Every finding on record at Playa del Rey Center

Based on interview and record review, for one of three sampled residents (Resident 1), the facility failed to:1). Offer the first available bed to Resident 1 on [DATE], who was transferred to a general acute care hospital (GACH) on [DATE], and had waited at a Long-Term Acute Care Hospital (LTACH - a medical facility that offers care to patients who are too medically fragile for a skilled nursing facility but no longer need the care in a short term hospital), to return to the facility since [DATE] following GACH hospitalization.2). Implement its policy and procedure (P&P) titled, Transfer or Discharge, Emergency Acute Care which indicated, when the bed hold expired, the resident should be allowed to return immediately to the first available bed.3). Ensure the facility had a documented evidence of Resident 1's Notice of Transfer/ Discharge.These failures resulted in the resident not being permitted to return to the facility timely and had the potential for psychosocial harm.Findings: During a record review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), dementia (a progressive state of decline in mental abilities), quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), carrier of infectious disease, and major depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated [DATE], the MDS indicated Resident 1's cognitive (a residents thought process) skills were moderately impaired. Resident 1 required partial/ moderate assistance (helper does less than half the effort) for putting on and off footwear, lower and upper body dressing, shower/bathe self and toileting hygiene. During a review of Resident 1's Hospital Transfer Form dated [DATE] at 1:24 p.m., the Hospital Transfer Form indicated Resident 1 was sent to a general acute care hospital (GACH) via 911 (Emergency Medical Services) with abnormal vital signs (vs - blood pressure, heart rate) blood pressure was 59/62 (normal ranges between 100/60 to 120/80), and the heart rate was 160 beats per minute (heart rate per minute, normal range is 60 to 100). During a review of Resident 1's Clinical Records indicated there was no documented evidence of a Notice of Transfer Discharge. During a review of the facility's census dated [DATE], the census indicated on [DATE], the facility had the first isolation bed that was available. During an interview on [DATE] at 1:22 p.m., the Director of Business Development (DOBD) stated the GACH called the facility on [DATE] and told facility that Resident 1 was ready to return to the facility. The DOBD stated that on [DATE], the facility did not have an available isolation bed for Resident 1. During a concurrent interview and record review on [DATE] at 3:44 p.m., with the Director of Nursing (DON), the Facility's census dated [DATE] was reviewed. The DON stated the census showed that on [DATE], the facility had an available bed for a resident requiring isolation precautions for C-auris. The DON stated she did not know why the available bed was not offered to Resident 1, who had been waiting to return to the facility since [DATE]. The DON stated the available bed should have been provided to Resident 1. During an interview on [DATE] at 5:40 p.m., with the DOBD, DOBD stated that on [DATE], a bed became available. The DBD stated she did not offer the available bed to Resident 1 because another resident (unidentified [other resident]) was expected to occupy the bed. The DOBD stated the other resident was expected to be discharged from the GACH on [DATE]. However, according to the DOBD, the GACH continued to report that the other resident would be discharged on [DATE], [DATE], and [DATE] until he (other resident) was discharged on [DATE], and was readmitted to the facility. During a review of the facility's P&P titled, Transfer or Discharge, Emergency Acute Care, revised 4/2025, the policy indicated that residents transferred to an acute care setting for an emergency treatment are provided with a notice of transfer and are permitted to return to the facility. The policy stated that when the bed hold expired, the resident is allowed to return immediately to the first available bed.

Based on observation, interview, and record review, the facility failed to:Ensure the correct medication dose of ferrous sulfate (iron (FE) supplement used to treat or prevent low levels of iron in the blood, which can cause anemia [a condition where the body does not have enough healthy red blood cells]) was available and administered to Resident 19 between [DATE] - [DATE] as ordered by the physician. Ensure an open vial of Humulin R Insulin (medicine for lowering blood glucose/ blood sugar in people with Diabetes Mellitus [DM, a disorder characterized by difficulty in blood sugar control and poor wound healing] in one of three inspected Medication Carts (Med Cart 1) without an open date, was not administered to Resident 51. Remove controlled medications (prescription drugs regulated due to the risk of abuse or addiction), Morphine (medication used to treat pain), Lorazepam (medication used to treat anxiety [mental health condition involving excessive, ongoing fear or worry that interferes with daily life]) and Hydrocodone with Acetaminophen (medication used to treat pain) for Resident 4 who had been discharged from the facility, from one of three Medication Carts (Med Cart 1) These failures may result in delayed treatment or worsening of Resident 19's anemia, increased risk for Residents 51 to receive expired or deteriorated insulin that could lead to ineffective blood sugar management and possible adverse health effects and the unauthorized access or misuse of controlled medications that could pose safety risks to residents and staff. Findings: 1.During a review of