON stated Resident 261 was at risk for isolation and decreased engagement if his activity interests were not implemented. During a record review of Resident 261's Care Plan, dated 4/3/25, the Care Plan indicated, Resident 261 enjoyed watching television independently in his room. The Care Plan did not reflect Resident 261's interest to draw, color or write. During a review of the facility's document titled, In Room Resident Council, dated 2/19/25, the document indicated, .Issues, concerns or comments .paint rocks .more paintings and coloring pages .paint or decorate . During a review of the facility's document titled, Department Response Form, Department Activities, dated 2/19/25, the document indicated, .AD to add past activities to new coming months calendars . The document was signed as reviewed by the AD 2. During a review of the facility's document titled, Resident Council Minutes, dated 3/19/25, the document indicated, .New activities suggestions .more painting color .painting .arts and crafts . The document was signed as reviewed by the AD 2. During a review of the facility's activity calendar titled, January 2025, dated 1/2025, the document indicated, five days for coloring and four days for arts and crafts. During a review of the facility's activity calendar titled, February 2025, dated 2/2025, the document indicated, four days for arts and crafts and four days for residents' choice. During a review of the facility's activity calendar titled, March 2025, dated 3/2025, the document indicated, five days for arts and crafts and four days for residents' choice. During a review of the facility's activity calendar titled, April 2025, dated 3/2025, the document indicated, four days for arts and crafts and four days for residents choice. During a review of the facility's job description document titled, Activities Director, undated, the document indicated, .Assists in planning, organizing, implementing, and evaluating all recreational, social, intellectual, emotional and spiritual programs, in accordance with facility policy, the resident's care plan, and as directed by supervisors . During a review of the facility's policy and procedure (P&P) titled, Comprehensive Care Plans, undated, the P&P indicated, .Resident specific interventions that reflect the resident's needs and preferences .the comprehensive care plan will be prepared by an interdisciplinary team, that includes .activities director/staff . During a review of the facility's P&P titled, Resident Self Determination and Participation (Schedules), undated, the P&P indicated, .According to federal regulations, the resident has the right to .choose activities . consistent with his or her interests, assessments, and plans of care .activity staff should assist the resident to engage in meaningful activity during the day, according to preference .activity staff should assist in obtaining needed supplies or equipment, to assist the resident in developing a lifestyle in the facility similar to that at home (examples may include .writing paper and pencils .) .plans of care should be considerate of resident preferences and routines, to help avoid problem behaviors .activity staff should assist the resident in scheduling of daily activities so that all interests can be accommodated . During a review of the facility's P&P titled, Activities, undated, the P&P indicated, .It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental and psychosocial well-being. Activities will encourage both independence and interaction with he community . activities will be designed with the intent to .create opportunities for each resident to have a meaningful life .promote or enhance emotional health .promote self-esteem, dignity, pleasure, comfort .independence .reflect resident's interests .reflect choices of the residents .

Based on observation, interview, and record review, the facility failed to ensure adequate supervision and monitoring for one of six sampled residents (Resident 1) when Resident 1 had a history of aggressive behavior towards other residents and staff did not implement interventions to protect other residents. On 7/12/24 Resident 1 was left unattended in the dining room. Resident 1 hit Resident 2 with a closed fist to his left hand. Resident 1 had a care plan intervention for one on one (1:1-constant observation for safety of residents) supervision. This failure resulted in Resident 1 not being supervised in the dining room and striking Resident 2 on his left hand, causing injuries to Resident 2 ' s left hand that required treatment for a skin tear (a wound that is caused by direct contact between the skin and another object) and bleeding to his left hand. Finding: During a review of Resident 1 ' s Admission Record (AR), dated 7/30/24, the AR indicated, Resident 1 was admitted on [DATE] with diagnoses that included, Dementia (loss of cognitive functioning, thinking remembering, and reasoning), and Type 2 Diabetes Mellitus (body has trouble controlling blood sugar). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive (mental process) and physical function) assessment dated [DATE], the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS -assessment of memory and judgment) assessment score was 99 (unable to complete) (a score of 13-15 indicates cognitively intact, 8-12 indicates moderately impaired, 0-7 indicates severe impairment). During a review of Resident 2 ' s Admission Record (AR), dated 7/30/24, the AR indicated, Resident 1 was admitted on [DATE] with diagnoses that included, Congestive Heart Failure (heart is unable to pump blood efficiently), and anemia (not enough healthy red blood cells). During a review of Resident 2's MDS assessment dated [DATE], the MDS indicated, Resident 1's BIMS assessment score was 4. The BIMS assessment indicated Resident 2 had severe cognitive impairment. During a concurrent observation and interview on 7/30/24 at 08:35 a.m. with Certified Nurse Assistant (CNA) CNA 1 in Resident 1 ' s room, Resident 1 was sitting in his wheelchair by the bed, dressed. CNA 1 stated, she was assigned to a 1:1 with Resident 1 from 08:30 a.m. to 09:00 a.m. CNA 1 stated, Resident 1 was on a 1:1 because of his aggressive behaviors to other residents. CNA 1 stated, Resident 1 should be 1:1 continuously for the safety of other residents. CNA 1 stated, all residents including Resident 1 had the right to be free from physical abuse. During a concurrent interview and record review on 7/30/24 at 9:20 a.m. with Licensed Vocational Nurse (LVN) LVN 1. Resident 1 ' s (AM SHIFT) document dated 7/12/24 1:1 document was reviewed. LVN 1 stated, Resident 1 liked to go up to other residents and shake their hand. LVN 1 stated, Resident 1 has had altercations with other residents. LVN 1 stated, we were in charge of assigning CNAs to a 1:1 daily, for Resident 1 starting at 6:00 a.m. to 10:00p.m. in 30- minute increments. LVN 1 stated Resident 1 was on a 1:1 due to his multiple altercations with other residents. LVN 1 stated, Resident 1 was a danger to other residents. LVN 1 stated, Residents have the right to be free from physical abuse from other residents. LVN 1 stated, Resident 1 and Resident 2 had an altercation in the large dining room on 7/12/24 at 2:30 p.m. LVN 1 stated, Resident 2 had a skin tear and was bleeding from his left hand. LVN 1 stated Resident 1 hit Resident 2 with a closed fist. LVN 1 stated 1:1 document dated 7/12/24 showed Resident 1 was on 1:1 on 7/12/24 at 6:00 am till 10:00 pm. LVN 1 stated the assignment sheet indicates at 2:00 p.m. to 2:30 p.m. and 2:30 p.m. to 3:00 p.m. a CNA was not assigned to provide 1:1 for Resident 1. LVN stated, because of the missing assignments on 7/12/24 placed other residents in danger. During a record review of Resident 1 ' s Care Plan (CP) undated, the CP indicated, .Focus .resident will be free of being involved in any resident to resident altercation .goal .resident will be free of physical altercation .intervention .one on one .CNA .date initiated 7/12/2024 . During an interview on 7/30/24 at 10:25 a.m. with LVN 2, LVN 2 stated, Resident 1 was on a 1:1 on 7/12/24 from 6:00 am to 10:00 pm. LVN 2 stated, Resident 1 was not on a 1:1 at the time of the incident. LVN 2 stated, the altercation took place on 7/12/24 at 2:30 p.m. in the dining room. LVN 2 stated, LVNs were responsible to complete the 1:1 log sheet for CNA assignments daily. LVN 2 stated LVN ' s were responsible to monitor and observe CNAs were providing the 1:1. LVN 2 stated, Resident 1 was on a 1:1 due to his behavior and aggression towards other residents. LVN 2 stated, Resident 1 was a danger to others because his aggression could escalate quickly, and he would become verbally and physically aggressive. LVN 2 stated, residents had the right to be free from physical abuse by other residents. During an interview on 7/30/24 at 10:40 a.m. with CNA 2, CNA 2 stated, she was assigned to Resident 1 to provide 1:1 from 6:00 a.m. to 12:00 p.m. on 7/12/24. CNA 2 stated, Resident 1 was on a 1:1 due to his aggression, especially towards other male residents. CNA 2 stated, residents had the right to be free from abuse from other residents. CNA 2 stated, Resident 1 was danger to other residents. During an observation on 7/30/24 at 11:00 a.m. in the patio, Resident 2 was sitting in his wheelchair. Resident 2 had a large bandage to the back of his left hand. Resident 2 was unable to recall how or what happened to his hand. During a review of Resident 4 ' s Admission Record (AR), dated 7/30/24, the AR indicated, Resident 4 was admitted on [DATE] with diagnoses that included, Schizophrenia (a disorder that affects a person ' s ability to think, feel, and behave) and muscle weakness. During a review of Resident 4's MDS assessment dated [DATE], indicated Resident 4's BIMS assessment score was 15. The BIMS assessment indicated Resident 4 was cognitively intact. During an interview on 7/30/24 at 11:15 a.m. with LVN 1, LVN 1 stated, a CNA did not witness the altercation. LVN 1 stated, if Resident 1 was on a 1:1 at the time of the incident, the assigned CNA would be the witness. LVN 1 stated, Resident 4 witnessed the incident. During an interview on 7/30/24 at 11:30 a.m. with Resident 4, Resident 4 stated, he was in the dining room watching a movie when he saw Resident 1 hit Resident 2 on his left hand several times with a closed fist. During a concurrent interview and record review on 7/30/24 at 1:00 p.m. with Director of Nursing (DON), Resident 1 ' s 1:1 document dated 7/12/24 was reviewed. The DON stated, the incident happened on 7/12/24 at 2:30 pm in the dining room. The DON stated, Resident 1 was on a 1:1 due to his physical aggression towards other residents. The DON stated the 1:1 log dated 7/12/24 indicated there were no CNAs assigned to Resident 1 on 7/12/24 from 2:00 p.m. to 3:00 p.m. The DON stated, because Resident 1 was not on the 1:1, the incident took place. The DON stated, Resident 1 should be on 1:1 always. The DON stated, if Resident 1 had been on 1:1 the CNA assigned would be a witness. The DON stated, there was no documentation of a CNA as a witness. The DON stated residents in the facility had the right to be free from physical harm from other residents. The [NAME] stated any injury to another resident from a resident-to-resident altercation was considered harm. The DON stated, Resident 2 sustained injuries to his left hand. The DON stated it was the facilities responsibility to keep residents safe. During an interview on 7/30/24 at 1:35 p.m. with CNA 3, CNA 3 stated, she was familiar with Resident 1 who could be aggressive with other residents. CNA 3 stated Resident 1 is currently on a 1:1 due to his behavior and is a danger to other residents. CNA 3 stated all residents had the right to be free from physical abuse from other residents. During a concurrent interview and record review on 7/30/24 at 1:55 p.m. with the DON, the facility Policy and Procedure (P&P) titled Abuse, Neglect and Exploitation dated 2024 was reviewed. The P&P indicated, .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . The DON stated, We did not follow our P&P. The DON stated we failed to protect Resident 2 from a resident who we knew was a danger to others in the facility. During a telephone interview on 07/31/24 at 10:52 a.m. with Administrator (ADM), The ADM stated the facility was responsible for the safety of all of their residents. The ADM stated Resident 1 was on a 1:1 because of his aggressive behavior and was danger to other residents. The ADM stated all residents had the right to be free from abuse per the facility P&P. During a review of the facility ' s P&P titled Abuse, Neglect and Exploitation dated 2024, the P&P indicated .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .abuse means the willful infliction of injury .resulting in physical harm or mental anguish .Instances of abuse of all residents .cause physical harm, pain, or mental anguish It includes verbal abuse, physical abuse .the facility will implement policies and procedures to prevent and prohibit all types of abuse .the facility will make efforts to ensure all residents are protected from physical harm .increased supervision of .residents .

Based on interview and record review the facility failed to hire a qualified Dietary Manager (DM) to carry out the functions of the food and nutrition services for 56 of 61 residents who receive food from the kitchen when the dietary supervisor did not meet the minimum qualifications for the role. This failure had the potential to affect the nutrition status and health of 56 of 61 residents who receive food from the kitchen. Findings: During an interview on 4/16/24 at 10:58 a.m., with the DM, the DM stated she was still in school to become a certified dietary manager. The DM stated she had not yet fully completed her schooling and training. The DM stated she was not certified as of 4/16/24. The DM stated she was unsure if she met the requirements for the dietary manager role. During an interview on 4/18/24 at 2:28 p.m., with the Registered Dietitian (RD), the RD stated the person hired as the dietary manager should have been certified. The RD stated the current DM was not certified for the role. The RD stated it was important to have a certified dietary manager in order to uphold state regulations and to ensure the appropriate rules and regulations were followed in the kitchen. During a review of Dietary Manager job description dated 2023, the job description indicated, . Minimum requirements include one of the following: Certification as a dietary manager, Certification as a food service manager. Has similar national certification for food service management and safety from a national certifying body. Has 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting . During a review of the Food Code U.S Food and Drug Administration, dated 2022, indicated, . 2-102.11 Demonstration. Based on the risks inherent to the food operation, during inspections and upon request the person in charge shall demonstrate to the regulatory authority knowledge of foodborne disease (illnesses that come from eating food) prevention . and the requirements of this code. the person in charge shall demonstrate this knowledge by . (b) being a certified food protection manager who has shown proficiency of required information through passing a test that is part of an accredited program .

Based on observation, interview, and record review, the facility failed to ensure safe preparation, distribution, and storage practices were followed in the kitchen for 56 of 61 residents in accordance with facility policy and procedure and the US Food Code when: 1. The top of the dish washer had crumbs, dust, and was covered in a white residue (material that gets leftover after not being cleaned for some time). 2. The cooking surface of three of seven pans was cracked and peeling. 3. The walk-in freezer had a large icicle (hanging piece of ice that grows as water drips). 4. Oven mitts were torn at the tip and the inside fabric was exposed. These failures had the potential to attract pests, contaminate residents' food, and cause foodborne illnesses to 56 of 61 sampled residents who receive food from the kitchen. Findings: 1. During a concurrent observation and interview on 4/14/24 at 9:33 a.m., with the Dietary Supervisor (DS) in the kitchen, the top of the dishwasher was covered with dirt, crumbs, and white residue. The DS stated the top of the dishwasher should have been cleaned. The DS stated dirt and crumbs on top of the dishwasher could have fallen on to the dishes and prevented them from being fully cleaned. During a concurrent observation and interview on 4/14/24 at 9:56 a.m., with cook (CK) 1, the CK 1 stated the top of the dish washer was covered with dirt, crumbs, and white residue. CK 1 stated the top of the dish washer should have been cleaned daily. CK 1 stated dishes being washed may have been contaminated by the dirt and crumbs on top of the dish washer. During an interview on 4/17/24 at 3:59 p.m., with the Registered Dietitian (RD), the RD stated the top of the dishwasher should not have had any dirt, crumbs, or white residue on top. The RD stated the white residue build up, food crumbs, and dirt could have led to improper cleaning of the dishes. The RD stated staff should have been trained on cleaning the surface of the dishwasher. During a review of the facility's policy and procedure (P&P) titled Sanitation, dated 10/2022, indicated, . 1. All food service areas shall be kept clean, sanitary, free from litter, rubbish 2. The department shall establish a sanitation program for food services based on applicable state and federal requirements 4. Sanitation inspections will be conducted in the following manner: b. weekly: The dietary manager shall inspect all food services weekly to ensure the areas are clean and comply with sanitation and food service regulations . During a review of the Food Code U.S Food and Drug Administration, dated 2022, indicated, . 4-602.13 Nonfood-Contact Surfaces. The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food . 2. During an observation on 4/14/24 at 9:44 a.m., in the kitchen, the cooking surface of three of seven pans was cracked, peeling, and missing. During an interview on 4/18/24 at 2:12 p.m., with the RD, the RD stated the cooking surface of the pans should have been intact. The RD stated the pans should have been replaced because the coating could have gone into a resident's food and caused cross contamination. During an interview on 4/19/24 at 2:28 p.m., with the DS the DS stated the cooking surface of the pans in the kitchen should not have been peeling. The DS stated the coating of the pans could have gotten into the residents' food when they were used to prepare food. During a review of the facility's P&P titled Sanitation, dated 10/2022, indicated, . 1. All food service areas shall be kept clean, sanitary, free from litter, rubbish 2. The department shall establish a sanitation program for food services based on applicable state and federal requirements. 4. Sanitation inspections will be conducted in the following manner: b. weekly: The dietary manager shall inspect all food services weekly to ensure the areas are clean and comply with sanitation and food service regulations . During a review of the Food Code U.S Food and Drug Administration, dated 2022, the Food Code indicated, . 4-601.11 EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. Microorganisms may be transmitted from a food to other foods by utensils, cutting boards, thermometers, or other food-contact surfaces . 3. during a concurrent observation and interview on 4/14/24 at 9:56 a.m., with CK 1 in the kitchen, the walk-in freezer had a large icicle hanging inside. CK 1 stated there should not have been an icicle in the freezer. CK 1 stated the icicle could have caused someone to get hurt, there should have been no ice buildup at all. During an interview on 4/18/24 at 2:16 p.m., with the RD, the RD stated the freezer should not have had a large icicle inside. The RD stated the icicle could have been caused by an error in the normal working condition of the inside of the freezer. The RD stated the freezer may not have been operating at its normal recommended capacity and it could have had problems cooling the food stored inside. During an interview on 4/19/23 at 11:34 a.m., with the DS, the DS stated a large icicle should not have been present in the walk-in freezer. The DS stated the icicle could have caused someone to get hurt and it could have indicated a problem with the working condition of the freezer. During a review of the facility's policy and P&P titled Sanitation, dated 10/2022, indicated, . 3. The sanitation program will be provided for inspections to be conducted of the food service areas . 5. Inspections will be conducted but not limited to the following areas: a. Dry Storage b. Freezer c. Refrigerator . During a review of the Food Code U.S Food and Drug Administration, dated 2022, the Food Code indicated, .Equipment and utensils must be designed and constructed to be durable and capable of retaining their original characteristics so that such items can continue to fulfill their intended purpose for the duration of their life expectancy and to maintain their easy cleanability. If they cannot maintain their original characteristics, they may become difficult to clean, allowing for the harborage of pathogenic microorganisms, insects, and rodents. Equipment and utensils must be designed and constructed so that parts do not break and end up in food as foreign objects or present injury hazards to consumers . 4. During a concurrent observation and interview on 4/19/24 at 11:34 a.m., with the DS in the kitchen, oven mitts were torn at the tip and had the interior fabric exposed. The DS stated the oven mitts should have been fully intact because ripped oven mitts could have led to someone getting burned. The DS stated torn oven mitts could have hidden pests and germs. During a concurrent observation and interview on 4/14/24 at 9:56 a.m., with CK1 in the kitchen, the oven mitts were torn at the tip and had the interior fabric exposed. CK 1 stated the oven mitts were torn and ripped. CK 1 stated having torn oven mitts could have caused someone to get burned while handling hot foods and it would have made cleaning the oven mitts more difficult. During an interview on 4/18/24 at 2:12 p.m., with the RD, The RD stated having torn oven mitts could have caused someone to get burned when handling hot items. The RD stated torn oven mitts could hide pathogens (bacteria that make someone sick) and cause contamination (to make dirty or unclean) of food. During a review of the facility's P&P titled Sanitation, dated 10/2022, indicated, . 1. All food service areas shall be kept clean, sanitary, free from litter, rubbish . 2. The department shall establish a sanitation program for food services based on applicable state and federal requirements . 4. Sanitation inspections will be conducted in the following manner: . b. weekly: The dietary manager shall inspect all food servicers weekly to ensure the areas are clean and comply with sanitation and food service regulations . During a review of the Food Code U.S Food and Drug Administration, dated 2022, the Food Code indicated, . 4-601.11 EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. Microorganisms may be transmitted from a food to other foods by utensils, cutting boards, thermometers, or other food-contact surfaces .