Resident 19's admission Record, the admission Record indicated Resident 19 was admitted to the facility on [DATE] with diagnoses that included, Gastrostomy (G-tube) Status, GERD, and anemia. During a review of Resident 19's History and Physical (H&P) dated [DATE], the H&P indicated Resident 19 did not have the capacity to understand and make decisions.During a review of Resident 19's Minimum Data Set (MDS, a resident assessment tool), dated [DATE], the MDS indicated Resident 19's cognition (ability to think, remember, and reason) was severely impaired. The MDS indicated Resident 19 was dependent (staff does all the effort) for toileting, showering, dressing, personal hygiene, and transfers from bed to chair.During a review of Resident 19's Order Summary Report dated [DATE], the Order Summary Report indicated on [DATE], Resident 19's Physician ordered Ferrous Sulfate Oral Solution 300 (60 elemental iron [Fe]) milligram (mg, unit of measure by weight) per five (5) milliliter (ml, unit of measure by volume), give 6.8 ml (408 mg, equivalent to 81.6 mg Fe) via G-tube three times a day for supplement.During a concurrent medication administration (pass) observation and interview on [DATE] at 8:46 AM with a Licensed Vocational Nurse (LVN) 1, in Station 2 at Medication Cart 3 (Med Cart 3), LVN 1 stated she would not administer Resident 19's iron because the strength available inside of the medication was Ferrous Sulfate Oral Solution 220 (44 mg elemental iron [Fe] ) mg/5 ml. LVN 1 stated Resident 19's physician order was for Ferrous Sulfate 300 mg/5 ml. LVN 1 stated she will call Resident's physician to get clarification.During a concurrent interview and record review on [DATE] at 2:06 PM, with LVN 1, Resident 19's Nursing Progress Notes and Order Summary Report for the months of 6/2026 and 7/2026 were reviewed for the administration of Ferrous Sulfate and physician notification. LVN 1 stated Resident 19's physician clarified and changed the resident's Ferrous Sulfate order to the strength on hand Ferrous Sulfate 220 mg/ 5ml with an order to administer 7.5 ml (330 mg, equivalent to 66 mg Fe). LVN 1 stated there was no documentation to indicate Resident 19's Physician was contacted to clarify the Ferrous Sulfate order before today, [DATE]. LVN 1 stated the facility did not stock Ferrous Sulfate 300 mg/ 5ml.During a concurrent interview and record review on [DATE] at 2:31 PM, with the Director of Nursing (DON), Resident 19's Order Summary Report and Medication Administration Record (MAR) for the Months of 6/2026 and 7/2026 were reviewed. The DON stated Resident 19's MAR indicated licensed nurses documented that Resident 19 was administered Ferrous Sulfate 300 mg/ 5 ml at the ordered amount of 6.8 ml three times a day between [DATE] through [DATE]. The DON stated the facility did not have Ferrous Sulfate 300 mg/ 5 ml in stock and was not available for administration. Only Ferrous Sulfate 220 mg/ 5 ml was available in the facility. The DON stated there was no documentation to indicate the Physician was notified for Resident 19 of the facility not having Ferrous Sulfate 300 mg/ 5 ml available for administration (between [DATE] through [DATE]).During a review of Resident 19's MAR for the months of 6/2026 and 7/2026 indicated licensed nurses documented the administration of Ferrous Sulfate 300 mg/5 ml at 6.8 ml three times a day: 24 doses in 6/2026 and 62 doses in 7/2026 totaling 86 doses. Ferrous Sulfate 300 mg/5 ml was not available for administration to Resident 19 according to the DON, and licensed nurses did not administer the medication to the resident in accordance with the physician's order.A review of the facility's Policy and Procedures (P&P) titled, Medication Administration - General Guideline, dated 10/2017, the P&P indicated, Medications are administered in accordance with written orders of the attending physician . Administration. The nurse calls the Provider pharmacy for clarification prior to administration of the medication or if necessary, contacts the prescriber for clarification. This interaction with the pharmacy and/ or prescriber and the resulting order clarification is documented in the nursing notes and elsewhere in the medical record as appropriate.2. During a review of Resident 51's admission Record, the admission Record indicated Resident 51 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included, Type 2 Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 51's H&P dated [DATE], the H&P indicated Resident 51 had no decision-making capacity.During a review of Resident 51's MDS dated [DATE], the MDS indicated Resident 51 cognition (ability to think, remember, and reason) was severely impaired.During a concurrent medication area observation, record review, and interview on [DATE] at 1:58 PM with LVN 1 in Station 1 at Med Cart 1, one opened vial of Humulin R Insulin labeled for Resident 51 was observed without an open date. LVN 1 stated she did not know when Resident 51's Humulin R Insulin was first opened as there was no open date marked on the insulin box or vial. LVN 1 stated it was very important to put an open date on the insulin once opened to know when the medication would expire and to ensure Resident 51 was not administered ineffective or expired medication.During a concurrent interview and record review on [DATE] at 3:10 PM with the Regional Support Resource Nurse (RSR), Resident 51's MAR for the month of 7/2026 was reviewed. The RSR stated that it was very important to have an open date placed on insulin when first opened and placed inside of the medication cart to ensure the medication was not expired and still good to use. RSR stated the MAR indicated nurses administered two doses of Humulin R Insulin four (4) units on [DATE] at 1307 (1:07 PM), and four (4) units on [DATE] at 2005 (8:05 PM) to Resident 51.During a review of the manufacturer's labeling for HUMULIN R - insulin human injection, solution, revised 5/2025, indicated when stored at room temperature, HUMULIN R can only be used for a total of 31 days including both not in-use (unopened) and in-use (opened) storage time. Do not use HUMULIN R past the expiration date printed on the label or 31 days after you first use it.3. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 4's diagnoses included Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities) and Adult Failure to Thrive (a state of decline that is multifactorial and may be caused by chronic concurrent diseases and functional impairments). Resident 19 expired and was discharged on [DATE]. During a concurrent observation and interview on [DATE] at 2:38 PM, with LVN 1, in Station 1 of Med Cart 1, the following medications were observed inside Med Cart 1 for Resident 4: a. One unopened bottle of Morphine Solution 100 mg/5ml, quantity of 15 ml, with a fill date of [DATE].b. One unopened bottle of Lorazepam Concentrate 2 mg/ml quantity of 30 ml, stored unrefrigerated inside of the medication cart, with a fill date [DATE].c. Two bottles of Hydrocodone/Acetaminophen 5/325 mg, one bottle with a quantity of 40 out of 40 with a fill date of 3 /27/26 and the second bottle with a remaining quantity of 39 out of 40, with a fill date of [DATE].LVN 1 stated Resident 4's controlled medications should have been removed from the medication cart when the resident was discharged and no longer in the facility.During a concurrent interview and record review on [DATE] at 3:03 PM, with the RSR and the DON, Resident 4's transfer and discharge report was reviewed. RSR stated Resident 4 was documented to have expired on [DATE] at 6:03 AM. The remaining controlled medications should have been removed from the medication cart and given to the DON the same day. The DON stated discharged residents' controlled medication should be given to the DON before the end of the shift and after hours, the very next day.During a review of the facility's P&P titled, Discontinued Medications, dated 12/2018, the P&P indicated, When medications are expired, discontinued by a prescriber, a resident is transferred or discharged and does not take medications with him/her, or in the event of a resident's death, the medications are marked as discontinued or stored in a separate location and later destroyed.During a review of the facility's undated P&P titled, Controlled Substances, the P&P indicated, 22. Controlled substances remaining in the facility after the order has been discontinued or the resident has been discharged are securely locked in an area with restricted access until destroyed.23. Accountability records for discontinued controlled substances are kept with the unused supply until it is destroyed or disposed of as required by applicable law or regulation.

Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was less than five percent. Two medication errors out of 29 opportunities contributed to an overall medication error rate of 6.9%, affecting one of seven residents observed for medication administration (Resident 19).The facility failed to ensure Resident 19 was administered Omeprazole Delayed Release (DR) Capsules (a medicine that slowly releases in the body to reduce stomach acid) and Multivitamins Liquid with Minerals (supplement) in accordance with physician's orders and/ or manufacturer's specification via gastrostomy tube (G-tube, a medical device inserted through the abdomen for nutrition, fluids, or medication administration).This failure had the potential to cause Resident 19's gastroesophageal reflux disease (GERD, a condition where stomach acid frequently flows back into the tube connecting the mouth and stomach, causing heartburn and irritation) to not be properly treated, increase the chances that Resident 19 would experience an upset stomach, feel nauseous, or vomit, and may result in multivitamins with minerals being less potent.Findings:During a review of Resident 19's admission Record, the admission Record indicated Resident 19 was admitted to the facility on [DATE] with diagnoses that included, Gastrostomy (G-tube) Status, GERD, and Anemia (a condition where the body does not have enough healthy red blood cells).During a review of Resident 19's History and Physical (H&P) dated 3/12/2026, the H&P indicated Resident 19 did not have the capacity to understand and make decisions.During a review of Resident 19's Minimum Data Set (MDS, a resident assessment tool), dated 6/7/2026, the MDS indicated Resident 19's cognition (ability to think, remember, and reason) was severely impaired. The MDS indicated Resident 19 was dependent (staff does all the effort) for toileting, showering, dressing, personal hygiene, and transfer from bed to chair.During a review of Resident 19's Order Summary Report dated 7/21/2026, the Order Summary Report indicated:1. On 5/29/2026 Resident 19's physician ordered Omeprazole DR 20 mg Capsules, give 20 milligram (mg, unit of measure by weight) via G-tube one time a day related to GERD. Open capsule and mix granules with 10 milliliters (ml, unit of measure by volume) apple juice or applesauce and administer via G-tube 60 minutes prior to starting tube feeding.2. On 6/18/2026, Resident 19's physician ordered Enteral Feed Order every shift Enteral Feed - Continuous Administer (Formula): GTF (Gastrostomy Tube Feeding) - Jevity 1.5 (a high-calorie, nutritionally complete enteral formula designed for tube feeding) at a rate of 65 cubic centimeters (cc) per hour, continuously for 20 hours to provide 1300 cc/ 1949 kilocalories (kcals), G-tube ON at 2pm, OFF AT 10AM or if preset dose limit is reached.3. On 6/23/2026 Resident 19's physician ordered Multivitamin-Minerals Liquid, give 7.5 milliliter (ml, unit of measure by volume) via G-tube one time a day for supplement. a. During a medication administration (pass) observation on 7/21/2026 between 9:26 AM to 10:09 AM, with Licensed Vocational Nurse (LVN) 2 in Station 2, at Medication Cart 3 (Medcart 3), LVN 2 prepared one dose of Omeprazole 20 mg. DR for administration to Resident 19. LVN 2 paused the G-tube feeding, after checking G-tube placement and residual, LVN 2 provided an initial G-tube flush of 30 ml of water. LVN 2 proceeded to pour the omeprazole mixed with 10 ml of apple juice into the G-tube syringe (device used to push medicine or fluids into a feeding tube) to administer the medication and was not observed providing a final flush. LVN 2 disconnected Resident 19's G-tube syringe and restarted the feeding at a different port on the G-tube. During a concurrent observation and interview on 7/21/2026 at 9:59 AM, with LVN 2, LVN 2 was asked to unstack the medication cup. LVN 2 stated the Omeprazole granules had collected and become stuck inside Resident 19's G-tube syringe tip, as well as in the G-tube Lopez valve (a special medical valve used to control the flow of fluids through feeding tubes), and some medication remained inside the medication cup. LVN 2 stated she did not have water or juice to do a final flush, to ensure the medication cleared the G-tube. LVN 2 left the resident's room to obtain more fluid from the medication cart. LVN 2 stated that she usually poured apple juice or water a few times to clear the medication from the syringe to make sure the medication was completely administered through the G-tube to the resident. LVN 2 attempted to flush the G-tube with water and stated, the water was going through, but the medication was stuck inside of the G-tube valve and syringe tip.During an interview on 7/21/2026 at 10:26 AM, with the Regional Support Resource (RSR), RSR stated that she trained LVNs at the facility. RSR stated she would need to contact the pharmacy and physician for the administration of omeprazole 20 mg DR capsules via G-tube and possible alternatives.During a telephone interview on 7/21/26 at 11:10 AM, with the facility's Consultant Pharmacist (Pharm) 2, in the presence of RSR, Pharm 2 reviewed the manufacturer's instructions and stated that Omeprazole DR capsules should be administered via G-tube as follows:Administer Omeprazole through the G-tube 60 minutes prior to G-tube feedingOpen the omeprazole capsuleMix the omeprazole granules with 10 ml of apple juiceDraw up into the syringe the solutionSlow push the medication through the syringe into the G-tubeSee that all the medication clears the syringeFlush with equal amount of water, 10 ml to help clean out the tube to prevent G-tube cloggingPharm 2 stated if the resident does not receive the full dose of Omeprazole medication, the resident may experience acid reflux (when stomach acid flows back up into the esophagus, causing heartburn and discomfort).During a concurrent interview and record review on 07/23/2026 2:05 PM, with the Director of Nursing (DON), Resident 19's Order Summary Report and MAR for the months of 5/2026 through 7/2026, were reviewed. The MAR indicated Resident 19's G-tube feeding ran 20 hours a day from 2 PM until 10 AM and the Omeprazole was scheduled for 8 AM administration daily. The DON stated from 5/29/26 until 7/22/26 the facility was administering the Omeprazole incorrectly and was not given 60 minutes prior to the start of feeding. The DON stated the doctor should have been called and notified that Resident 19 was not scheduled to receive the Omeprazole 60 minutes before feeding to have the doctor order changes and provide guidance. The DON stated there was no documentation the doctor was notified that the resident was not being administered the Omeprazole 60 minutes prior to the start of feeding b. During a medication pass observation on 7/22/2026 at 8:29 AM, with LVN 1, LVN 1 prepared a total of four medications for Resident 19 that included:1. Famotidine (a medicine that slowly releases in the body to reduce stomach acid) 20 mg, tablet, one tablet2. Multivitamin with Minerals Liquid. 3. Vitamin C (Supplement) 500 mg, one tablet4. Ipratropium-Albuterol inhalation Solution 0.5-2.5 (3) MG/3MLLVN 1 was observed pouring the Multivitamin with Minerals 7.5 ml and administered the medication to Resident 19 via G-tube. LVN 1 was not observed shaking the Multivitamin with Minerals Liquid in accordance with the manufacturer's instructionsDuring an interview on 7/22/2026 at 9:25 AM, with LVN 1, LVN 1 reviewed the manufacturer labeling for Resident 19's Multivitamin with Minerals Liquid, which indicated, Shake Well Before Use. LVN 1 stated that she did not shake the Multivitamin with Minerals Liquid which could result in the medication settling at the bottom of the bottle. LVN 1 stated that she should have shaken the medication well to ensure that Resident 19 received the full dose of the medication.During an interview on 7/23/2026 at 2:23 PM, with the DON, the DON stated if the Multivitamin with Minerals Liquid was not shaken well the resident (Resident 19) would not receive the full dose of medication as ordered.A review of the facility's Policy and Procedures (P&P) titled, Medication Administration - General Guideline, dated 10/2017, the P&P indicated, Medications are administered as prescribed in accordance with good nursing principles and practices. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication .Prior to administration, the medication dosage schedule on the resident's medication administration record (MAR) is compared with the medication label.if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule.