Based on observation, interview and record review, the facility failed to meet professional standards of practice for three of eight sampled residents (Residents 8, 11 and 57) when: 1. Licensed Vocational Nurse (LVN) 2 failed to follow facility's procedure on Proper Inhalation Technique for Metered Dose Inhaler (MDI-small, hand-held device filled with medicine to treat breathing problem) when she administered MDI medication to Residents 11 and 8. This failure had the potential for Residents 8 and 11 to suffer from respiratory infection which could lead to serious health condition. 2. Licensed Nurses (LNs) were signing the Electronic Treatment Administration (eTAR- electronic version of standard paper treatment administration record) on Resident 57's order for splint/orthotic device (support to an injured or weakened body part) from 4/1/24- 4/17/24 and not following the treatment order on how the splint/orthotic device was to be applied to Resident 57. This failure had the potential for Resident 57 to not received the full benefits of using the splint/orthotic device. Findings: 1. During a medication administration observation on 4/17/24, at 7:23 a.m. in west wing hallway with LVN 2, LVN 2 prepared Resident 11's medications. Resident 11's medications included fluticasone-sameterol (used to treat asthma [long term condition affecting the airways in the lungs]). LVN 2 walked in Resident 11's room, LVN 2 observed sliding the lid of the inhaler to the side exposing the mouthpiece and instructed Resident 11 on how to use the medication inhaler. After medication was administered to Resident 11, LVN slid the lid back to cover the mouthpiece of the inhaler, placed inside the medication box and put it inside the medication cart. LVN 2 did not wash or wipe the inhaler's mouthpiece before and after medication use. During a medication administration observation on 4/17/24, at 7:45 a.m. in west wing hallway with LVN 2, LVN 2 prepared Resident 8's medications. Resident 8's medication included umeclidinium and vilanterol inhalation powder (medication used for chronic obstructive pulmonary disease [COPD-group of diseases that causes airflow blockage and breathing-related problems]). LVN 2 walked into Resident 8's room, slid the lid of the inhaler to the side exposing the mouthpiece and instructed Resident 8 on how to use the medication inhaler. After medication was administered to Resident 8, LVN 2 slid the lid back to cover the mouthpiece of the inhaler and placed inside the medication box and put inside the medication cart. LVN 2 did not wash or wipe the mouthpiece of the inhaler's mouthpiece before and after medication use. During a review of Resident 11's Admission Record (document with resident demographic and medical diagnosis information), dated 4/18/24, indicated Resident 11 was admitted to the facility on [DATE] with diagnoses which included COPD, asthma and heart failure. During a review of Resident 11's Minimum Data Set (MDS-a functional and cognitive abilities assessment) assessment dated [DATE], indicated the Brief Interview for Mental Status (BIMS) score was 15 out of 15 (a BIMS score of 13-15 indicates cognitively intact, 8-12 indicates moderately impaired and 0-7 indicates severe impairment), which indicated Resident 11 was cognitively intact in decision making. During a review of Resident 8's Admission Record, dated 4/18/24, indicated Resident 8 was admitted to the facility on [DATE] with diagnoses which included COPD, hypertension (high blood pressure) and muscle weakness. During a review of Resident 8's Minimum Data Set (MDS-a functional and cognitive abilities assessment) assessment dated [DATE], indicated the Brief Interview for Mental Status (BIMS) score was 6 out of 15 (a BIMS score of 13-15 indicates cognitively intact, 8-12 indicates moderately impaired and 0-7 indicates severe impairment), which indicated Resident 11 was severely impaired in decision making. During an interview on 4/17/24, at 2:15 p.m. with LVN 2, she stated during medication administration of Resident 11 and Resident 8 she did not wash the mouthpiece of Resident 11 and Resident 8's inhaler medication after used. LVN 2 stated she just had skills checked and the instruction was to wash the mouthpiece of inhalers with water after resident use. LVN 2 stated it was an infection control issue. LVN 2 stated residents put their mouth over the mouthpiece and if not washed it could grow bacteria which could cause respiratory infection. LVN 2 stated she should have been more careful and mindful of what she was doing when she was doing her medication pass. During an interview on 4/19/24, at 10:20 a.m. with the Director of Nursing (DON), the DON stated the licensed nurses just had skills checked and the nurses were supposed to wash the mouthpiece of inhalers with water after administration and before placing it back in the box. The DON stated the licensed nurse should have cleaned the inhaler's mouthpiece after resident use as a means of infection prevention. The DON stated not cleaning the inhaler's mouthpiece could harbor bacteria which could lead to serious respiratory disease. During a review of facility's clinical record titled, Medication Administration Observation/Training/Education and Skills Competency, undated, the Medication Administration Observation/Training/Education and Skills Competency indicated, .Proper Inhalation Technique for Metered Dose Inhalers (MDI) . Clean mouthpiece with water and store following manufacturer's recommendation . 2. During concurrent observation, interview and record review on 4/17/24, at 2:15 p.m. with LVN 2, Resident 57's order summary report was reviewed. LVN 2 stated Resident 57's least splinting/orthotic device was ordered on 1/31/24. LVN 2 stated she did not know where the splint/orthotic device goes because she did not remember applying the splint/orthotic device to Resident 57 and did not know who was supposed to apply the splint/orthotic device. LVN 2 walked into Resident 57's room and checked where the splint/orthotic device was applied, Resident 57 was lying in bed and was not wearing the splint/orthotic device. LVN 2 reviewed the eTAR (electronic Treatment Administration Record-) dated 4/1/24-4/30/24, LVN 2 stated the eTAR was signed every shift daily from 4/1/24 to 4/17/24. LVN 2 stated she signed the eTAR daily when working not knowing what she was signing. LVN 2 stated she should not have signed the eTAR until she knew the splint/orthotic device was applied. During a review of Resident 57's Admission Record, dated 4/18/24, indicated Resident 57 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels), hypertension (high blood pressure) and weakness. During a concurrent interview and record review on 4/18/24, at 3:14 p.m. with LVN 4, Resident 54's eTAR was reviewed. LVN 4 stated she signed Resident 57's eTAR for the application of splint/orthotic device. LVN 4 stated she signed the eTAR because she thought Resident 57 was wearing the sling/orthotic device. LVN 4 stated she should have made sure Resident 57 was wearing the sling/orthotic device prior to signing. LVN 4 sated it was not a good nursing practice not knowing what she was signing. During an interview on 4/19/24, at 10:21 p.m. with the DON, she stated the licensed nurses were responsible in making sure Resident 57's splint was applied before signing eTAR. The DON stated, . It is not acceptable they are just signing without knowing what they are signing . The DON stated the licensed nurses should have checked first then sign. The DON stated it was not an acceptable practice in the facility. During a review of facility's policy and procedure (P&P) titled, Resident Mobility and Range of Motion [ROM-how far you can move or stretch a part of your body, such as a joint or a muscle], dated 7/17, the P&P indicated, . 2. Residents with limited range of motion will receive treatment and services to increase and/or prevent further decrease in ROM. 3. Resident with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility .

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles when Licensed Vocational Nurse (LVN) 6 did not lock her medication cart and went inside a resident room to administer medication. This failure had the potential for residents, staff, and visitors to have access to the unlocked medication cart. Findings: During a review of Resident 12's Admission Record (document with resident demographic and medical diagnosis information), dated 4/18/24, indicated Resident 12 was readmitted in the facility on 9/2/22 with diagnoses which included asthma (difficulty breathing), quadriplegia (weakness of upper and lower body) and heart failure. During a concurrent observation and interview on 4/16/24, at 12:06 a.m. during medication pass observation in south wing hallway. LVN 6 observed preparing medications for Resident 12, after LVN 6 prepared Resident 12, she turned her back on her medication cart, did not locked the medication cart and went inside Resident 12's room and closed the privacy curtain. The medication cart was not within LVN 6 view. During an interview on 19/19/24, at 10: a.m. with the Director of Nursing (DON), the DON stated the facility practice was to make sure to lock the medication cart whenever the medication cart was left unattended. The DON stated medications inside the unlocked medication cart was accessible to residents, staff, and visitors and ingest the medication which could lead to allergic reactions. The DON stated licensed nurses were trained to make sure medication carts were locked when unattended. During a review of the facility's policy and procedure (P&P) titled, Medication Storage, dated 10/22, the P&P indicated, . All drugs and biologicals will be stored in locked compartments .Only authorized personnel will have access to keys to locked compartments. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart .

Based on observation, interview and record review, the facility failed to ensure a physician Informed Consent (the process in which residents are given important information of the possible risk and benefits of psychoactive medications) for the use of psychotropic medication (medication capable of affecting mind, emotions, and behavior) was obtained for one of six sampled residents (Resident 26) when Resident 26 was administered quetiapine fumarate and risperidone (medications used to treat anxiety [intense excessive, and persistent worry and fear about everyday situations]) on 3/26/24 to 4/8/24 and informed consent was not obtained prior to medication administration. These failures resulted in Resident 26 to be administered psychotropic medications and not be fully informed of the risk and benefits and did not have the knowledge to make an informed decision which placed Resident 26 at a potential risk for negative side effects. Findings: During an observation on 4/15/24, at 12:25 p.m. in the dining room, Resident 26 was seated in a geriatric chair (large, padded chair designed to help seniors with limited mobility) appropriately dressed and appeared clean and neat. Resident 26 did not answer any questions asked but instead was observed eating lunch. During a review of Resident 26's Admission Record (AR-document with resident information), dated 4/18/24, the AR indicated, Resident 26 was admitted on [DATE], with diagnosis of dementia (loss of brain function such as memory, thinking, language, judgment, or behavior), with unspecified severity with psychotic disturbance (severe mental disorders that causes abnormal thinking and perceptions [belief or opinion]). During a review of Resident 26's Order Summary Report, dated 4/19/24, the Order Summary indicated, .[QUEtiapine Fumarate brand name] Oral Tablet 50 MG [milligram-unit of measurement] Give one tablet by mouth at bedtime related to unspecified dementia . Risperidone 1 MG Give two tablet by mouth at bedtime related to unspecified dementia . During a review of Resident 26's Medication Administration Record (MAR-a document that shows the medications ordered and taken by a resident), dated 3/1/24-3/31/24 and 4/1/24-4/30/24, the MAR indicated, quetiapine fumarate was administered every day starting from 3/26/24 thru 3/31/24 and 4/1/24 thru 4/1/24 thru 4/8/24. During a review of Resident 26's MAR, dated 3/1/24-3/31/24 and 4/1/24-4/30/24, the MAR indicated, risperidone was administered every day starting from 3/27/24 thru 3/31/24 and 4/1/24 thru 4/1/24 thru 4/8/24. During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 3 on 4/18/24, at 1:40 p.m. Resident 26's order summary for quetiapine and risperidone was reviewed by LVN 3. LVN 3 stated Resident 26 medications were ordered when resident was admitted on [DATE]. LVN 3 stated the informed consents for the quetiapine and risperidone was signed on 4/9/24. LVN 3 stated the quetiapine was administered to Resident 26 daily from 3/26/24-3/31/24 and from 4/1/24- 4/8/24 without a signed informed consent. LVN 3 stated the risperidone was administered to Resident 26 daily from 3/27/24-3/31/24 and from 4/1/24-4/8/24 without a signed informed consent. LVN 3 stated psychotropic medications should have had a signed informed consent prior to administration of the medication. LVN 3 stated licensed nurses were responsible in making sure an informed consents were obtained and explained the risk and benefits to Resident 26 and family prior to administration of medications. During an interview on 4/19/24, at 9:30 a.m. with the Minimum Data Set Coordinator (MDSC), the MDSC stated the admitting nurse was responsible in making sure informed consents were signed prior to administration of a psychotropic medication. MDSC stated psychotropic medication could not be administered without a signed informed consent. During an interview on 4/19/24, at 10:45 a.m. with the Director of Nursing (DON), the DON stated it was the responsibility of the licensed nurse to obtain an informed consent and to make sure there was a signed informed consent prior to administering psychotropic medications. The DON stated Resident 26 was already on quetiapine and risperidone when admitted to the facility. The DON stated Resident 26's family member (FM) did not want to discontinue the medications. The DON stated informed consent were important to explain the risk and benefits of medication to resident and family, so they can decide to take the medication or refused. During a review of the facility's policy and procedure (P&P) titled, Antipsychotic Medication Use dated 7/2022, the P&P indicated, . Residents (and/or resident representative) will be informed of the recommendation, risks, benefits, purpose and potential adverse consequences of antipsychotic medication use . All antipsychotic medications should have informed consent . During review of the facility's policy and procedure (P&P) titled, Use of Psychotropic Medication dated 2/2022, the P&P indicated, . Residents and/or representatives shall be educated on the risks and benefits of psychotropic drug use, as well as alternative treatments/non-pharmacological interventions .