Based on observation, interview, and record review, the facility failed to:Label one opened vial of Humulin R Insulin (medicine for lowering blood glucose/ blood sugar in people with diabetes, a condition causing high blood glucose) with the open date for Resident 51 in one of three inspected Medication Carts (Med Cart 1). 2. Ensure liquid Lorazepam (medication used to treat anxiety [mental health condition involving excessive, ongoing fear or worry that interferes with daily life]) was refrigerated and not stored in one of three inspected Medication Carts (Med Cart 1).These failures increased the risk of administering ineffective, expired or deteriorated medications to Resident 51 and Resident 4, possibly leading to adverse health effects for the residents. Findings:1. During a review of Resident 51's admission Record, the admission Record indicated Resident 51 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included, Type 2 Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 51's History and Physical H&P dated [DATE], the H&P indicated Resident 51 had no decision-making capacity.During a review of Resident 51's MDS dated [DATE], the MDS indicated Resident 51's cognition (ability to think, remember, and reason) was severely impaired.During a concurrent medication area observation, record review, and interview on [DATE] at 1:58 PM, with LVN 1 in Station 1 at Med Cart 1, one opened vial of Humulin R Insulin for Resident 51 was observed without an open date. LVN 1 stated she did not know when Resident 51's Humulin R Insulin was first opened as there was no open date marked on the insulin box or vial. LVN 1 stated it was very important to put an open date on the insulin once opened to know when the medication would expire and to ensure Resident 51 was not administered ineffective or expired medication.During an interview on [DATE] at 3:10 PM with the Regional Support Resource Nurse (RSR), the RSR stated it was very important to have an open date placed on insulin when first opened and placed inside of the medication cart to ensure the medication was not expired and still good to use. A review of the manufacturer's labeling for HUMULIN R - insulin human injection, solution, revised 5/2025, indicated when stored at room temperature, HUMULIN R can only be used for a total of 31 days including both not in-use (unopened) and in-use (opened) storage time. Do not use HUMULIN R past the expiration date printed on the label or 31 days after you first use it.2. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 4's diagnoses included Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities) and Adult Failure to Thrive (a state of decline that is multifactorial and may be caused by chronic concurrent diseases and functional impairments). Resident 19 expired and was discharged on [DATE]. During an observation on [DATE] at 2:38 PM, with LVN 1, in Station 1 of Med Cart 1, one unopened bottle of Lorazepam Concentrate 2 milligrams per milliliter (mg/ml, unit of measurement of liquid medicine strength) quantity of 30 ml was observed to be stored unrefrigerated inside of Med Cart 1, with a fill date [DATE].During an interview on [DATE] at 3:08 PM, with the RSR, the RSR stated Resident 4's Lorazepam Concentrate 2 mg/ml quantity of 30 ml should have been stored in the refrigerator and not in the medication cart upon arrival with a fill date of [DATE]. The RSR stated storing Lorazepam Concentrate 2 mg/ml inappropriately would result in a loss of potency and may be ineffective to relieve the condition in which the medication was indicated.During a review of the facility's P&P titled, Storage of Medications, undated, the P&P indicated, Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured location.

Based on observation, interview, and record review, the facility failed to ensure:Three expired health shakes were removed from refrigerator #2.One opened container of Kikkoman soy sauce was labeled with an open date in refrigerator #4.These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (any illness resulting from eating contaminated/spoiled foods). Findings:During a concurrent observation and interview on 7/21/2026 at 8:25 a.m., with the Certified Dietary Manager (CDM), of refrigerator #2, three containers of health shakes with use by date of 7/14/2026 were observed. The CDM stated the three containers of health shakes were expired according to the container label and should have been thrown away. During a concurrent observation and interview on 7/21/2026 at 8:30 a.m., with the CDM of refrigerator #4, one opened container of Kikkoman soy sauce was observed without a label indicating the opened date. The CDM stated an opened Kikkoman soy sauce was good for 30 days. The CDM stated it was important to label food items with an open date to know when it would expire.During an interview on 7/21/2026 at 8:36 a.m., with the CDM, the CDM stated providing expired food items to the residents would compromise their immune system (body's personal defense network made of cells, tissues, and organs that work together to protect you from germs, sickness, and diseases) and cause gastrointestinal (stomach) issues to residents such as diarrhea.During a review of the facility's policy and procedure (P&P) titled, Receiving, dated 2/2023, the P&P indicated, all food items will be appropriately labeled and dated either through manufacturer packaging or staff notation. The P&P indicated all food items will be stored in a manner that ensures appropriate and timely utilization.

Based on observation, interview, and record review, the facility failed to implement its infection prevention and control measures for two of six sampled residents (Residents 13 and 51) by failing to:Perform hand hygiene (washing hands or using an alcohol-based hand sanitizer), before obtaining and donning (putting on) gloves to provide care to Resident 13. Date Resident 51's foley catheter (F/C-a hollow tube inserted into the bladder to drain or collect urine) bag, to indicate when it was placed and to prompt staff to change it. These failures had the potential to result in cross contamination (transfer of harmful bacteria or viruses from one place, object or person to another) to Resident 13, prolonged F/C use, beyond the recommended change date, which increased the risk of Urinary Tract Infection ([UTI] an infection in the bladder/urinary tract) for Resident 51, and an increased risk of transmitting disease-causing organisms leading to illness for Residents 13 and 51. Findings:During a review of Resident 13's admission Record, the admission Record indicated Resident 13 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (brain disfunction due to chemical imbalance) and transient ischemic attack (stoke caused by a temporary blockage) and cerebral infarction (death of brain tissue).During a review of Resident 13's History & Physical (H&P), dated 6/20/2026, the H&P indicated Resident 13 had the capacity to understand and make decisions.During a review of Resident 13's Minimum Data Sheet (MDS), dated [DATE], the MDS indicated Resident 13 had severe cognitive (ability to think and reason) impairment. The MDS indicated Resident 13 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs and provides more than half the effort) for personal hygiene, dressing and walking. During an observation and interview on 7/23/2026 at 10:15 a.m., with Licensed Vocational Nurse (LVN) 5 in Resident 13's room, LVN 5 was observed removing gloves from the glove dispenser box on the wall and donning gloves without performing hand hygiene. LVN 5 proceeded to assist Resident 13 with his wander guard. LVN 5 stated failing to perform hand hygiene before taking gloves from the box dispenser, donning and assisting residents could lead to cross contamination and spread of infection. During a review of Resident 51's admission Record, the admission Record indicated Resident 51 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 51's diagnoses included retention of urine and benign prostatic hyperplasia (non-cancerous overgrowth of the prostate).During a review of Resident 51's Order Summary Report, dated 6/24/2026, the Order Summary Report indicated that Resident 51 has an indwelling Foley catheter and staff were to perform foley catheter care every day shift and as needed.During a review of Resident 51's Minimum Data Set (MDS), dated [DATE], the MDS indicated Resident 51 had severe cognitive impairment. The MDS indicated Resident 51 required partial/moderate assistance (Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort) for toileting hygiene, upper body dressing, personal hygiene and transfers. The MDS indicated Resident 51 had a F/C for urinating. During a review of Resident 51's History & Physical, dated 7/21/2026, the H&P indicated Resident 51 did not have the capacity to make decisions. During a review of Resident 51's Care Plan Report titled Baseline Care Plan: Resident is newly admitted to the facility, dated 6/24/2026, the Care Plan Report indicated Resident 51 is at risk for complication related to the indwelling catheter.During a concurrent observation and interview on 7/21/2026 at 9:35 a.m., with LVN 4, Resident 51's F/C bag did not indicate when the F/C was placed. LVN stated Resident 51's F/C should have been dated. Failing to date the F/C bag could lead to staff not knowing when it was placed and placed the resident at risk of infection. During a review of the facility's Policy and Procedure (P&P) titled, Handwashing/Hand Hygiene dated 9/18/2023, the P&P indicated the facility considers hand hygiene the primary means to prevent the spread of infections. The P&P indicated hand hygiene is indicated before and after contact with the resident and after contact with objects in the resident's room. During a review of the facility's P&P titled, Infection Prevention and Control, dated 5/6/2026, the P&P indicated that the objectives of the infection prevention and control policies and procedures are to: a) monitor, prevent, detect, investigate, and control infections in the facility; b) maintain a safe, sanitary, and comfortable environment for personnel, resident, visitors, and the general public; and c) provide evidence-based guidelines for infection prevention and control based on current best practices.

Based on observation, interview and record review, the facility failed to provide a safe environment by failing to ensure the laminate flooring in the lobby of the facility was in good repair and did not pose a safety risk for 25 ambulatory residents, staff and visitors.This deficient practice had the potential to cause falls, injuries, and could compromise health, safety, and well-being for residents, staff and visitors. Findings:During a concurrent observation and interview on 7/21/2026 at 10:15 a.m., with the Infection Preventionist Nurse (IP), the laminate flooring in the lobby was observed with cracks, and a raised area with an open gap. The IP stated she was aware of the gap on the floor since 7/20/2026. The IP stated the raised open gap in the lobby floor could lead to residents, staff and visitors falling and sustaining injuries. During a concurrent observation and interview on 7/21/2026 at 10:20 a.m., with the Maintenance Director (MD), the MD stated he discovered the cracked laminate flooring in the lobby on 7/20/2026. The MD stated the opening in the laminate flooring was a safety risk for residents, staff, and visitors, and safety measures such as placing a black mat over the opening needed to be done until repairs could be done. During a review of the facility's Policy and Procedures (P&P) titled, Maintenance Service dated 12/2009, the P&P indicated the facility is responsible for maintaining the building in good repair and free from hazards to protect residents, staff and visitors. The P&P indicated the facility maintenance personnel must ensure the building remains safe and operable by adhering to established safety regulations to ensure safeguarding the well-being of all individuals in the facility.

Based on interview and record review, the facility failed to identify ethnic/cultural food preferences for one of five sampled residents (Resident 110).This failure placed Resident 110 at risk for decreased oral intake, unintended weight loss, and compromised nutritional status. Findings:During a review of Resident 110's admission Record, the admission Record indicated Resident 110 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), dysphagia (difficulty swallowing), myelodysplastic syndrome (a group of diseases where the body has trouble making healthy blood cells), anemia (a condition where the body does not have enough healthy red blood cells), and rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility).During a review of Resident 110's History and Physical (H&P) dated 7/11/2026, the H&P indicated Resident 110 had the capacity to understand and make decisions.During a review of Resident 110's [NAME] Data Set (MDS, a resident assessment tool), dated 7/17/2026, the MDS indicated Resident 110 was able to understand and be understood by others. The MDS indicated Resident 110's cognition (ability to think and process) was intact. The MDS indicated Resident 110 required set up to substantial assistance (helper does more than half the effort) from staff for activities of daily living such as eating, toileting hygiene and lower body dressing. During a review of Resident 110's admission Food Preferences Interview form dated 7/17/2026, the form indicated N/A (not applicable) was documented under section for Ethnic/Religious preferences. During a concurrent interview and record review on 7/23/2026 at 8:19 a.m., with the Dietary Manager (DM), Resident 110's Dietary Profile dated 7/22/2026 was reviewed. The DM stated she documented not applicable for religious or cultural preferences, based on information from the Food Preferences Interview form completed by the kitchen Assistant Manager (AM) [on 7/17/2026]. The DM stated she did not meet with Resident 110 and was unaware that Resident 110 had cultural preferences for her meals. The DM stated it was important to interview residents to understand their religious and cultural food preferences to ensure residents' nutritional intake was maintained within acceptable parameters, such as usual or desirable body weight range and electrolyte balance.During a concurrent interview and record review on 7/23/2026 at 8:25 a.m., with the AM, Resident 110's Dietary Profile dated 7/22/2026 was reviewed. The AM stated a language barrier (Spanish) prevented the completion of certain sections of the food preferences form. The AM stated she marked N/A under section about cultural preferences because Resident 110 could not understand and answer the question. The AM stated she should have requested for an interpreter to facilitate communication with Resident 110 and help identify cultural preferences, to support the nutritional value of Resident 110's meals.During a record review of the facility's Policy and Procedure (P&P) titled, Food and Nutrition Service undated, the P&P indicated the facility commits to providing residents with nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. During a record review of the facility's P&P titled, Resident Food Preferences dated 2001, the P&P indicated the Dietary Manager will complete a Dietary Profile for residents to reflect current food preferences and nutritional needs upon admission, readmission, quarterly, annually or as needed. During a record review of the facility's P&P titled, Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol undated, the P&P indicated the facility commits to defining each resident's current nutritional status, including weight and food/fluid intake, and identifies residents with anorexia, weight loss or gain, and those at significant risk for impaired nutrition. The P&P indicated the staff, and physician to identify pertinent interventions based on the resident's identified causes, overall condition, prognosis, and personal wishes. osis, and personal wishes.