Based on observation, interview, and record review, the facility failed to honor resident's rights for one of eight sampled residents (Resident 12), when Resident 12 was not informed or allowed to decline plan of care. Resident 12 was placed on a low air loss mattress (LAL-enhancing circulation and reducing prolonged pressure in one area) that was contraindicated for fitted sheets and resident's request for fitted sheets was not addressed. This failure resulted in Resident 12 feeling frustrated, ignored, disrespected and physically uncomfortable when she was not allowed to have fitted sheets on her mattress. Findings: During a review of Resident 12's admission record (AR- document with resident demographic and medical diagnosis information) dated 4/17/24, the AR indicated Resident 12 was admitted on [DATE] with diagnosis of Injury of the Cervical (cervical- uppermost region) Spinal Cord, major depressive order (persistently low or depressed mood, decreased interest in pleasurable activities, feelings of guilt or worthlessness, lack of energy, poor concentration, appetite changes, agitation, sleep disturbances, or suicidal thoughts), quadriplegia (paralysis of torso and all four limbs), and asthma (a condition in which airways narrow and swell and may produce extra mucus). During a review of Resident 12's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 3/30/24, the MDS section C indicated Resident 4 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15) score of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated Resident 12 was cognitively intact. During a concurrent observation and interview on 4/15/24 at 12:40 p.m. with Resident 12, in Resident 12's room, Resident 12 was lying on a blue air mattress without any barriers between her upper back and the mattress, a thick multicolored cloth was present from the middle of the resident's back to just below her buttocks. Resident 12 stated, . I bought fitted sheets with deep pockets to fit the air mattress . I was told by a male staff member he would put it on my care plan and get the sheets put on my mattress . Resident 12 began to cry and stated, she felt unsanitary lying on the bare mattress. Resident 12 stated, .I keep requesting for staff to put the sheets on my bed, but they never do . I bought my own sheets so I could have something between me and the mattress . I bought my own sheets with deep pockets so they would fit on to the mattress . I do not understand why they will not put them on . I feel frustrated and ignored . During an observation on 4/16/24 at 4:17 p.m., with Resident 12 in Resident 12's room, Resident 12 was lying on her back, on blue air mattress without a fitted sheet on her bed. Resident 12 appeared to be sleeping. During a concurrent interview and record review on 4/17/24 at 9:50 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, the fitted sheet would inhibit the healing property of the mattress. LVN 1 stated he did not educate Resident 12 on how the LAL mattress worked or the reason for not having a fitted sheet. LVN 1 stated the resident should have been educated prior to being placed on the LAL mattress. LVN 1 stated, if the resident was educated and involved in her care, she would not have purchased sheets, she would have had the option to decline being placed on the LAL mattress. LVN 1 stated, Resident 12 was not included in her plan of care. During an interview on 4/17/24 at 2:46 p.m. with the Director of Nursing (DON), the DON stated the resident should have been educated on the reason for placing her on the LAL mattress, how the mattress functions and given the decision to accept or decline being placed on the LAL mattress. DON stated, Resident 12's requests for having fitting sheets placed on the LAL mattress should have been addressed and if the resident no longer wanted to be on the LAL mattress, she should have been given other options for wound prevention. DON stated, Resident 12 was not informed of her right to refuse the mattress. DON stated the facility should have informed her of the right to refuse and honored her rights. During an interview on 4/18/24 at 2:17 p.m. with LVN 3, LVN 3 stated, Resident 12 was placed on the LAL mattress as a preventative measure when a red area on her right buttock was noted. LVN 3 stated, Resident 12 did ask for a fitted sheet but with the low air loss mattress it was contraindicated. LVN 3 stated she did not educate the resident and did not know if anyone else had educated the resident. LVN 3 stated she never discussed alternative options with Resident 12 or informed anyone of Resident 12's concerns. LVN 3 stated Resident 12 should have been involved in the decision to place her on the LAL mattress. LVN 3 stated Resident 12 had the right to decline being placed on the LAL mattress. During a review of the facility's policy and procedure titled, Resident Rights dated 10/2022, indicated . 2. Planning and Implementing care. The resident has the right to be informed of, and participate in, his or her treatment, including b. The right to participate in the development and implementation of his or her person centered-centered plan of care, including but not limited to: i.The right to participate in the planning process, including . the right to request meetings and the right to request revisions to the person-centered plan of care . During a review of facility's document, titled, Low Air Loss Mattress Systems: Your Top Questions Answered undated, the Low Air Loss Mattress Systems: Your Top Questions Answered indicated, .fitted sheets should not be placed over low air loss mattresses because they compress the air cells and restrict air flow. Thin knit or jersey material flat sheets should be used instead. Low air loss mattress covers are specifically designed to allow air flow to pass through and prevent moisture build up. This creates a microclimate between the skin and mattress to keep the user comfortable and prevent skin breakdown. Quilted reusable pads and incontinence briefs will block airflow and trap moisture against the skin .

Based on observation, interview and record review, the facility failed to provide a clean and homelike environment for one of 18 sampled residents (Resident 45), when Resident 45's room had chipped, missing and peeling paint on the walls of the bathroom and mirror. This failure had the potential for Resident 45 to not have living space in a homelike environment and possibly feeling depressed. Findings: During a review of the Resident 45's Admission Record (AR- document with resident information), dated 4/17/24, the AR indicated Resident 45 was admitted on [DATE] with diagnosis of malnutrition (not getting enough nutrients for body to thrive), and anxiety disorder (feeling of fear, dread, and uneasiness). During a review of Resident 45's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 3/30/24, the MDS section C indicated Resident 4 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated Resident 45 was cognitively intact. During an interview on 4/15/24 at 12:39 p.m. with Resident 45, in Resident 45's room, Resident 45 stated, the bathroom was dirty, the paint was missing around the sink and paint on the wall was chipped and peeling. Resident 45 stated there was sand in the bottom of the toilet bowl and takes a long time for the bathroom to be cleaned. Resident 45 stated she used her briefs instead of using the bathroom. Resident 45 stated. Using the bathroom is worse than using my brief. During an interview on 4/17/24 at 9:30 a.m. with Licensed Vocational Nurse (LVN) 1, the LVN 1 validated, the chipped and missing paint on and around the bathroom sink in Resident 45's bathroom. LVN stated, this was not a homelike environment. LVN 1 stated, I would not have my bathroom at home in this condition. During an interview on 4/17/24 at 1:55 p.m. with the Director of Nursing (DON), the DON stated the bathroom in Resident 45's bathroom was not kept in a homelike environment. During an interview on 4/18/24 at 12:35 p.m. with Director of Maintenance (DM), the DM stated, the bathroom in Residents 45's bathroom did not provide a homelike environment. During a review of the facility's policy and procedure (P&P) titled, Resident Rights dated 10/2022, the P&P indicated . 8. Safe Environment. The Resident has a right to a safe, clean, comfortable, and homelike environment, .

Based on observation, interview and record review, the facility failed to ensure the Minimum Data Set assessment ((MDS -assessment of physical and psychological functions and needs) accurately reflected resident's health and functional status for one of three sampled residents (Resident 57) when Resident 57's functional limitation in range of motion was inaccurately coded on the MDS assessment. This failure had the potential to result in Resident 57's care needs not being met. Findings: During a concurrent observation and interview on 4/15/4, at 10:20 a.m. in room [ROOM NUMBER], Resident 57 was lying in bed and observed with right sided weakness. Resident 57 stated he was not able to move his right arm and right leg and used his left hand to move his right arm and right leg. During a review of Resident 57's Admission Record (document with resident demographic and medical diagnosis information), dated 4/18/24, indicated Resident 57 was admitted in the facility on 1/30/24 with diagnoses which included cerebral infarction (interrupted blood flow to the brain), muscle weakness and hypertension (high blood pressure). During a review of Resident 57's Minimum Data Set (MDS-a functional and cognitive abilities assessment) assessment, dated 2/4/24, indicated, the Brief Interview for Mental Status (BIMS) score was 6 out of 15 (a BIMS score of 13-15 indicates cognitively intact, 8-12 indicates moderately impaired and 0-7 indicates severe impairment), which indicated Resident 57 was cognitively impaired in decision making. During an interview on 4/17/24, at 1:49 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 57 was weak on his right side, he needed assistance with his activities of daily living (ADL-related to personal care which includes bathing, dressing, transfers, toilet use). LVN 2 stated Resident 57 was not able to move his right arm and right leg without assistance. During a concurrent interview and record review on 4/17/24, at 3:32 p.m. with Minimum Data Set Coordinator (MDSC), Resident 57's admission MDS assessment dated [DATE], section GG was reviewed by MDSC. The MDSC stated Resident 57 has right sided weakness, he was not able to move his right side without assistance. The MDSC stated Resident 57's functional limitation in range of motion was not coded correctly. The MDSC stated, . It was a mistake, I coded the section wrong . The MDSC stated it was his responsibility to make sure the MDS assessment was accurate. During an interview on 4/19/24, at 11:30 a.m. with the Director of Nursing (DON), the DON stated it was the responsibility of the person completing MDS assessments to ensure their assessments of residents were accurate. The DON stated the MDS assessment should have been accurate, and staff were expected to complete MDS assessments with accuracy. During a review of the facility's policy and procedure (P&P) titled, Conducting an accurate Resident assessment dated ,d+[DATE], the P&P indicated, .Qualified staff who are knowledgeable about the resident will conduct an accurate assessment addressing each resident's status, needs, strengths and areas of decline .

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive care plan for one of six sampled residents (Resident 57) when Resident 57 was administered apixaban (anticoagulant-blood thinner) medication for atrial fibrillation (an irregular, often rapid heart rate that commonly caused poor blood flow and blood clot formation) and the facility did not initiate a care plan for apixaban. This failure placed Resident 57 at a potential risk for use of anticoagulant needs not met. Findings: During a concurrent observation, and interview on 4/15/24, at 10:20 a.m. in Resident 57's room, Resident 57 was lying down in his bed. Resident 57 stated he was not able to move the right side of his body and needed assistance with his care. Resident 57 stated he wanted to get stronger so he can go home to his ranch but needed someone to take care of him. During a review of Resident 57's Admission Record (document with resident demographic and medical diagnosis information), dated 4/18/24, indicated Resident 57 was admitted in the facility on 1/30/24 with diagnoses which included cerebral infarction (interrupted blood flow to the brain), atrial fibrillation and hypertension (high blood pressure). During a review of Resident 57's clinical record titled Order Summary Report undated, indicated apixaban Oral Tablet 5 MG [blood thinner medication] Give 1 tablet by mouth two times a day related to PERMANENT ATRIAL FIBRILLATION Order date 1/30/24 . During a concurrent interview and record review on 4/17/24, at 2:30 p.m. with Licensed Vocational Nurse (LVN) 2, Resident 57's order summary report was reviewed. LVN 2 stated Resident 57's apixaban was prescribed on 1/30/24. LVN 2 stated she did not find a care plan for Resident 57's anticoagulant use. LVN 2 stated there should have been a care plan developed and it was the charge nurse's responsibility to initiate a care plan. During a concurrent interview and record review on 4/19/24, at 9:15 a.m. with the Minimum Data Set Coordinator (MDSC), Resident 57's care plan was reviewed. The MDSC stated he did not find a care plan for Resident 57's use of anticoagulant medication. The MDSC stated there should have been a care plan to monitor side effects of the anticoagulant medication. The MDSC stated it was the responsibility of the licensed nurses to initiate a care plan and it should be personalized to the need of the resident. During an interview on 4/19/24, at 10:15 a.m. with the Director of Nursing (DON), the DON stated charge nurses are responsible in initiating a base line care plan within 24 hours of admission and comprehensive care plan were to be completed within seven days of admission or medication order. The DON stated there should have been a care plan for the use of anticoagulant medication to monitor for bleeding which was one of the side effects of the medication. The DON stated care plans were important because it directed the staff to care for each resident and care plan should be individualized to each resident needs. During a review of facility's policy and procedure titled Care Plans, Comprehensive Person-Centered, dated 3/22, the P&P indicated, . The comprehensive, person-centered care plan is developed within seven (7) days . and no more than 21 days after admission . includes measurable objectives and timeframe; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .

Based on observation and interview, the facility failed to establish and maintain an infection control program to provide a safe, sanitary, and comfortable environment to help prevent infection for one of three sampled residents (Resident 40) when Licensed Vocational Nurse (LVN) 7 failed to sanitize (disinfect) the blood pressure cuff (device used to measure the pressure of blood in the circulatory system), stethoscope (device used to listen to internal sounds of a human body or an animal) after use and did not wash her hands after checking the blood pressure of Resident 40. These failures had the potential to result in cross contamination (bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) and transmission of infection between residents. Findings: During a concurrent observation and interview on 4/16/24, at 4:05 p.m. in the east wing hallway by Resident 40's room, LVN 7 was passing medications. LVN 7 checked Resident 40's blood pressure using an arm cuff and a stethoscope and did not sanitize the blood pressure cuff and stethoscope, LVN 7 also was not using disposable gloves. LVN 7 walked out of Resident 40's room and placed the blood pressure cuff and stethoscope on top of medication cart and prepared medications. LVN 7 stated she did not sanitize the blood pressure cuff and stethoscope after she used it on Resident 40 and did not wash her hands before she started preparing medications for Resident 40. LVN 7 stated she did not sanitize the blood pressure cuff and stethoscope after she used it on Resident 40 and did not wash her hands after she checked Resident 40's blood pressure and prior to preparing medications. LVN 7 stated she should have sanitized the blood pressure cuff and stethoscope after each use and before using on another resident. LVN 7 stated she should have washed her hands before preparing Resident 40's medication. LVN 7 stated it was an infection control issue, she could be the carrier of bacteria and spread to other residents. During a review of Resident 40's Admission Record (AR- document containing resident personal information), dated 4/18/24, the AR indicated, Resident 40 was admitted to the facility on [DATE], with diagnoses that included . hypertensive heart disease with heart failure ([long term condition that develops over many years in people with high blood pressure], atherosclerotic heart disease [build up of fats and other substances in the artery wall] . During an interview on 4/19/24, at 11:05 a.m. with the Director of Nursing (DON), the DON stated the licensed nurse should have washed her hands or used alcohol gel and sanitized the blood pressure cuff and stethoscope after she took Resident 40's blood pressure. The DON stated licensed nurse should washed their hands before preparing residents' medications. The DON stated it was infection control issue. During a review of facility's policy and procedure (P&P) titled, Resident-Care Equipment, dated 10/2022, the P&P indicated, . Staff shall follow established infection control principles for cleaning and disinfecting reusable, non critical equipments . Each user is responsible for routine cleaning and disinfection of multi-resident items after each use, particularly before use for another resident . Multiple-resident use equipment shall be cleaned and disinfected after each use . During a review of the facility's P&P titled, Medication Administration, dated 2/22, the P&P indicated, . Medications are administered by licensed nurses . in a manner to prevent contamination or infection . Wash hands prior to administering medication per facility protocol and product .