Based on interview and record review, the facility failed to ensure a written Notice of Proposed Transfer and Discharge Form was provided to the resident representative and sent to local ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) for two of five sampled residents (Resident 7 and Resident 55).This deficient practice had the potential to compromise Residents 7 and 55's due process rights related to transfer.Findings:During a review of Resident 7's admission Record, the admission Record indicated Resident 7 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 7's diagnoses included gastrostomy tube placement (GT, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia (a progressive decline in mental abilities).During a review of Resident 7's History and Physical (H&P), dated 2/12/2026, the H&P indicated Resident 7 did not have the capacity to understand and make decisions.During a review of Resident 7's Situation, Background, Assessment and Recommendation (SBAR, a communication tool used by healthcare workers when there is a change of condition among the residents), dated 3/23/2026, the SBAR indicated Resident 7 was transferred to the General Acute Care Hospital (GACH) for weakness and elevated blood sugar (amount of glucose present in the blood).During a review of Resident 7's Minimum Data Set (MDS, a resident assessment tool), dated 6/8/2026, the MDS indicated Resident 7's cognition (ability to think and process) was severely impaired. The MDS indicated Resident 7 required moderate assistance (helper does less than half the effort) from staff with oral hygiene, upper body dressing, and personal hygiene.During a review of Resident 7's SBAR, dated 6/26/2026, the SBAR indicated Resident 7 was transferred to the GACH for GT blockage or displacement.During a review of Resident 55's admission Record, the admission Record indicated Resident 55 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 55's diagnoses included congestive heart failure (CHF, a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), respiratory failure (a serious medical condition that makes it difficult to breathe on your own), and dysphagia (difficulty swallowing).During a review of Resident 55's MDS, dated [DATE], the MDS indicated Resident 55's cognition was intact. The MDS indicated Resident 55 required supervision (helper provided verbal cues and/or contact guard assistance as resident completes activity) from staff with eating, oral hygiene, and upper body dressing.During a review of Resident 55's SBAR, dated 6/15/2026, the SBAR indicated Resident 55 was transferred to the GACH for cough, congestion, and vomiting.During an interview on 7/22/2026 at 4:00 p.m. with the Medical Records Director (MRD), the MRD stated the Notice of Proposed Transfer and Discharge forms for Resident 7 when she was transferred to the GACH on 3/23/2026 and 6/26/2026 were not completed and a written copy was not provided to Resident 7's representative nor faxed to the local ombudsman office. The MRD stated the Notice of Proposed Transfer and Discharge form for Resident 55 when she was transferred to the GACH on 6/15/2026 was not completed and a written copy was not provided to Resident 55's representative nor faxed to the local ombudsman office.During an interview on 7/23/2026 at 10:02 a.m. with the Social Service Director (SSD), the SSD stated it was important to provide a written Notice of Proposed Transfer and Discharge to the resident or resident representative so they would be aware of their rights to make an appeal if they feel the resident was inappropriately transferred or discharged . The SSD stated it was important to notify and fax the Notice of Proposed Transfer and Discharge to the local ombudsman so they would be aware of the resident's location and for transparency, especially if there was an issue with abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) or neglect (failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress).During a review of the facility's policy and procedure (P&P), titled Transfer or Discharge, dated 3/2025, the P&P indicated when a resident was sent emergently to an acute care setting, the Notice of Proposed Transfer and Discharge was provided to the resident and representative as soon as practicable before the transfer and to the long-term care ombudsman.