Based on observation, interview, and record review, the facility failed to ensure five of five Residents (Residents 6, 8, 11, 16, and 55) were assessed for the risk of entrapment (resident caught, trapped, or entangled in the space in or about the bed and side rail) from bed (side) rails (adjustable metal or rigid plastic bars in various sizes that attach to the bed, and can be placed in a guard (raised) or lowered) prior to installation and had no consent (form signed by resident or family explaining the risks of side rail use), physician order, indication for use, and care plans prior to the use of side rails when: 1. Resident 6 had two bed rails raised up and had sustained an injury of unknown origin on [DATE] prompting the facility to pad the bed rails. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment; no consent, physician order and care plan were done prior to the use of the two bed rails for Resident 6. 2. Resident 16 had two bed rails on both sides of the bed in the guard position (A position that is intended to prevent an individual from inadvertently rolling out of bed). Resident 16 did not have a physician's order, consent, and plan of care prior to the use of the bed rails. 3. Resident 11 had two bed rails on both sides of the bed in the guard position and did not have a consent prior to use of bed rails. 4. Resident 8 had two bed rails on both sides of the bed in the guard position and did not have a physician's order, consent, entrapment risk assessment, and plan of care prior to use of the bed rails. 5. Resident 55 had two bed assist bed rails in the guard position and no entrapment risk assessment, consent, physician order and care plan were done prior to use. These failures had the potential to cause entrapment, serious harm, injury, or death to Residents 6, 8, 11, 16, and 55. Because of the serious potential harm such as injury and entrapment to Residents 6, 8, 11, 16, and 55 and the serious potential harm to all residents with bed rails used without an entrapment risk assessment, no consent, no physician order, no indication for use, and no care plans prior to use, an Immediate Jeopardy (IJ, a situation in which non-compliance with one or more regulatory requirements has caused or is likely to cause serious injury, harm, impairment, or death to a resident) situation was called., on [DATE] at 6:07 p.m., under Code of Federal Regulations (CFR) 483.25 (F700) with the Administrator (ADM) and Director of Nursing (DON). The facility was provided the IJ template which indicated the need to submit an acceptable written Plan of Removal that addressed the need for immediate action for the IJ situation. The facility submitted a Plan of Removal (POR) on [DATE], at 11:02 p.m., to address the IJ situation. The IJ POR included: 1) immediately conduct entrapment risk assessments for affected Residents, obtain consents for all affected residents and obtain physician's order and develop and implement a care plan for each affected resident. 2) Develop immediate safety processes and monitoring steps to ensure the residents do not get entrapped and sustain injuries. 3) Implement processes regarding the difference between bedrolls and/or mobility aids, consents, physician orders, entrapment risk assessment, care planning, equipment monitoring & maintenance that would ensure all residents' safety. 4) Implement Training and Education and measure of competencies to all staff regarding Physical Restraints [Physical Restraint is defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body]/Bedrails to ensure residents' safety at all times. The IJ Plan of Removal was accepted on [DATE] at 12:28 p.m. While onsite, the surveyors validated the POR implementation action items through observations, interviews, record reviews and confirmed that all POR action interventions to address the IJ situation were fully implemented. The IJ was removed on [DATE] at 5:50 p.m., with the ADM. Findings: 1. During an observation on [DATE], at 2:55 p.m., in Resident 6's room, Resident 6 was asleep in bed with two bed rails up and a soft, hallow piece of foam covered the top of the half bed rails. During an interview on [DATE], at 3:09 p.m., with the DON, the DON stated Resident 6 had an injury of unknown origin on [DATE]. The DON stated Certified Nursing Assistants (CNAs) were doing last rounds on [DATE] and saw Resident 6's right hand was reddened, swollen and warm to touch. The DON stated Licensed Vocational Nurse (LVN) 1 called her to look at Resident 6's right hand. The DON stated Resident 6 said don't touch when the DON looked at her hand. The DON stated an x-ray (digital image of a part of the body) was done at the facility. The DON stated Resident 6's physician wanted the staff to place a soft splint (soft, padded material that is used to secure an injury by holding it in place ) on her right hand. The DON stated Resident 6 would not let staff put a splint on her hand. The DON stated Resident 6 was sent to the hospital on [DATE] to get a splint on the right hand, and the hospital repeated the x-ray. The DON stated the x-ray at the hospital showed no fracture of the right hand. The DON stated the x-ray indicated [CONDITION(S)] joints (decrease in function of joints) of Resident 6's right hand. The DON stated the hospital placed a soft splint on Resident 6's hand. The DON stated staff or residents did not witness the injury. The DON stated Resident 6's injury could have occurred as a result of her hand hitting the bed rail. During an interview on [DATE], at 3:38 p.m., with LVN 1, LVN 1 stated CNA 3 asked her to look at Resident 6's right hand on [DATE] at 2:24 p.m. LVN 1 stated Resident 6's knuckles on her right hand were red, swollen, and warm to touch. LVN 1 stated staff had not reported any past falls for Resident 6. LVN stated the physician ordered x-rays of Resident 6's right hand. LVN stated the x-ray was done at the facility. LVN stated the x-ray results showed Resident 6 had a fracture. The physician ordered to put a splint on Resident 6's right hand. LVN 1 stated the staff was not able to get a splint on Resident 6's hand and Resident 6 was sent out to the hospital to get her right hand splinted. LVN 1 stated the second x-ray that was done at the hospital on [DATE] did not indicate a fracture. LVN 1 stated that after the injury Resident 6's side rails were padded to keep her from hurting her hand. LVN 1 stated Resident 6's injury could have been caused by her hitting the bed rail. During a concurrent interview and record review on [DATE], at 3:38 p.m. with LVN 1, Resident 6's Radiology Interpretation, dated [DATE], was reviewed. The X-ray indicated, .Impression: Impaction fractures age unknown, distal right second and third metacarpals (miniature long bone near the second and third finger of the right hand) . LVN 1 stated the first x-ray was done at the facility on [DATE]. LVN 1 stated the second x-ray was done at the hospital on [DATE]. The second X-ray indicated, .Findings: . There is no acute fracture or dislocation. Advanced [CONDITION(S)] changes involving interphalangeal and first carpal metacarpal joints (first joint of the finger and is located between the first two bones of the finger). Soft tissues (supports internal bones) are unremarkable . During a concurrent observation and interview, on [DATE], at 9:40 a.m., with CNA 1 in Resident's 6 room, Resident 6's bed had two bed rails up. CNA 1 stated the bed rails were padded because Resident 6 had hurt her hand. CNA 1 stated they used two CNAs to get Resident 6 up because she sometimes hits at them. CNA 1 stated Resident 6's injury could have been a result of her hand hitting the bed rail. During a concurrent interview and record review, on [DATE], at 1:00 p.m., with LVN 3, Resident 6's electronic health record (EHR), dated between [DATE] and [DATE] was reviewed. LVN 3 stated she could not find the physician's order, no entrapment risk assessment, no consent, or care plan for the padded bedrails before the injury on [DATE]. Resident 6's care plan indicated padded bed rails were initiated on [DATE]. LVN 3 stated there should be a physician's order, an entrapment risk assessment, a consent form signed by Resident 6's responsible party and a care plan done before the bed rails were used for Resident 6. During an interview, on [DATE], at 2:37 p.m., with the CNA 2, the CNA 2 stated she had worked at the facility since [DATE] and was familiar with Resident 6. CNA 2 stated Resident 6 would swat at the staff and was confused at times. CNA 2 stated Resident 6 had bed rails up since she started working at the facility in 2021. During a concurrent interview and record review, on [DATE], at 2:43 p.m., with LVN 4, Resident 6's EHR, dated [DATE] to [DATE] was reviewed. LVN 4 stated there were no consent form, and physician orders for the bed rails for Resident 6. LVN 4 stated she did not recall how long Resident 6 had been using bed rails. During a concurrent observation and interview, on [DATE], at 3:15 p.m. with Director of Maintenance (DOM), in Resident 6's room, Resident 6's had two bed rails up. DOM stated the bed rails came with Resident 6's bed. DOM stated he put the padding on the bed rails. DOM was unable to provide a copy of the Resident 6's bed manufacturer's guidelines. DOM demonstrated how Resident 6 was supposed to lower the bed rails by pulling on a knob below the side rail. DOM stated Resident 6 could not remove the bed rail because she was unable to reach down to where the knobs were located on the bed. During a concurrent observation and interview on [DATE], at 3:34 p.m., with the Director of Rehabilitation (DOR) in Resident 6's room, Resident 6's bed rails were observed up. DOR stated there should be an entrapment risk assessment, and a consent form prior to use. DOR stated the bed rails were considered a restraint since Resident 6 was unable to remove it. DOR stated the importance of doing an entrapment risk assessment was to prevent entrapment injury. During an interview on [DATE], at 5:37 p.m. with the DOM, the DOM stated he was responsible for installing bed rails on Resident 6's bed. The DOM stated he did not perform necessary measurements to ensure bed and bed rail compatibility for Resident 6 and other residents with bed rails. The DOM stated that he was unaware of the requirements for the measurements of the bed rails. During a review of the facility's policy and procedure (P&P) titled, Bed Rails, dated [DATE], the P&P indicated, .Maintenance/Designee will assess the bed dimensions no less than quarterly by utilizing Maintenance Inspection Checklist-Resident Rooms. Maintenance will also check bed rails regularly to ensure they are installed correctly, as rails may shift or loose over time . During a concurrent observation and interview on [DATE], at 5:53 p.m., with CNA 2, CNA 3, and the DON in Resident 6's room, CNA 3 stated the bed rails on Resident 6's bed was used as a mobility device. CNA 2 asked Resident 6 to grab the bed rails, Resident 6 did not follow commands and did not grab the bed rails. CNA 2 stated Resident 6 would not be able to remove the bed rails. During a concurrent interview and record review, on [DATE], at 9:15 a.m. with ADM, Facility Reported Event (Facility Reported Event), dated [DATE] was reviewed. The Facility Reported Event indicated, on [DATE] .CNA notified the LVN that resident had redness, warm and swelling to her right hand .notified the physician and received and order for x-ray to right hand .All LVNs and CNAs were interviewed .Through an investigation of residents behaviors and interviews of staff .the Interdisciplinary Team (IDT-staff members of different expertise that work together toward a common goal for the resident) determined that redness and swelling of the hand was likely caused by accident by the resident . ADM stated that the staff determined that Resident 6 probably hit her hand on the bed rail causing her injury. ADM stated nobody actually witnessed the injury. During an interview on [DATE], at 2:50 p.m. with Resident 6's responsible party (RP), the RP was notified by the facility regarding Resident 6's injury of unknown origin on [DATE]. RP stated Resident 6 had cracked bones in her right hand and thought Resident 6 was probably trying to grab something on her bedside table and hit her hand against the bed rail. During a review of Resident 6's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment were reviewed. MDS dated [DATE], indicated, .Resident 6's Brief Interview for Mental Status (BIMS - screening tool used to assess resident cognitive level) score was 3 out of 15 (,d+[DATE] indicated severe cognitive impairment - [memory loss, poor decision making-skills], ,d+[DATE] moderate cognitive impairment, and (,d+[DATE]) cognitively intact) . MDS Section G (Function Status) indicated . B. Transfer how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position . code 3 (two-person physical assist) . C. Walk in room how resident walks between locations in her room Code 8 (activity did not occur) . D. Walk in corridor how resident walks in corridor on unit . code 8 . 2. During an observation on [DATE], at 2:38 p.m., in Resident 16's room, Resident 16 was asleep in bed. Resident 16 had a half beds rail on the upper left and upper right side of the bed in the guard position; the right side of the bed was next to the wall. During a concurrent interview and record review, on [DATE], at 3:38 p.m., with LVN 5, Resident 16's EHR as reviewed. LVN 5 stated Resident 16 did not have a physician's order, Care Plan, and consent prior to the use of bed rails. Resident 16's Enabler [a bed rails used to facilitate movement /Restraints-Physical [a device used to impede movement] initial evaluation) was reviewed. The Enabler/Restraint-Physical (initial evaluation), dated [DATE], indicated, .Reason for use of physical restraint . No restraints in use . History/Alternatives Attempted . No restraints in use .Communication . Family/POA [Power of Attorney], Decision Maker notified . No . Restraint Order . No . During an interview on [DATE], at 3:38 p.m., with LVN 5, LVN 5 stated there should be a physician's order, entrapment assessment, consent, and care plan prior to use of bed rails for Resident 16. During a review of Resident 16's MDS and physical assessment dated [DATE], the MDS indicated Resident 16's BIMS score was 4 which indicated severe cognitive impairment. Resident 16's functional status assessment indicated Resident 16 required two-person extensive assistance from staff with bed mobility. 3. During an observation on [DATE], at 2:42 p.m., in Resident 11's room, Resident 11 was asleep in bed. Resident 11 had a half bed rail on the upper right and upper left side of the bed. During a concurrent interview and record review, on [DATE], at 3:21 p.m. with LVN 5, Resident 11's Physician's Order, dated [DATE] was reviewed. Resident 11's physician's order indicated, .side rail/enabler bed mobility . Resident 11's Enabler/Restraint-Physical (initial evaluation), dated [DATE] was reviewed. The Enabler/Restraint-Physical (initial evaluation) indicated, .Reason for use of physical restraint . No restraints in use . History/Alternatives Attempted . No restraints in use . Communication . Family/POA [Power of Attorney], Decision Maker notified . No . Restraint Order . No . Resident 11's Care Plan, dated [DATE] was reviewed. Resident 11's care plan indicated, .I have physical functioning deficit related to: limited assistance need with ADL's [Activities of Daily Living] . I will improve or maintain my current level of physical functioning. Assistive devices (assist bar [a bed rail used to facilitate movement] to one side of the bed) . LVN 5 stated Resident 11 had no consent prior to the use of the half bed rails . During an interview on [DATE], at 3:38 p.m., with LVN 5, LVN 5 stated there should be a physician's order, entrapment risk assessment, consent, and care plan prior to the use of bed rails for Resident 11. 4. During an observation on [DATE], at 2:50 p.m., in Resident 8's room, Resident 8 was asleep in bed. Resident 8 had a half upper bed rails on both side of the bed in the guard position. During a concurrent interview and record review, on [DATE], at 3:13 p.m., with LVN 5, Resident 8's EHR was reviewed. LVN 5 stated Resident 8 did not have a physician's order, care plan, and entrapment risk assessment prior to use of bed rails . During an interview on [DATE], at 3:38 p.m., with LVN 5, LVN 5 stated there should be a physician's order, entrapment assessment, consent, and care plan prior to use of bed rails for Resident 8. 5. During an observation on [DATE], at 2:39 p.m., in Resident 55's room, Resident 55 was laying on his back in bed, with two assist bed rails attached to the midsection of the bed and was in the guard down position. Resident 55's bed was observed in the low position with two floor mats on both sides of the bed. During a concurrent observation and interview on [DATE], at 2:42 p.m., with CNA 2, in Resident 55's room, Resident 55 was laying in bed with both bed rails in the lowered position. CNA 2 stated, Resident 55 was not alert and required total assist for mobility. CNA 2 stated, Resident 55's bed rails were in place to prevent him from falling out of bed. During a review of Resident 55's Minimum Data Set and physical functional level assessment dated [DATE], the MDS indicated Resident 55's Brief Interview for Mental Status score was 0 out of 15, Section G indicated . B. Transfer how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position . code 3 . C. Walk in room how resident walks between locations in her room Code 8 . D. Walk in corridor how resident walks in corridor on unit . code 8 . During a concurrent interview and record review on [DATE], at 3:01 p.m., with Minimum Data Set Coordinator (MDSC), MDSC reviewed Resident 55's clinical record. MDSC stated, he did not know when the bed rails were installed on Resident 55's bed. MDSC reviewed the clinical record and stated there was no physician order, no informed consent for bed rail use, no bed rail care plan, and no entrapment risk assessment. MDSC reviewed Section P of the MDS, dated [DATE] titled, Restraint and Alarms, indicated, .Physical Restraints .Physical restraints are any manual method, or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body .Bed rail 0 . MDSC stated, the MDS section P was inaccurate because it was coded as 0 which meant not used. MDSC stated, he had worked with Resident 55 in the past and stated he was non-verbal and had limited mobility. During a concurrent observation and interview on [DATE], at 3:08 p.m., with MDSC, in Resident 55's room, Resident 55 was laying in bed with both bed rails in the guard down position. MDSC stated, the quick release knob was located on the bottom of the bed rail and Resident 55 would not be able to remove the bed rail independently. MDSC proceeded to move the bed rail from its guard down position into the assist up position (assisting the resident in standing or sitting in bed) and stated the assist bed rail should not be down because there was no order, consent, care plan, or entrapment risk assessment. MDSC stated, without an entrapment risk assessment the bed rails were an endangerment to Resident 55 and could cause more harm than good. During an interview on [DATE], at 3:38 p.m., with DOR, DOR stated when the therapy department makes a recommendation for bed rail use a resident or resident representative consent was required prior to use. DOR stated, if bed rails were installed just because a resident was a fall risk that would be considered a restraint. DOR stated, there should be an entrapment risk assessment and care plan interventions for the use of bed rails. During an interview on [DATE], at 5:45 p.m., with DON, DON stated, the facility had different bed rail sizes. DON stated, there was no determination of which residents' bed had longer or shorter bed rails, the bed rails were installed based on whatever fit the bed. During a review of the facility policy and procedure titled Bed Rails dated ,d+[DATE] was reviewed. The policy indicated .Decisions to use or discontinue the use of a bed rail will be made in the context of an individualized resident assessment using an Interdisciplinary Team (IDT) and will take into account the resident's medical needs, comfort, and freedom of movement .The Assessment of whether to use bed rails should include an evaluation of the alternatives to the use of bed rail that were attempted and how these alternatives failed to meet the resident's assessed needs. If bed rails are to bed used, the assessment Bed Rail Utilization [would be conducted] by a Licensed Nurse and/or the IDT. The Licensed Nurse and/or the IDT may refer to the Bed Rail Decision Tree during the assessment. Before installing a bed rail, the Facility must: Assess the resident for risk for entrapment from bed rails; and Ensure the bed's dimensions are appropriate for the resident's size and weight. If the bed rail is used as a restraint, the Facility will refer to Policy Restraints, for informed procedures. If a bed rail is used as an enabler, the resident/resident representative's informed consent will be obtained by a Licensed Nurse or the physician. The resident's plan of care will be updated to reflect the use of bed rails. The plan of care should also include documentation of the type of specific direct monitoring and supervision provided during the use of the bed rails and the identification of how needs will be met during the use of bed rails . During a review of the facility's P&P titled, Restraints, dated [DATE], the P&P indicated, .Physical Restraint is defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. This may include bed rails, .if underlying causes of medical symptoms cannot be eliminated, alternative measures must be tried before a restraint is used .if the Facility is utilizing bed rails, the assessment Bed Rail Entrapment Risk Assessment .will be completed by a Licensed Nurse prior to the installation of bed rails .if a bed rails is being used as an enabler, the resident must be able to easily and voluntarily get in and out of bed when the equipment is in use. If the resident cannot easily and voluntarily release the bed rails and/or use the bed rails to reposition, the use of the bed rails may be considered a restraint . During a review of the manufactured guidelines titled Assist Rails retrieved from http://www.invacare.com/doc_files/ 85.pdf dated [DATE] indicated, .The assist rails have three positions: Guard (Down) A: This position is intended to prevent an individual from inadvertently rolling out of bed. Assist (Up) B: Assist the user in the standing or sitting in bed. Transfer (Back) C: Allows unimpeded access to user. When changing position of the assist rail, hold and raise the rail with one hand while pulling the adjustment knob outward with the other hand . During a review of professional reference from the FDA- Food and Drug Administration, titled A Guide to Bed Safety Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts retrieved from https://www.fda.gov/medical-devices/hospital-beds/guide-bed-safety-bed-rails-hospitals-nursing-homes-and-home-health-care-facts dated [DATE], indicated, . Today there are about 2.5 million hospital and nursing home beds in use in the United States. Between 1985 and [DATE], 803 incidents of patients* caught, trapped, entangled, or strangled in beds with rails were reported to the U.S. Food and Drug Administration. Of these reports, 480 people died , 138 had a nonfatal injury, and 185 were not injured because staff intervened. Most patients were frail, elderly or confused . Patients who have problems with memory, sleeping, incontinence, pain, uncontrolled body movement, or who get out of bed and walk unsafely without assistance, must be carefully assessed for the best ways to keep them from harm, such as falling. Assessment by the patient's health care team will help to determine how best to keep the patient safe . Potential risks of bed rails may include: Strangling, suffocating, bodily injury, or death when patients or part of their body are caught between rails or between the bed rails and mattress. More serious injuries from falls when patients climb over rails. Skin bruising, cuts, and scrapes. Inducing agitated behavior when bed rails are used as a restraint. Feeling isolated or unnecessarily restricted. Preventing patients, who are able to get out of bed, from performing routine activities such as going to the bathroom or retrieving something from a closet . During a review of professional reference from the FDA- Food and Drug Administration, titled FDA Entrapment Zones and Guidelines undated, indicated, . This product [bed rail] in not [is not] recommended for individuals with cognitive problems (difficulty in understanding their surroundings) .

Based on interview and record review, the facility failed to implement and maintain a safe environment with an effective infection prevention and control program for the prevention of [MEDICAL CONDITION] (COVID-19- a contagious serious respiratory infection transmitted from person to person) transmission when: 1. Two of two Certified Nursing Assistants (CNA 1 and 2) worked in the facility while having COVID-19 symptoms (fever or chills cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea) and LVN 1 who was assigned to screen (employees assigned to review for signs and symptoms of COVID-19 before an employee enters a facility) for COVID-19 symptoms did not follow their policies and procedures based on Centers for Disease Control (CDC) standards and CNA 1, CNA 2 and LVN 1 were not aware of all COVID-19 symptoms. 2. The facility did not develop and implement a screening procedure tool for employees, prior to entering the facility in order to identify COVID-19 signs and symptoms, that accurately reflected all current COVID-19 symptoms, the symptoms missing on the screening tool were fatigue, headache, congestion or runny nose, nausea or vomiting and diarrhea as listed by facility's policies and procedures and COVID-19 Plan based on CDC guidance. These failures resulted in an outbreak of COVID-19 from [DATE] -[DATE] and 48 of 55 (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35 36 37, 38, 39, 40 41, 42, 43, 44, 45, 46, 47, 48) developed a COVID-19 infection, five of the 48 Residents (Residents 1, 2, 3 4, and 6) were transferred to the general acute care hospital (GACH) for higher level of care and six of the 48 Residents (Residents 1, 2, 3, 4, 5, 6) died following being diagnosed with [REDACTED]. Because of the serious actual and potential harm related to not following the facility's policies and procedures and COVID-19 Plan based on CDC standards for active screening of healthcare workers prior to the start of their shift and facility practice of permitting healthcare workers (CNA 1 and CNA 2) with COVID-19 symptoms to work, expose and transmit COVID-19 to Residents 1 through 48 and the subsequent deaths following being diagnosed with [REDACTED]. The facility submitted an acceptable removal plan (Version 3) on [DATE] at 2:58 p.m., to develop a screening tool and process with screening questions and assessment of illness that includes all signs and symptoms of COVID-19 and follow CDC standards; develop a monitoring program to monitor for signs and symptoms of COVID-19 for all residents and staff; provide immediate training and in-services to all staff on the signs and symptoms of COVID-19; provide immediate training and in-services screening staff on how to address employees who develop symptoms while working; provide immediate training and in-service staff to make sure staff are screened at the beginning of their shift for fever and signs and symptoms of COVID-19; and the Infection Preventionist must continually monitor the screening. The components of the IJ Removal Plan were validated through observations, interviews, and record review onsite on [DATE]. The IJ situation was removed on [DATE] at 4:29 p.m. with the ADM, CS, Regional Vice President of Operations (RVPO), Director of Staff Development (DSD)/Consultant, Senior Vice President of Clinical Operations, and Senior Vice President of Operations. Findings: 1. During an interview on [DATE] at 11:28 a.m. with the CS, the CS stated she was the facility's Infection Preventionist (IP). The CS stated the ADM had the line list for residents and staff. During an interview on [DATE], at 1:10 p.m., with the ADM, the ADM stated CNA1 was the first employee in the facility to test positive for COVID-19 on [DATE]. The ADM stated CNA 1 worked from [DATE] to [DATE] with a headache. The ADM stated and confirmed headache was a COVID-19 symptom. During an interview on [DATE], at 1:15 p.m., with the ADM, the ADM stated on [DATE], [DATE], and [DATE], CNA 1 was assigned and provided care to Resident 1, 2, 3, 4, 7, 8, 14, 24, 37, and 47. The ADM stated CNA 1 was having a headache and continued to provide care and did not notify anyone in the facility. The ADM stated on [DATE], CNA 1's headache worsened, and CNA 1 called the facility and was instructed to come to the outside of the facility to get tested for Covid-19. The ADM stated on [DATE], CNA 1's COVID-19 rapid test was positive. The ADM stated CNA 1 was the first staff tested positive for COVID-19 in the facility. The ADM stated on [DATE], [DATE], and [DATE], CNA 1 provided care to Resident 8. The ADM stated on [DATE], Resident 8 was transferred to the acute hospital for possible blood clot and tested positive for COVID-19 on [DATE]. The ADM stated Resident 8 was the first residents who tested positive for COVID-19. The ADM stated she did not conduct a root cause analysis (a technique of identifying the root cause of the problem or event and findings ways to prevent them from happening again) and contact tracing (is the process of identification of persons who may have come into contact with an infected person) for staff. The ADM stated the importance for conducting a root cause analysis and contact tracing was to prevent the spread of COVID-19 from happening again. During an interview on [DATE], at 3 p.m., with CNA 1, CNA 1 stated she would drink alcohol at home and would get headaches. CNA 1 stated she did not wear a mask or adhere to social distancing (the practice of increasing the space between individuals and decreasing the frequency of contact to reduce the risk of spreading a disease to maintain at least six feet between all individuals in accordance with CDC standards) when she was not working in the facility. CNA 1 stated on [DATE] she called the facility and spoke to a Licensed Nurse (LN) to notify her of continued and worsening headache. CNA 1 stated she was instructed by the LN to get a COVID-19 rapid test (test sample that can have results available in minutes). CNA 1 stated she tested positive for COVID-19 on [DATE]. During an interview on [DATE], at 9:40 a.m., with the ADM, the ADM stated when she was made aware of the CNA 1's positive result for COVID-19 the facility started to test residents in the facility for COVID-19. The ADM stated she did not conduct a root cause analysis of the COVID-19 outbreak because she was busy. The ADM stated CNA 1 worked with COVID-19 signs and symptoms and exposed residents she was assigned from 11/ ,[DATE] to [DATE]. The ADM stated she did not conduct contract tracing for staff. During an interview on [DATE], at 11:08 a.m. with the CS, the CS stated she did know when CNA 1 last worked, she did not know when CNA 1 worked with symptoms and she did not know what residents were assigned to CNA 1. The CS stated she did not conduct a root cause analysis of the COVID-19 outbreak. During an interview on [DATE], at 2 p.m., with CNA 1, CNA 1 stated she worked from [DATE] to [DATE] with headache and fatigue. CNA 1 stated on [DATE] and [DATE] she did not write down on the Employee Screening tool she had a headache and runny nose. CNA 1 stated she had a pounding headache for two days. CNA 1 stated on [DATE] she had a runny nose and continued to work and did not notify any staff member in the facility. CNA 1 stated on [DATE] she did not get screened by the screener with the Employee Screening Tool for COVID-19 symptoms before the start of her shift. CNA 1 stated she did not report the symptoms to the DON because she did not think headache and fatigue were COVID-19 symptoms. CNA 1 stated she worked overtime hours on [DATE] and [DATE] and she thought she was fatigued from working long hours. CNA 1 stated she did not think her symptoms were COVID-19 related and continued to work for four and half hours on [DATE]. During a review of CNA 1's Final Report (FR) (lab results) dated [DATE], the FR indicated CNA 1 tested positive for COVID-19 and confirmed on [DATE]. During a review of CNA 1's Timecard Report for (SNF), dated [DATE] to [DATE], indicated CNA 1 worked from [DATE], [DATE], and [DATE]. On [DATE], CNA 1 worked from 6:05 a.m. to 8:48 p.m. On [DATE], CNA 1 worked from 5:59 a.m. to 3:07 p.m. On [DATE], CNA 1 worked from 8 a.m. to 12:30 p.m. During a review of the facility document CNA Assignment Sheet dated [DATE] to [DATE], the CNA Assignment Sheet indicated, CNA 1 cared for Residents 1, 2, 3, 4, 7, 8,, 14, 24, 37, and 47 from [DATE] to [DATE] concurrent with the days CNA 1 worked with COVID-19 symptoms. During a review of CNA 1's, Employee Screening Tool (EST-tool used to identify COVID-19 symptoms) dated [DATE], indicated, the screening tool was not completely filled out and did not indicate a time CNA 1 was screened and a signature was missing to verify CNA 1 had been screened prior to the beginning of her shift. During a review of CNA 1's, EST dated [DATE], indicated, the screening tool was not completely filled out and did not indicate a time CNA 1 was screened prior to the start of shift. During an interview on [DATE], at 9:17 a.m., with the ADM, the ADM stated she could not locate CNA 1's EST dated [DATE]. The ADM stated the COVID-19 Screening Tool was not completed on [DATE] for CNA 1. During an interview on [DATE], at 1:45 p.m., with CNA 2, CNA 2 stated she worked from [DATE] to [DATE], in the facility while she had a headache and sore throat. CNA 2 stated the facility had developed a screening process to ensure employees had their temperature checked and answered the screening tool questions before working. CNA 2 stated she came to work on [DATE] at 6 a.m. Licensed Vocational Nurse (LVN) 1 did not verify and screen her before working. CNA 2 stated she had to screen herself on [DATE]. CNA 2 stated on [DATE] she had developed a stomachache, fatigue, along with her headache and sore throat while she worked. CNA 2 stated on [DATE] she notified Licensed Vocational Nurse (LVN) 1 about not feeling well at the beginning of the shift at 6 a.m. CNA 2 stated LVN 1 asked her if she had a fever (?100.0°F), and CNA 2 stated she did not have a fever. CNA 2 stated she continued to work on [DATE] with symptoms of headache, stomachache, and fatigue until approximately 2 p.m. CNA 2 stated on [DATE] she got tested for COVID-19 and on [DATE] she received a phone call from the DON at 5 p.m. and notified her of the COVID-19 positive result. CNA 2 stated she worked in the COVID-19 unit (area of the facility used to house COVID-19 positive residents that is separated with a plastic tarp from the rest of the facility to prevent further exposure of [MEDICAL CONDITION]) from [DATE] to [DATE] and cared for Residents (Residents 4 through 48) in the COVID-19 unit on different days. CNA 2 stated she did not notify the DON of her COVID-19 symptoms from [DATE] to [DATE] because she was scheduled to work, and the facility management would get upset when the CNA's would call in sick. CNA 2 stated working with COVID-19 symptoms placed the residents in the facility at risk of becoming infected with COVID-19 and lead to further harm of residents. During an interview on [DATE], at 2:27 p.m., with LVN 1, LVN 1 stated every staff member was to be screened for COVID-19 symptoms before the start of their shift. LVN 1 stated every staff member needed to have their temperature checked and answer the questions on the screening tool. LVN 1 stated the screening tool needed to be verified by the employee who was assigned to screen to make sure staff did not come in to work with symptoms. LVN 1 stated if staff members reported symptoms of COVID-19 they would need to report to an LVN and be sent home. LVN 1 stated CNA 2 worked on [DATE] and reported to LVN 1 between 8 a.m. and 9 a.m. she had fatigue. LVN 1 stated because CNA 2 did not have a fever she was allowed to work on [DATE] with fatigue and feeling drained. LVN 1 did not review CNA 2's EST dated [DATE]. LVN 1 stated CNA 2 came to him at approximately 2 p.m. on [DATE] with worsening symptoms of stomachache, headache and fatigue and he sent CNA 2 home. LVN 1 stated he was later notified at 4 p.m. CNA 2's COVID-19 test result was positive. During an interview on [DATE], at 2:37 p.m., with the DON, the DON stated on [DATE] she informed CNA 2 she had tested positive for COVID-19. The DON stated she informed CNA 2 she would be off work due to being COVID-19 positive. The DON stated CNA 2 did not report symptoms to her and was not aware CNA 2 had COVID-19 symptoms on [DATE]. The DON stated all staff members needed to be screened for COVID-19 signs and symptoms every day before the beginning of their shift. The DON stated the facility did not have an assigned staff member to screen employees and any staff member could screen employees locked door and screen the staff member. The DON stated CNA 1 and CNA 2 should not have worked with COVID-19 symptoms while they cared for residents in the facility, to prevent the spread of COVID-19 in the facility including residents and staff. During a review of CNA 2's FR (lab results) dated [DATE], the FR indicated CNA 2 was tested for COVID-19 on [DATE] and confirmed positive on [DATE]. During a review of CNA 2's Timecard Report for (SNF), dated [DATE] - [DATE], indicated CNA 2 worked on [DATE], [DATE], [DATE], [DATE], and [DATE]. CNA 2's timecard indicated CNA 2 worked on [DATE] from 5:53 a.m. to 6:07 p.m. On [DATE], CNA 2 worked from 1:48 a.m. to 2:08 p.m. On [DATE], CNA 2 worked from 1:49 a.m. to 3:41 p.m. On [DATE], CNA 2 worked from 5:54 a.m. to 6:07 p.m. On [DATE], CNA 2 worked from 6:01 a.m. to 2:08 p.m. During a review of CNA 2's COVID-19 screening tool titled, EST dated [DATE] at 6 a.m., did not indicate CNA 2 was screened by a staff member. During a review of CNA's COVID-19 screening tool, EST dated [DATE] at 2 a.m. was completely filled out and signed by a staff member who conducted the screening. During a review of CNA 2's COVID-19 screening tool titled EST dated [DATE] at 2 a.m., did not indicate CNA 2 was screened by a staff member. During a review of CNA 2's COVID-19 screening tool titled EST dated [DATE] at 5:54 a.m., did not indicate CNA 2 was screened by a staff member. During a review of CNA 2's COVID-19 screening tool titled EST dated [DATE] at 11 a.m., did not indicate CNA 2 was screened by a staff member. The screening tool indicated, . 1. Do you have symptoms of cough, fever, shortness of breath, sore throat, chills, headache, muscles pains, and new onset of loss of taste or smell? Yes . 2. Have you had contact with someone with a confirmed [DIAGNOSES REDACTED].? This includes having been in a COVID (positive) facility/hospital. Yes . During an interview on [DATE], at 9:17 a.m., with the ADM, the ADM stated CNA 2's start time on [DATE] was 6 a.m. The ADM stated she could not locate CNA 2's screening tool for [DATE] at 6 a.m. The ADM stated the screening was not completed at the beginning of the morning shift on [DATE] for CNA 2. During an interview on [DATE], at 3:10 p.m., with the ADM, the ADM stated the facility had a total of 48 residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35 36 37, 38, 39, 40 41, 42, 43, 44, 45, 46, 47, 48) who tested positive for COVID-19 from [DATE] to [DATE]. The ADM stated two Residents (Residents 1, 3) were tested on [DATE] with a rapid COVID-19 test; two residents (Residents 2, 7) were tested on [DATE] with a rapid COVID-19 test; three residents (Residents 18, 20, 37) were tested on [DATE] with a rapid COVID-19 test; four residents (Resident 4, 5, 14, 46) were tested on [DATE] with a rapid COVID-19 test; nine residents (Residents 15, 17, 21, 25, 28, 29, 30, 33, 47) were tested on [DATE] with a rapid COVID-19 test; 10 residents (Residents 6, 12, 16, 27, 36, 38, 40, 43, 44, 45) were tested on ,[DATE] with a PCR COVID-19 test; two residents (Residents 31, 42) were tested on [DATE] with a PCR COVID-19 test; one resident (Resident 35) was tested on [DATE] with a PCR COVID-19 test; 13 residents (Residents 9, 10, 11, 13, 19, 22, 23, 24, 26, 32, 34, 39, 48) were tested on [DATE] with a PCR COVID-19 test; one resident (Resident 41) was tested on [DATE] with a PCR COVID-19 test; one resident (Resident 8) was tested on [DATE] at the General Acute Care Hospital (GACH). The ADM stated six of 48 Residents (Resident 1, 2, 3, 4, 5, and 6) who were positive for COVID-19 expired. The ADM stated five residents (Residents 1, 2, 3, 4, and 6) were transferred to the GACH. The ADM stated Resident 1 expired in the ACH. The ADM stated Resident 2 was transferred to the ACH returned to the Skilled Nursing Facility (SNF) and expired. The ADM stated Resident 3 expired in the SNF. The ADM stated Resident 4 expired in the SNF. The ADM stated Resident 6 expired at the ACH. During a review of Resident 1's Admission Record (AR), dated [DATE], the AR indicated, Resident 1 was admitted to the facility on [DATE]. Resident 1's Progress Note dated [DATE] at 1:31 p.m., indicated, Resident 1's rapid test was positive for COVID-19 on [DATE]. Resident 1's Progress Note dated [DATE], indicated, Resident 1 was transferred to the GACH after he collapsed and coded (when a person stops breathing or heart stops) Resident 1's ED (emergency department) Assessment, dated [DATE], the ED Assessment indicated Resident arrived to the ED at 4:09 p.m. and was given CPR (cardiopulmonary resuscitation.) until time of death at 4:21 p.m. Resident 1's Coroner's Report, dated [DATE], the Coroner's Report, indicated, Resident 1's final causes of death were, . A. [MEDICAL CONDITION] .B. COVID-19 . During a review of Resident 2's AR, dated [DATE], the AR indicated, Resident 2 was admitted to the facility on [DATE]. Resident 2's Progress Note dated [DATE], indicated, Resident 2's rapid test was positive for COVID-19. Resident 2's Progress Note dated [DATE], indicated, Resident 2 was transferred to the GACH for low oxygenation when O2 saturation was 85% (measurement of oxygen in the blood with normal values being ,[DATE]%). %). Resident 2's ED Assessment, dated [DATE], indicated Resident 2 was placed on comfort measures (medical treatment of [REDACTED]. Resident 2's Progress Note dated [DATE], indicated Resident 2 returned from the GACH at 11:40 a.m., and expired at 11:55 a.m. During a review of Resident 3's AR, dated [DATE], the AR indicated, Resident 3 was admitted to the facility on [DATE]. Resident 3's Progress Note dated [DATE], indicated, Resident 3's rapid test was positive for COVID 19. Resident 3's Progress Note dated [DATE] indicated, Resident 3 was sent to the GACH for shortness of breath. Resident 3's GACH history and physical (H&P) dated [DATE], indicated, Resident 3 was admitted to the GACH for [MEDICAL CONDITION]. Resident 3's GACH discharge summary, dated [DATE], indicated, Resident 3 was discharged back the facility on hospice care (end of life care for residents experiencing an advanced, life-limiting illness). Resident 3's Progress Note dated [DATE] at 4:45 p.m., indicated, Resident 3 returned from the GACH with labored breathing and low O2 saturation of 76% (indicating very low oxygen in the blood). Resident 3 expired on [DATE] at 6:55 p.m. During a review of Resident 4's AR, dated [DATE], the AR indicated, Resident 4 was admitted to the facility on [DATE]. Resident 4's Progress Note dated [DATE], indicated, Resident 4's rapid test was positive for COVID -19. Resident 4's Progress Note dated [DATE], indicated, Resident 4 had [MEDICAL CONDITION] (heart stopped) and paramedics were called to do CPR (cardiopulmonary resuscitation.) Resident 4 expired at 9:58 p.m. on [DATE]. During a review of Resident 5's AR, dated [DATE], the AR indicated, Resident 5 was admitted to the facility on [DATE]. Resident 5's Progress Note dated [DATE], indicated, Resident 5's rapid test was positive for COVID 19. Resident 5's Progress Note dated [DATE], indicated, Resident 5 had no pulse and was not breathing and expired at 5:40 p.m. Resident 5's Coroner's Report, dated [DATE], the Coroner's Report, indicated, Resident 5's final causes of death were, .A. Acute [MEDICAL CONDITION] .B. Pneumonia .C. COVID-19 . During a review of Resident 6's AR, dated [DATE], the AR indicated, Resident 6 was admitted to the facility on [DATE]. Resident 6's lab results (PCR) dated [DATE], indicated, Resident 6 was positive for COVID-19. Resident 6's Progress Note dated [DATE], indicated Resident 6 had low O2 saturation of 70% (indicating very low oxygen in the blood) and was sent to the GACH. Resident 6's hospital Progress Note, dated [DATE], indicated Resident 6 developed [MEDICAL CONDITION] (low blood pressure) and required vasopressors (medications used to contract blood vessels and raise blood pressure in people who are critically ill). Resident 6 developed [MEDICAL CONDITION] and expired on [DATE] at 9:04 a.m. Resident 6's Coroner's Report, dated [DATE], the Coroner's Report indicated, Resident 6's final causes of death were, . Acute [MEDICAL CONDITION] .B. Septic Shock .C. Pneumonia .D. COVID-19 . During a review of Resident 7's AR, dated [DATE], the AR indicated, Resident 7 was admitted to the facility on [DATE]. Resident 7's Progress Note dated [DATE], indicated Resident 7's rapid test was positive for COVID-19. During a review of Resident 8's AR, dated [DATE], the AR indicated, Resident 8 was admitted to the facility on [DATE]. Resident 8's hospital history and physical, dated [DATE], indicated Resident 8 was positive for COVID-19. During a review of Resident 9's AR, dated [DATE], the AR indicated, Resident 9 was admitted to the facility on [DATE]. Resident 9's lab results (PCR) dated [DATE], indicated, Resident 9 was positive for COVID-19. During a review of Resident 10's AR, dated [DATE], the AR indicated, Resident 10 was admitted to the facility on [DATE]. Resident 10's lab results (PCR) dated [DATE], indicated, Resident 10 was positive for COVID-19. During a review of Resident 11's AR, dated [DATE], the AR indicated, Resident 11 was admitted to the facility on [DATE]. Resident 11's lab results (PCR) dated [DATE], indicated, Resident 11 was positive for COVID-19. During a review of Resident 12's AR, dated [DATE], the AR indicated, Resident 12 was admitted to the facility on [DATE]. Resident 12's lab results (PCR) dated [DATE], indicated, Resident 12 was positive for COVID-19. During a review of Resident 13's AR, dated [DATE], the AR indicated, Resident 13 was admitted to the facility on [DATE]. Resident 13's lab results (PCR) dated [DATE], indicated, Resident 13 was positive for COVID-19. During a review of Resident 14's AR, dated [DATE], the AR indicated, Resident 14 was admitted to the facility on [DATE]. Resident 14's Progress Note dated [DATE], indicated, Resident 14's rapid test was positive for COVID-19. During a review of Resident 15's AR, dated [DATE], the AR indicated, Resident 15 was admitted to the facility on [DATE]. Resident 15's Progress Note dated [DATE], indicated, Resident 15's rapid test was positive for COVID-19. During a review of Resident 16's AR, dated [DATE], the AR indicated, Resident 16 was admitted to the facility on [DATE]. Resident 16's lab results (PCR) dated [DATE], indicated, Resident 16 was positive for COVID-19. During a review of Resident 17's AR, dated [DATE], the AR indicated, Resident 17 was admitted to the facility on [DATE]. Resident 17's Progress Note dated [DATE], indicated, Resident 17's rapid test was positive for COVID-19. During a review of Resident 18's AR, dated [DATE], the AR indicated, Resident 18 was admitted to the facility on [DATE]. Resident 18's Progress Note dated [DATE], indicated, Resident 18's rapid test was positive for COVID19. During a review of Resident 19's AR, dated [DATE], the AR indicated, Resident 19 was admitted to the facility on [DATE]. Resident 19's lab results (PCR) dated [DATE], indicated, Resident 19 was positive for COVID-19. During a review of Resident 20's AR, dated [DATE], the AR indicated, Resident 20 was admitted to the facility on [DATE]. Resident 20's Progress Note dated [DATE], indicated, Resident 20's rapid test was positive for COVID19. During a review of Resident 21's AR, dated [DATE], the AR indicated, Resident 21 was admitted to the facility on [DATE]. Resident 21's Progress Note dated [DATE], indicated, Resident 21's rapid test was positive for COVID-19. During a review of Resident 22's AR, dated [DATE], the AR indicated, Resident 22 was admitted to the facility on [DATE]. Resident 21's lab results (PCR) dated [DATE], indicated, Resident 22 was positive for COVID-19. During a review of Resident 23's AR, dated [DATE], the AR indicated, Resident 23 was admitted to the facility on [DATE]. Resident 23's lab results (PCR) dated [DATE], indicated, Resident 23 was positive for COVID-19. During a review of Resident 24's AR, dated [DATE], the AR indicated, Resident 24 was admitted to the facility on [DATE]. Resident 24's lab results (PCR) dated [DATE], indicated, Resident 24 was positive for COVID-19. During a review of Resident 25's AR, dated [DATE], the AR indicated, Resident 25 was admitted to the facility on [DATE]. Resident 25's Progress Note dated [DATE], indicated, Resident 25's rapid test was positive for COVID-19. During a review of Resident 26's AR, dated [DATE], the AR indicated, Resident 26 was admitted to the facility on [DATE]. Resident 26's lab results (PCR) dated [DATE], indicated, Resident 26 was positive for COVID-19. During a review of Resident 27's AR, dated [DATE], the AR indicated, Resident 27 was admitted to the facility on [DATE]. Resident 27's lab results (PCR) dated [DATE], indicated, Resident 27 was positive for COVID-19. During a review of Resident 28's AR, dated [DATE], the AR indicated, Resident 28 was admitted to the facility on [DATE]. Resident 28's Progress Note dated [DATE], indicated, Resident 28's rapid test was positive for COVID-19. During a review of Resident 29's AR, dated [DATE], the AR indicated, Resident 29 was admitted to the facility on [DATE]. Resident 29's Progress Note dated [DATE], indicated, Resident 29's rapid test was positive for COVID-19. During a review of Resident 30's AR, dated [DATE], the AR indicated, Resident 30 was admitted to the facility on [DATE]. Resident 30's Progress Note dated [DATE], indicated, Resident 30's rapid test was positive for COVID-19. During a review of Resident 31's AR, dated [DATE], the AR indicated, Resident 31 was admitted to the facility on [DATE]. Resident 31's lab results (PCR) dated [DATE], indicated, Resident 31 was positive for COVID-19. During a review of Resident 32's AR, dated [DATE], the AR indicated, Resident 32 was admitted to the facility on [DATE]. Resident 32's lab results (PCR) dated [DATE], indicated, Resident 32 was positive for COVID-19. During a review of Resident 33's AR, dated [DATE], the AR indicated, Resident 33 was admitted to the facility on [DATE]. Resident 33's Progress Note dated [DATE], indicated, Resident 33's rapid test was positive for COVID-19. During a review of Resident 34's AR, dated [DATE], the AR indicated, Resident 34 was admitted to the facility on [DATE]. Resident 34's lab results (PCR) dated [DATE], indicated, Resident 34 was positive for COVID-19. During a review of Resident 35's AR, dated [DATE], the AR indicated, Resident 35 was admitted to the facility on [DATE]. Resident 35's lab results (PCR) dated [DATE], indicated, Resident 35 was positive for COVID -19. During a review of Resident 36's AR, dated [DATE], the AR indicated, Resident 36 was admitted to the facility on [DATE]. Resident 36's lab results (PCR) dated [DATE], indicated, Resident 36 was positive for COVID-19. During a review of Resident 37's AR, dated [DATE], the AR indicated, Resident 37 was admitted to the facility on [DATE]. Resident 37's Progress Note dated [DATE], indicated, Resident 37's rapid test was positive for COVID-19. During a review of Resident 38's AR, dated [DATE], the AR indicated, Resident 38 was admitted to the facility on [DATE]. Resident 38's lab results (PCR) dated [DATE], indicated, Resident 38 was positive for COVID-19. During a review of Resident 39's AR, dated [DATE], the AR indicated, Resident 39 was admitted to the facility on [DATE]. Resident 39's lab results (PCR) dated [DATE], indicated, Resident 39 was positive for COVID-19. During a review of Resident 40's AR, dated [DATE], the AR indicated, Resident 40 was admitted to the facility on [DATE]. Resident 40's lab results (PCR) dated [DATE], indicated, Resident 40 was positive for COVID-19. During a review of Resident 41's AR, dated [DATE], the AR indicated, Resident 41 was admitted to the facility on [DATE]. Resident 41's lab results (PCR) dated [DATE], indicated, Resident 41 was positive for COVID-19. During a review of Resident 42's AR, dated [DATE], the AR indicated, Resident 42 was admitted to the facility on [DATE]. Resident 42's lab results (PCR) dated [DATE], indicated, Resident 42 was positive for COVID-19. During a review of Resident 43's AR, dated [DATE], the AR indicated, Resident 43 was admitted to the facility on [DATE]. Resident 43's lab results (PCR) dated [DATE], indicated, Resident 43 was positive for COVID-19. During a review of Resident 44's AR, dated [DATE], the AR indicated, Resident 44 was admitted to the facility on [DATE]. Resident 44's lab results (PCR) dated [DATE], indicated, Resident 44 was positive for COVID-19. During a review of Resident 45's AR, dated [DATE], the AR indicated, Resident 45 was admitted to the facility on [DATE]. Resident 45's lab results (PCR) dated [DATE], indicated, Resident 45 was positive for COVID-19. During a review of Resident 46's AR, dated [DATE], the AR indicated, Resident 46 was admitted to the facility on [DATE]. Resident 46's Progress Note, dated [DATE], indicated, Resident 46's rapid test was positive for COVID-19. During a review of Resident 47's AR, dated [DATE], the AR indicated, Resident 47 was admitted to the facility on [DATE]. Resident 47's Progress Note, dated [DATE], indicated, Resident 47's rapid test was positive for COVID-19. During a review of Resident 48's AR, dated [DATE], the AR indicated, Resident 48 was admitted to the facility on [DATE]. Resident 48's lab results (PCR) dated [DATE], indicated, Resident 48 was positive for COVID-19. During a review of the facility's document titled COVID-19 Plan [DATE], indicated, The facility will begin an investigation if it is determined that a staff member who is demonstrating sign and symptom of infection reported to work or developed signs and symptoms of respiratory infection while at work . During a review of a professional reference retrieved from https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/steps-when-sick.html titled, What(TRUNCATED)

Based on observation, interview and record review, the facility failed to provide adequate monitoring and supervision to prevent one of three residents, Resident 1, from leaving the facility on 4/2/18 in her wheelchair, unnoticed and unsupervised. Prior to the incident Resident 1 was assessed as a cognitively (pertaining to reasoning, memory and judgement) impaired individual with known elopement behavior. The facility failed to ensure Resident 1's personal alarm system (PAS - an alarm system to alert staff when residents try to leave the facility or wander into restricted areas) device and/or the alarm system component at the lobby exit door were functioning properly. The facility failed to implement an individualized monitoring plan to address Resident 1's known elopement behavior. These failures resulted in Resident 1 leaving the facility unassisted and unsupervised, falling off the sidewalk curb in her wheelchair on 4/2/18 at 8:40 a.m., landing face down on the city street, and sustaining a two centimeter (cm) laceration (cut) and large hematoma (solid swelling of clotted blood) in the soft tissues in the area around the left eye. Resident 1 required transportation by ambulance to the General Acute Care Hospital (GACH) for evaluation. The facility failed to have a system in place to ensure the safety and protection of five of 59 residents assessed as having behaviors of wandering and elopement. Staff did not respond to door alarms intended to prevent residents from eloping. The facility did not have a system in place to ensure door alarms and PAS devices functioned properly and staff responded appropriately. Because of the serious actual harm to Resident 1, the potential serious harm to all residents assessed for being at risk of wandering and elopement and the failure to have an effective system in place to ensure the safety of residents with elopement behaviors an Immediate Jeopardy (IJ) Situation was called on 4/2/18 at 5:35 p.m. The facility administrator (Admin), the Director of Nursing (DON) and the Director of Maintenance (DOM) were present and were provided verbal notification of the IJ situation. The facility submitted an Action Plan (AP) which addressed wandering risk assessment, checking placement and function of the Residents' PAS and staff response to all exit door alarms. The facility's AP was reviewed, revised, and formally accepted on 4/3/18 at 2:25 p.m. The determination was made that the facility implemented the AP and trained or re-trained staff sufficiently to remove the immediacy. The IJ was removed during an onsite visit on 4/3/18 at 5:06 p.m. with the Admin and the DON present. Findings: Resident 1's Admission Record (AR - record containing personal information) indicated Resident 1 was [AGE] years old and was admitted to the skilled nursing facility (SNF) on 11/11/14. The AR indicated Resident's 1 [DIAGNOSES REDACTED]. The AR indicated Resident 1 was her own Responsible Party (RP - decision maker). Resident 1's clinical record titled, Minimum Data Set (MDS - a resident assessment tool used to plan resident care) assessment dated [DATE], indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of 9 points out of a possible 15 points, which indicated moderate cognitive impairment. On 4/2/18 at 2:10 p.m., during an interview and concurrent record review, the DON stated on Saturday, 3/31/18 at 6:20 p.m., the Licensed Nurse (LN) 1 learned from a visitor that Resident 1 was outside self-propelling her wheelchair down the street. The DON stated, Then, this morning (4/2/18) at 8:40 a.m., a visitor called staff and made them aware that a resident was outside in the street with a wheelchair flipped over off the curb. The DON stated staff ran out to the street and found Resident 1 face down with a two cm laceration above her left eyebrow. The DON stated Resident 1 left the faciity on [DATE], unnoticed and unsupervised for the second time in three days. The DON stated it was unknown which door Resident 1 had exited from. The DON stated it was unknown whether or not alarms sounded, whether staff did not hear alarms, or if staff did hear the alarms and did not respond. The DON stated Resident 1 was transported to the GACH by ambulance and had not returned to the facility. Resident 1's GACH clinical record indicated Resident 1 was transferred to the GACH on 4/2/18 for evaluation following the fall and remained in the GACH for eight days for medical follow-up, not directly related to the elopement and fall. The GACH clinical record indicated Resident 1 was transferred back to the SNF on 4/10/18. Resident 1's GACH clinical record titled, History and Physical dated 4/2/18 indicated, (Resident 1) is a 72 y/o (year old) female with a history of mental health issues .She presented (arrived in the emergency department) after tipping over in her wheelchair and falling and was found to have a left-orbital (area around the eye) hematoma . The GACH Radiology Report indicated a Computed Tomography (CT - a computer assisted specialized X-Ray) imaging of the head was performed on 4/2/18 with the following results: There is a large hematoma noted in the soft tissues in the left periorbital region. The orbit in the left appears to be intact .No evidence of acute intracranial (within the skull) hemorrhage .mass or bleeding . On 4/2/18 at 2:35 p.m., during a joint interview with the DON and LN 1, LN 1 stated she arrived at work on Saturday 3/31/18 at 6:03 p.m. LN 1 stated a resident's family member (FM) was standing near the front door in the lobby. LN 1 stated, He (FM) said one of your patients is getting away. LN 1 stated Resident 1 was outside on the sidewalk a short distance from the facility. LN 1 stated she went outside and brought Resident 1 back into the building in her wheelchair. LN 1 stated Resident 1 was wearing a PAS (a bracelet which should trigger an alarm if Resident 1 was close to the lobby exit door). LN 1 stated the PAS alarmed when she brought Resident 1 through the lobby door. LN 1 stated, I didn't know she had a (PAS) until I brought her back inside through the front door and it went off (alarmed). The DON stated on 3/31/18 Resident 1 had a PAS on without a physician order and no one was checking to ensure it was functioning properly. The DON stated Resident 1's current PAS order was obtained after the first elopement on 3/31/18. LN 1 and the DON both stated they did not know how Resident 1 got out of the building unnoticed and unsupervised while wearing a PAS on both 3/31/18 and 4/2/18. On 4/2/18 at 3 p.m., during a joint interview with the DON and LN 2, LN 2 stated Resident 1 had a PAS, since she started working at the SNF approximately two months ago. LN 2 stated she did not check the PAS to ensure it was working properly. LN 2 stated, I check to see if it's (PAS) attached to her (Resident 1). If there was damage I would think it might not work, but if it's there and it looks okay I expect it to work. I just assume. LN 2 stated she routinely checked to ensure the PAS was in place on Resident 1's wrist. LN 2 stated she documented the placement of the PAS on Resident 1 in the Medication Administration Record [REDACTED]. The DON stated the only documentation of checking placement or function of the PAS was in the Treatment Administration Record (TAR), dated 4/1/18 and at midnight on 4/2/18. The DON stated, No one was checking the doors to make sure the alarm triggered and alarmed. Resident 1's clinical record titled, Order Summary Report dated 3/31/18 indicated, (MONTH) have (PAS) every shift to prevent elopement. The Order Summary Report indicated 4/1/18 was the start date for the PAS. On 4/2/18 at 3:30 p.m., during an interview, the DOM stated he had worked for the facility for about two months. The DOM stated he had never worked with the PAS devices prior to his employment at the facility. The DOM stated about a month before Resident 1 eloped, the PAS devices did not always cause the door alarm to sound. The DOM stated at that time (a month ago) he took three residents with a PAS to the lobby door and the alarm did sound when they neared the exit. On 4/2/18 at 3:40 p.m., during an observation and joint interview with the DOM and the Admin, the DOM attempted to demonstrate the PAS alarm system by wheeling Resident 5 up to the front lobby door which was equipped with PAS alarming system, but the alarm did not go off. The DOM stated he had used Resident 5's PAS earlier to check the alarm and it worked well. The DOM patted down Resident 5's forearms checking for a bracelet with the PAS tag attached. The Admin stated facility staff determined there was no physician order for [REDACTED]. A very loud alarm sounded when Resident 2 was pushed up to and through the lobby door. A staff member approached the hall doorway into the lobby and requested information unrelated to the alarm. No staff members came forward to investigate why the PAS was alarming and rule out the possibility of an elopement. On 4/2/18 at 4:40 p.m., during an interview, the Admin stated, It (the PAS system) works at least part of the time. Because of the serious actual harm to Resident 1, the potential serious harm to all residents assessed for being at risk of wandering and elopement, and the failure to have an effective system in place to ensure the safety of residents with elopement behaviors an IJ Situation was called on 4/2/18 at 5:35 p.m. The facility Admin, the DON and the DOM were present and were provided verbal notification of the IJ situation. The facility submitted an AP which addressed wandering risk assessment, checking placement and function of the Residents' PAS, and staff response to all exit door alarms. The facility's AP was reviewed, revised, and formally accepted on 4/3/18 at 2:25 p.m. The determination was made that the facility implemented the AP and trained or re-trained staff sufficiently to remove the immediacy. The IJ was removed during an onsite visit on 4/3/18 at 5:06 p.m. with the Admin and the DON present. On 4/3/18 at 3 p.m., during an interview and concurrent review of the facility Wander Risk Assessment forms, the DON stated an error had been identified in the computerized Risk Assessment form. The DON stated all wander risk assessments would be reviewed and recalculated because they inaccurately measured residents' wander risk lower than they actually were. Resident 1's risk assessment completed on 3/31/18 at 9:11 p.m. resulted in a score of 8, which placed her at low risk for wandering. The risk assessment completed on 4/2/18 at 12:30 p.m., indicated a score of 13. Another risk assessment also completed on 4/2/18 at 12:30 p.m., indicated a score of 16. An assessment score of 11 and above indicated a high risk to wander. The DON stated residents were evaluated to better plan their care and heighten staff awareness of the residents' risk to wander. On 4/11/18 at 9:20 a.m., during a telephone interview, LN 3 stated on 4/2/18 at 8:35 a.m., he had seen Resident 1 on the south hallway. LN 3 stated at 8:40 a.m., a visitor phoned that Resident 1 was outside. LN 3 stated multiple staff members ran outside and found Resident 1 face down in the street near the gutter, bleeding from a two cm laceration above her left eye. LN 3 stated, She (Resident 1) was yelling, I hurt. LN 3 stated Resident 1's PAS was in place on her wrist. LN 3 stated, We think she went out the front lobby door because all the other doors are perimeter doors which automatically alarm, PAS or not. LN 3 stated, Residents at risk for elopement have a (PAS) on for their safety. I know she was at risk for elopement. She was already wearing a (PAS). LN 3 stated Resident 1 had a PAS in place since she was admitted on [DATE]. LN 3 stated the PAS alarm was loud and if it had alarmed it would have been heard at the nurses' station. LN 3 stated, I did not hear the alarm the morning she (Resident 1) eloped. The business office staff did not hear the alarm. The visitor who alerted us she (Resident 1) was outside in the street, said the door alarm was not alarming when she (the visitor) left. All the other doors (perimeter doors) would have alarmed. On 4/12/18 at 10 a.m., during a phone interview and concurrent record review, the DOM stated only the front lobby door was equipped with the PAS system. The DOM stated all other exit doors alarmed unless a code was entered before opening, except the exit door located on the service hallway (which was behind another locked door). On 4/12/18 at 11:30 p.m., during a telephone interview, the Corporate Director of Maintenance (CDOM) stated he did not know if the SNF had developed policies that outlined which personnel were authorized to test the PAS or a procedure which outlined the steps to test the PAS system and door alarms. On 4/16/18 at 2:15 p.m., an observation and concurrent interview with Resident 1 was conducted in the hallway near the nurses' station. Resident 1 was sitting in her wheelchair and rubbed both sides of her face repeatedly with her open palm. Her left cheek and the area above her left eye was red and abraded (scraped). Resident 1 hesitated, and then stated she did not recall which door she used to leave the facility on 3/31/18 and 4/2/18. On 4/25/18 at 8:45 a.m., during a telephone interview, the DOM stated he had no knowledge of the PAS being checked and/or any documentation of the PAS checks prior to his hire date of 1/22/18. The DOM stated prior to Resident 1's elopement on 4/2/18, I was checking the alarm, but not daily, maybe weekly . and I was not documenting the test results. The DOM stated he created a log and began documenting the PAS testing on 4/3/18, after the Immediate Jeopardy was called, due to Resident 1's elopements. The DOM stated the first time he documented Resident 1's PAS test was 4/11/18, after Resident 1 returned to the SNF from the GACH. On 5/1/18 at 9:30 a.m., during an interview, the DON stated the staff were expected to respond immediately when a door alarm went off. The DON stated by staff she meant licensed and unlicensed staff, to include all staff employed by the facility. The DON stated staff would need to identify which door was alarming and look to ensure that a resident had not gone out without permission and unsupervised. The DON stated if the alarm went off and a resident was not near the door, staff should look outside to see if a resident had left the facility unsupervised. The DON stated if staff did not see a resident and could not determine why the alarm had sounded they should report to a charge nurse to get a head count in order to ensure there had not been an elopement. The DON stated this expectation was not new and had always been the expectation for staff employed by the facility. Review of the facility PAS purchase and product information from the supplier, dated 10/18/16, described the essential part of the PAS worn by residents at risk for elopement, as a one inch square shaped tag attached to an arm or ankle strap. The Specification Sheet (PAS) Tag indicated, The (PAS) Tag provides protection to wander-prone residents. Each tag is identified by its own unique code. The system generates an Exit alarm if the tag is brought near to an exit protected by a Door Controller (PAS alarm sensor equipment at the door) .When attached, the tag provides additional tamper-resistant protection for the residents. The Specification Sheet (PAS) Door Controller indicated, (PAS) Door Controller monitors an exit in a facility using the (PAS) wander prevention system. The system provides freedom of mobility to residents in senior care facilities, while helping to ensure that they remain safe. The Controller generates an exciter field, which defines the door coverage area for resident tags. When a tag enters the Controller's exciter field while the door is open a Wander alarm is generated . The Pocket Tag Reader (PTR - hand held testing device for the PAS) User Guide, dated 4/11, indicated, .Important Recommendation (name of alarm company) systems are designed to assist staff in providing a high degree of safety for people and assets and therefore should be used as a component of a comprehensive security program of policies, procedures, and processes. As with every security system, you must perform regular system operational checks to verify functional integrity .Introduction .The PTR is a test tool for reading, testing and configuring .active Radio Frequency .Used improperly, the PTR can compromise the security system. Ensure that adequate procedures and precautions are in place to control the movement of this device; and to prevent the use of this device by unauthorized personnel.PTR Operation Overview For best results, place skin sensing tags on a shielded (e.g. metal) surface when testing .The type of tag and radio frequency (RF) noise may affect the performance of the PTR, RF noise radiates from notebook computers, PC (personal computer) monitors, and other devices . The facility's policy and procedure (P&P) titled, Wandering, Unsafe Resident dated 8/14, indicated .The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement . 1. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). 2. The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering. 3. The resident's care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety, such as a detailed monitoring plan will be included . Resident 1's Care Plan, initiated 3/31/18, indicated F[NAME]US At Risk for elopement r/t (related to): Impaired safety awareness . Resident wanders aimlessly. GOAL: Resident's safety will be maintained through the next review date. Interventions: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. Wander Alert: Device (PAS). The Care Plan did not include a detailed monitoring plan. The facility's undated P&P titled, WANDERING RISK SCALE indicated STANDARD: A safe environment is provided for patients/residents who are at risk to wander . The facility's undated P&P titled, . (PAS) indicated, POLICY: The (PAS) would be used for residents at risk for elopement. PURPOSE: For each resident to reach his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience. PR[NAME]EDURE: 1. Nursing Assessment of each resident must be done on admission and change in status to evaluate if he/she is at risk for falls or elopement. 2. A plan off care must be formulated .5. The (PAS) bracelet will be applied to the resident's wrist or ankle and not removed until replacement is needed .7. The (PAS) bracelets are checked daily on the night shifts by the Supervisor and are documented in the treatment book on the units and the (PAS) Folder in Peach Treatment Room.

Based on observation, interview, clinical record and administrative document review, the facility failed to protect two of two random sampled residents (Residents 15 and 16) from abuse when: 1. Resident 15 was inappropriately touched by Resident 14 when Resident 14 was observed with his finger inside Resident 15's vagina. 2. Resident 16's crotch was groped by a visitor who was a registered sex offender certified by Megan's Law when staff failed to effectively supervise the location of the offender at all times as instructed by the Administrator (ADM). These failures had the potential to cause psychological harm to Residents 15 and 16. Findings: 1. On 11/29/16 at 3:35 p.m., during a concurrent observation and interview, Resident 15 sat in a wheelchair in the hallway and held a teddy bear. Resident 15 became tearful and stated, I've been bad. Resident 15 was unable to answer coherently additional questions. On 11/29/16 at 3:45 p.m., during a telephone interview, Certified Nurse Aide (CNA) 1 stated she was aware Resident 14 was on every 15 minute checks (staff observe resident every 15 minutes) due to his behaviors of touching residents and staff inappropriately. CNA 1 stated staff were to visualize and document every 15 minutes Resident 14's activities. CNA 1 stated on 11/23/16 around 4 p.m., she was across the hall from Resident 14's room and noticed the stop sign (a cloth with a red stop sign in the middle with Velcro on both ends that extended across the door opening) hung down one side of the door. (The absence of the sign going across the door would have allowed others to go in and out of the room without the presence of a visual barrier.) CNA 1 stated as she had entered Resident 14's room, Resident 15 sat in a wheelchair beside Resident 14's bed. CNA 1 stated Resident's 14 hand was clearly on Resident 15's crotch with his middle finger of the left hand inserted into Resident 15's vagina. CNA 1 stated Resident 15's pants had been pulled down enough to access the brief (disposable underwear) which was pushed to one side. CNA 1 stated she pulled Resident 15's pants up, removed her from the room to the large dining room, and reported the incident to Licensed Nurse (LN) 1. CNA 1 stated the ADM called her into his office where she provided a full verbal report on what she had observed during this incident. Resident 15's face sheet (a facility form that contained resident identifying information on admission) indicated she was diagnosed with [REDACTED]. Resident 15's Minimum Data Set Assessment (MDS) (a tool which is used to assess functional and cognitive abilities) assessment, dated 8/14/16, indicated under the area of Cognitive Skills For Daily Decision Making, Resident 15 was moderately impaired cognitively, decisions poor and cues/supervision required. On 11/29/16 at 4:11 p.m., during an interview, CNA 2 stated Resident 15 was quieter than usual since the incident with Resident 14. CNA 2 stated she had worked two days with Resident 15 since the incident and had noted Resident 15 would stare off more and did not seem as happy as before the incident. On 11/29/16 at 4:40 p.m., during a concurrent observation and interview CNA 2 stated Resident 14 was Spanish speaking and staff would provide a language interpreter. Through the interpreter Resident 14 was asked about the incident with Resident 15. Resident 14 stated he didn't know anything. Resident 14 stated he watched television, slept, or walked in his room when he was bored. Resident 14 further stated, he didn't know that woman. Resident 14's affect and behavior changed as the interview progressed. Resident 14 appeared angry, his relaxed sitting posture changed to a standing position, waved his arms while speaking, and the volume of his speech became louder. Resident 14 moved his face next to the face of the female interpreter and stated, he didn't know anything. Resident 14's face sheet indicated a [DIAGNOSES REDACTED]. Resident 14's MDS assessment, dated 11/6/16, indicated a Brief Interview for Mental Status (BIMS) score of 6 of 15 which indicated severe cognitive impairment. On 11/29/16 at 6:05 p.m., during an interview, the ADM stated on 11/23/16, CNA 1 reported she had been across the hall from Resident 14's room and noticed the stop sign was down. The ADM stated CNA 1 then went into Resident 14's room. The ADM stated CNA 1 saw Resident 14 on his bed and Resident 15 sat in a wheelchair next to the bed. CNA 1 stated she observed Resident 14's hand down Resident 15's pants. On 1/3/17 at 12:55 p.m., during a telephone interview, the Social Service Director (SSD) stated Resident 14 had a known behavior of inappropriate touching of others. The SSD stated she had been aware of Resident 14's sexual behaviors towards other residents and staff prior to the incident with Resident 15 on 11/23/16. On 1/6/17 at 12:55 p.m., during a telephone interview, Resident 14's Primary Care Physician (PCP), PCP 1 stated he was aware of the resident's long history of sexual behaviors. On 1/10/17 at 10 a.m., during a telephone interview, CNA 1 stated the time of the incident was around 3:30 p.m. CNA 1 stated she provided a clear description of the incident to the ADM, which included Resident 14's finger in Resident 15's vagina. On 1/13/17 at 3:50 p.m., during an interview, the SSD stated, for the last year, Resident 14 had continual monitoring for sexual behaviors. The SSD stated Resident 14 had a history of [REDACTED]. On 1/17/17 at 5:30 p.m., during an interview, LN 2 stated she was on duty when the incident between Resident 14 and Resident 15 occurred (on 11/23/16). LN 2 stated CNA 1 initially gave report to LN 1 and later reiterated her report to both LN 1 and LN 2. LN 2 stated CNA 1 told her, That is one visual I never want to see again. LN 2 stated she, CNA 1 and CNA 2 went to Resident 15's room where she performed an assessment of Resident 15. LN 2 stated Resident's 15 cognition was impaired to the point where she was almost child like and unable to recognize boundaries or danger. LN 2 stated Resident 14 was higher functioning than Resident 15 and knew right from wrong. LN 2 stated Resident 15 had become quieter with less rummaging and wandering behaviors since the incident. LN 2 stated Resident 15 sat in one spot for periods of time staring into space for about two days, which was unusual for her. LN 2 stated, in her opinion, the incident should have been avoided. On 3/17/17 at 8:40 a.m., during an interview, the Director of Nursing (DON) stated for the last eleven months, Resident 14 had been on one to one monitoring by staff for his sexual behaviors. The DON stated she had spoken to Resident 14's PCP about the possibility of prescribing medication to treat Resident 14's sexual behaviors. The DON stated the Interdisciplinary Team (IDT) (a team of professionals which included the SSD, who met a minimum of quarterly to discuss resident care and issues related to residents) notes dated 11/5/15 and 3/11/16, lacked an entry from the SSD. The DON stated the SSD should have revised Resident 14's care plan to add an action to protect the other residents from Resident 14's sexual behaviors and unwanted advances. The DON stated quarterly psychiatric evaluations for Resident 14 would have been appropriate, but none were done. The DON stated a psychiatric consult after every inappropriate physical contact with another resident by Resident 14 should have been done, but was not. The DON stated Resident 15's SSD and IDT notes dated 11/10/16 failed to address behaviors of Resident 14 and safety of other residents. On 3/22/17 at 4:00 p.m., during an interview, the SSD stated if the IDT had followed up on Resident 14's behavior monitoring data five times a week, as stated under corrective actions on the document, the IDT could have assessed whether staff actually complied with the one to one and every 15 monitoring of Resident 14. The SSD stated the care plan written by herself had not addressed Resident 15's behavior. Resident 14's record titled, Q (every) - 15 Minutes Visual Monitoring dated 11/23/16, indicated, columns for time, Activities/Observations, and staff initials. The columns timed from 2:15 p.m. to 3:45 p.m. did not indicate documentation of Resident 14's activities, and did not include staff initials to signify staff had made an observation of Resident 14 during those times. Resident 14's nursing progress note dated 11/23/16 at 11:02 p.m., indicated, Res (Resident 14) on alert charting for 15 min (minute) checks. Was an incident of sexual aggression today at 1515 (3:15 p.m.). A female resident (Resident 15) with dementia . they were found with his hand (Resident 14) in her crotch (Resident 15) . Resident 14's nursing care plan dated 9/9/16, indicated, RESOLVED: I sometimes have behaviors which include . [MEDICAL CONDITION], i.e . inappropriate touching. On 3/23/17 at 1:40 p.m., during an interview, the Medical Director stated he was not made aware of the incident with Resident 14 and Resident 15 until 12/14/16 (three weeks after the incident). Resident 14's Psychologist Consultation/Followup form dated 6/29/16, indicated Resident 14 was on one-to-one monitoring for sexual behavior towards female peers. Resident 14's Psychologist Consultation/Followup form dated 10/17/16, indicated under recommendations staff were to continue to monitor for sexually inappropriate behavior. The facility policy and procedure titled, Abuse Policy, undated, indicated, It is the policy of the Company to prevent the occurrence of abuse . 2. On 10/7/16 at 12:30 p.m., during an interview, the facility Ombudsman (a volunteer program who assists residents and the facility with concerns of residents and families) stated CNA 4 had reported seeing a visitor put his hands down Resident 16's pants. CNA 4 separated the visitor from Resident 16, escorted him to the ADM's office, and phoned the local police department to report an abuse occurrence. Resident 16's nursing progress notes dated 10/7/16 at 12:42 p.m., indicated, CNA witnessed visitor groping resident between legs . On 10/10/16 at 11:45 a.m., during a concurrent observation and interview with the SSD and Resident 16, the SSD stated Resident 16 had a [DIAGNOSES REDACTED]. On 10/11/16 at 11:38 a.m., during an interview, CNA 4 stated (on 10/7/16) Resident 16 sat in her wheel chair in the main corridor. CNA 4 stated she had been working in another room when she observed a visitor walk toward Resident 16 and put his hand between Resident 16's legs. CNA 4 stated she then yelled across the room for him to stop. CNA 4 and LN 5 then escorted the visitor to the ADM who escorted the visitor outside and told him to never come back. CNA 4 stated the staff were previously told the visitor had a history of [REDACTED]. CNA 4 stated staff were told if staff were not directly with the visitor, they were to keep him in their line of sight at all times. CNA 4 stated a process was set up which included the visitor was to first check himself in with the business office staff and sign the visitor registration book. CNA 4 stated the visitor was then to go to the nurses station to check in, then the staff would bring the resident he came to visit, and escort the visitor and the resident to the activity room where they could visit. On 12/19/16 at 4:32 p.m., during an interview, the ADM stated the visitor was not allowed to go into the residents' room whom he came to visit, and he could only visit from 10 a.m. to 12 p.m. The ADM stated staff were aware the visitor was to be supervised. On 1/4/17 at 12:15 p.m., during an interview, LN 5 stated on (on 10/7/16 at 9:50 a.m.) she heard CNA 4 yell, after the visitor came into the facility. LN 5 stated she went to help CNA 4 separate the visitor from Resident 16. LN 5 stated she had escorted the visitor to the ADM who escorted the visitor out the door and told him never to come back. LN 5 stated from the area where the visitor had entered the building, staff were able to observe his actions. Resident 16's MDS assessment dated [DATE], indicated Resident 16 rarely or never understood (conversations) and was unable to be understood (during conversations). The MDS assessment indicated Resident 16's memory was severely impaired. Resident 1 required extensive assistance with transfers (required staff assistance to get out of chair). The police report dated 10/7/16, indicated a report made by the facility of a visitor sexually assaulting a resident. The report indicated a member of the care center was sexually assaulted on 10/7/16. The report indicated the policeman spoke to CNA 4 (the witness), the ADM, and the visitor accused. The police were unable to converse with Resident 16. The visitor was a registered sex offender certified by Megan's Law. On 1/4/17 at 1:30 p.m., during an observation and interview, Resident 16 laid in bed covered with bed linen. Resident 16's eyes were open, but she would not answer any questions. Resident 16's nursing progress notes dated 10/7/16 indicated, CNA witnessed visitor groping resident between legs . The facility policy and procedure titled, Abuse Policy, undated, indicated, It is the policy of the Company . to prevent the occurrence of abuse .

Based on staff and family interviews, clinical record and administrative document review, the facility failed to provide supervision to prevent accidents for one sampled resident (Resident 1) as evidenced by: Resident 1 was unsupervised and unaccounted for on 6/8/15, for a period of one hour and 15 minutes (4:45 p.m. - 6:00 p.m.) during which time, she fell from her wheelchair while outside on the facility's designated smoking patio. As a direct result of her fall, and being allowed to lie unnoticed on the hot cement, Resident 1 sustained 2nd degree burns (involving the first two layers of skin causing redness, blisters, and loss of some skin) and 3rd degree burns (full tissue burn which permanently destroy the entire skin layers and extends into the tissues, muscles, or bones) to her left and right feet and to her right knee. This failure resulted in Resident 1's deep tissue burns on her feet and right knee which required prolonged (over 3 months) hospitalization for treatment and subsequent amputation of both of Resident 1's feet. Findings: On 6/10/15, an onsite visit was conducted to investigate CA 939. Resident 1's Face Sheet indicated she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment (a federally mandated comprehensive assessment of residents in a skilled nursing facility to identify each resident's functional abilities and health problems) dated 5/24/15, indicated Resident 1 required extensive physical assistance by one staff person to move into standing position from her wheelchair, and limited physical assistance by one staff person when moving to or returning from off-unit locations. The Plan of Care initiated on 2/11/15 and updated on 4/10/15, indicated Resident 1 had impaired mobility and required staff assistance to transfer and ambulate. The Activities of Daily Living (ADL) documents dated 5/1/15 to 6/8/15, indicated Resident 1 was provided limited to extensive physical assistance by one person during transfers and off-unit locomotion. Resident 1's Fall Risk Evaluation dated 3/30/15, indicated she was at high risk for falls (Score of 18 - where a score of 10 or higher indicated higher risk for falls) due to: multiple falls, visual impairment, loss of balance while standing, and decreased muscular coordination. Resident 1's Care Plan for falls dated 2/11/15, indicated, Assist with transfers and ambulation, as needed . This Care Plan was revised on 2/13/15 to include, Encourage resident to wait for assistance. On 6/10/14 at 10:15 a.m., during an interview, the Director of Nursing (DON) stated Resident 1 was found unconscious on the ground on 6/8/15 at 6:00 p.m. The DON stated staff told her they did not know Resident 1 was outside on the smoking patio. She stated staff did not know Resident 1 had fallen or how long she had been on the ground. The DON stated, It was too hot that day and stated, no one should have been allowed to go out unsupervised. During this interview, the DON was advised of the weather report for 6/8/15, per http://www.localconditions.com/weather-chowchilla-california. The temperature at 5:53 p.m. was 104 degrees Fahrenheit. During this interview, when asked to see Resident 1's licensed nurse (LN) assessment after she had fallen, the DON provided a document titled, Departmental Notes written by LN 2 on 6/8/15 at 7:08 p.m., (who was not present during the incident). LN 2 wrote, .Noticed her out of the window in smoking area lying prone (face down) on the ground with her legs twisted in her wheels of the chair . Res (Resident 1) was given a head-to-toe assessment .given cool wet cloths . vital signs were taken . when she started to wake up . Res was sent out to hospital . On 6/10/15 at 10:24 a.m., an interview was conducted with Resident 1's regular caregiver, Certified Nursing Assistant (CNA 4). CNA 4 stated when she came to work on 6/8/15 at 2:00 p.m., she saw Resident 1 at the Nurses' Station asking LN 2 for her (Resident 1's) cigarettes. CNA 4 stated, I saw (Resident 1) again while I was on my break at 4:45 p.m. She was pushing her wheelchair past the Nurses' Station . I was not sure if she was heading to the patio. CNA 4 stated dinner trays came out between 4:55 p.m. to 5:10 p.m. in the area of Resident 1's bedroom. CNA 4 stated she asked CNA 5 to help pass the dinner trays. When asked if she had checked on or provided care to Resident 1 at any time from 2:00 p.m. to 6:00 p.m., CNA 4 stated she had not. On 6/10/15 at 11:08 a.m., a telephone interview was conducted with Licensed Nurse 2 (LN 2). According to LN 2, she saw Resident 1 at the Nurses' Station when she clocked in at 2:00 p.m. and again at 4:15 p.m. when she administered her medications. When asked if she had seen or checked on Resident 1 after she had taken her medications, LN 2 stated, No, I did not. LN 2 stated she was out of the building for her break at 5:30 p.m. She stated when she came back at 6:05 p.m., she was told Resident 1 had fallen outside and was found unconscious on the ground. LN 2 stated Resident had fallen before (on 2/13/15 and 4/7/15), when she attempted to transfer herself and lost her balance. On 6/10/15 at 11:45 a.m., during an interview, CNA 3 stated Resident 1 had to be supervised, assisted, and monitored with activities of daily living (ADLs). CNA 3 stated Resident 1 was forgetful, had no safety awareness, had fallen before because she was weak on her left side. When asked to describe how the facility monitored residents who smoked on the patio, CNA 3 stated, Our policy is to bring them to the patio and stay with them even if they are independent. We help them put on their smoking apron and light their cigarettes for them. When asked to describe the facility's standard procedure for resident care during hot weather, CNA 3 stated, We would encourage our residents to stay inside the building and if they insist, we should go out with them so they could be monitored. On 6/10/15 at 1:10 p.m. during an interview, CNA 1 stated that on 6/8/15 at 6:00 p.m., she was picking up meal trays in Resident 1's room when she noticed Resident 1's meal tray had not been touched. CNA 1 stated, I peeked out from the blinds and saw Resident 1 lying on the ground on the patio. I ran out of the room and called for help. CNA 1 stated she saw CNA 2 and they both ran to the patio followed by LN 1. CNA 1 stated Resident 1 was lying on the cement on her left side with her feet criss-crossed and stuck on the wheelchair's metal footrests. During the same interview, CNA 1 stated Resident 1's eyes were closed and she did not respond to verbal command or physical stimulation. She stated Resident 1's mouth was covered with slobber (saliva or other type of fluid); her skin was very hot to touch. Her feet were purple-bluish in color, and the skin on the upper part of her right knee was torn and bloody. She stated the lower part of Resident 1's right knee was blistered. CNA 1 stated, We took her back to her room and wiped her down with washcloth until she became responsive. She stated LN 2 had called 9-1-1 and Resident 1 was taken to the hospital on [DATE] at 6:30 p.m. When asked to describe Resident 1's overall condition and functional status prior to the incident, CNA 1 stated, (Resident 1) was weak on her left side and had to be assisted during transfers from bed to chair and vice-versa. She stated Resident 1 had fallen before. CNA 1 stated Resident 1 was forgetful and had poor safety awareness, for example, she forgets to lock her wheelchair when standing up from the chair, and attempts to transfer herself without help. She stated Resident 1 had to be monitored or assisted to ensure she would not fall again. CNA 1 stated, If I didn't look out, we would not have known she had fallen on the ground, or that she was outside and alone in the heat. CNA 1 stated none of the three residents who smoked went out that day because of the extreme heat. CNA 1 stated, Someone gave her (Resident 1) a cigarette and someone knew she was outside alone. She stated the residents' cigarettes and lighters were kept in the medication room and only licensed nurses could access them. CNA 1 stated, Whoever that is, we (CNAs) should have been told so we could check on the resident! On 6/15/15 at 9:20 a.m., a telephone interview was conducted with Resident 1's responsible party (RP). The RP stated she had requested the facility to keep Resident 1 on the scheduled smoking social because she had been smoking excessively. The RP stated, I told the Social Services my (family member - Resident 1) could not and should not smoke on her own whenever she wants it. She had to be supervised or monitored or else she would be smoking all day. The RP stated, My (family member - Resident 1) is weak on her left side and had fallen before at the facility because she tried to transfer herself and she felt dizzy . more reason to supervise her .Staff did not supervise or monitor my (family member - Resident 1) as I have asked them to do. On 6/19/15 at 1:42 p.m. during a telephone interview, LN 3 stated that on 6/8/15 at 4:45 p.m., Resident 1 came to the Nurses' Station and asked for her cigarette. LN 3 stated she gave Resident 1 a cigarette and a lighter. LN 3 stated she did not warn Resident 1 that it was extremely hot outside; did not offer to accompany or assist her; did not inform any of the staff that Resident 1 was out on the patio so they could assist and monitor her; and, did not check on Resident 1 prior to leaving the facility at the end of her shift at 5:30 p.m. LN 3 stated, I did not follow through. Resident 1's fall was preventable. On 8/6/15 at 8:00 a.m., during a telephone interview, Surgeon 1 stated Resident 1 was brought to the Emergency Department (ED) on 6/8/15, with 2nd degree and 3rd degree burns on her feet and right knee. Surgeon 1 stated Resident 1 told the ED physicians (upon her arrival), that she fell face first out of her wheelchair on the facility's patio, when she attempted to pick up her cigarette and lighter which she dropped on the ground. Surgeon 1 stated Resident 1 had prolonged exposure to extremely hot cement and her feet, toes, and right knee were pretty much cooked. Surgeon 1 stated Resident 1 underwent debridement (removal of dead tissues), skin grafting (a patch of skin is transplanted to another area), amputation (surgical removal of all or part) of the toes of the left and right feet, and would eventually undergo amputation of her feet. The acute hospital record indicated Resident 1 underwent the following surgeries and procedures: 1. 6/16/15: Excision and debridement (removal and cutting away of dead tissue) of bilateral lower extremities burns with [DEVICE] placement (a technique to apply negative pressure). 2. 7/17/15: Burn excision of burns of the feet and right knee with transmetatarsal amputations (a surgical procedure to remove the forefoot in cases where the tissues in a patient's foot have been injured beyond repair) of toes 2 through 5 on the right foot and toes 1 through 5 on the left foot, with allografting (transplant of an organ or tissue from one individual to another) to the open wounds of both feet and right knee. 3. 7/23/15: Excision of bilateral lower extremity allograft with placement of autograft (transplant of tissue from one point to another of the same individual's body). 4. 8/5/15: Left foot wound excision and debridement with amputations of the tarsal bones (bones located in the midfoot and rearfoot areas) and primary closure (skin edges are sutured together); right foot wound excision (removal) and debridement, amputation (cutting) of the right great toe and all the metatarsal heads (the group of bones in the foot, between the ankle and the toes) primary closure; and, wound excision, debridement and partial closure of the right knee wound with application of a VAC (vacuum-assisted closure) dressing. The hospital document dated 9/1/15, titled, Burn Service Note indicated .Remains in the hospital, now day 86. She still has open wounds, specifically on the right knee where there is some granulating tissue (connective tissue and tiny blood vessels that form on the surfaces of a wound during the healing process), but also some fibrous tissue (containing fibers), which would not be capable of holding a graft .continuing leak (loss of fluid) from her joints because of the depth of injury . On 10/7/15 at 3:34 p.m., during a telephone interview, Resident 1's RP stated the resident remained in the Intensive Care Unit of the hospital. The RP stated Resident 1's feet were gone and her right knee was not healing. The RP stated Resident 1's physicians had recommended hospice care (for end-of-life comfort care only).