Based on observation, interview, and record review, the facility failed to meet professional standards of quality when licensed staff failed to follow physician orders for one of seven residents (Residents 19) when Resident 19's Gastrostomy tube (G-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) was not flushed with sufficient fluid as ordered by the physician before and after medication administration.This failure placed Resident 19 at an increased risk of gastrointestinal conditions, G-tube clogging, and the potential need for additional medical interventions.Findings:During a review of Resident 19's admission Record, the admission Record indicated Resident 19 on 3/6/2026 with diagnoses that included, Gastrostomy Status, gastroesophageal reflux disease (GERD, a condition where stomach acid frequently flows back into the tube connecting the mouth and stomach, causing heartburn and irritation), and anemia (a condition where the body does not have enough healthy red blood cells).During a review of Resident 19's History and Physical (H&P), dated 3/12/2026, the H&P indicated Resident 19 did not have the capacity to understand and make decisions.During a review of Resident 19's Minimum Data Set (MDS, a resident assessment tool), dated 6/7/2026, the MDS indicated Resident 19's cognition (ability to think and process) was severely impaired. The MDS indicated Resident 19 was dependent (staff does all the effort) on staff for toileting, shower, dressing, personal hygiene, and transfer from bed to chair.During a review of Resident 19's physician order, dated 6/4/2026, the physician order indicated to flush the tube (G-tube) with 30 milliliters (ml, unit of measure by volume) of water before and after medication administration every shift. The physician order indicated to flush the tube with 5 ml of water between each medication administration every shift.During a review of Resident 19's physician order, dated 6/23/2026, the physician order indicated to administer Famotidine (a medicine that slowly releases in the body to reduce stomach acid) 20 milligrams (mg, unit of measurement) via G-tube two times a day for GERD. The physician order indicated to administer Multivitamin-Minerals Liquid 7.5 ml via G-tube one time a day for supplement. The physician order indicated to administer Ascorbic Acid (Vitamin C, supplement) Tablet 500 mg via G-tube one time a day for supplement.During a medication pass observation on 7/22/2026 at 8:29 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 prepared medication for Resident 19. LVN prepared one tablet of Famotidine 20 mg, one tablet of vitamin C 500 mg, and 7.5 mL of Multivitamin with Minerals. LVN 1 was observed not shaking the Multivitamin with Minerals Liquid in accordance with the manufacturer's instructionsDuring a concurrent medication pass observation and interview on 7/22/2026 at 9:05 a.m., with LVN 1 at Station 2's Medication Cart 3 (MedCart 3), LVN 1 flushed the G-tube with 5 ml of water and administered the first medication. LVN 1 used her fingers to squeeze the G-tube tubing and LVN 1 stated the G-tube was clogged and she would flush the tube with 30 ml of water for the medication to go through the tubing. LVN 1 administered the next two medications with a 5 ml water flush in between and a final flush of 5 ml of water. During a concurrent interview and record review on 7/22/2026 at 9:32 a.m. with LVN 1, Resident 19's physician orders were reviewed. LVN 1 stated the physician order indicated to flush the G-tube with 30 mL of water before and after medication administration. LVN 1 stated she flushed the G-tube with 5 mL of water before and after medication administration. LVN 1 stated the larger amount of water ordered by the physician was to ensure all of the medication administered cleared the G-tube line.During a concurrent interview and record review on 7/23/2026 at 2:46 p.m. with the Director of Nursing (DON), Resident 19's physician orders were reviewed. The DON stated Resident 19's physician order indicated to flush the G-tube with 30 ml of water before and after medication administration. The DON stated flushing the G-tube before administering medication was to ensure the G-tube was patent (open and not blocked), and flushing after medication administration was to ensure all the medication was administered to the resident through the G-tube. The DON stated flushing the tube with 5 ml of water was not in accordance with the physician's order.During a review of the facility's policy and procedures (P&P) titled, Medication Administration - General Guideline, dated 10/2017, the P&P indicated medications were administered in accordance with written orders of the attending physician.During a review of the facility's P&P titled, Enteral Tube Medication Administration, dated 10/2017, the P&P indicated to prepare medications for administration by following specific physician orders regarding liquid amounts.

Based on observation, interview, and record review, the facility failed to provide padded side rails for one of one sampled resident (Resident 63), who had a diagnosis of epilepsy (a brain disorder that causes repeated, unprovoked seizures [a sudden uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]), as ordered by the physician.This deficient practice had the potential to place Resident 63 at risk for injuries such as severe bruising, lacerations (deep cuts) and fractures (broken bone). Findings:During a review of Resident 63's admission Record, the admission Record indicated Resident 63 was admitted to the facility on [DATE] with diagnoses including epilepsy, cerebral infarction (a condition when the blood supply to part of the brain is blocked or reduced), and dysarthria (difficulty speaking).During a review of Resident 63's History and Physical (H&P), dated 11/20/2024, the H&P indicated Resident 63 did not have the capacity to make medical decisions.During a review of Resident 63's Care Plan titled, Resident exhibits and/or is at risk for seizure activity related to seizure disorder, dated 4/18/2025, the Care Plan goal indicated for the resident to be free of any seizure related injury, until the next review date. The Care Plan intervention included to provide padded side rails as ordered.During a review of Resident 63's Physician Order, dated 6/10/2025, the Physician Order indicated, to place padded side rails on Resident 63's bed for seizure precautions.During a review of Resident 63's Minimum Data Set (MDS, a resident assessment tool), dated 4/22/2026, the MDS indicated Resident 63's cognitive (ability to think and reason) skills for daily decision making were severely impaired. The MDS indicated Resident 63 required substantial assistance (helper does more than half the effort) from staff with toileting hygiene, upper body dressing, and personal hygiene.During an observation on 7/22/2026 at 1:55 p.m., in Resident 63's room, Resident 63's bed was observed with one-fourth side rails up (a pair of short safety guards each covering about one-fourth of a bed's length, installed on a medical or hospital bed) on both sides of the bed that were not padded. During an interview on 7/23/2026 at 9:16 a.m., with the Assistant Director of Nursing (ADON), the ADON stated Resident 63 had a seizure disorder. The ADON stated one of the seizure precaution measures was to apply pads on the side rails of the resident as ordered by the Physician. The ADON stated, Resident 63 was at risk to sustain major injury that would require hospitalization if the resident had an active seizure and her side rails were not padded.During a concurrent observation and interview on 7/23/2026 at 9:24 a.m., with the ADON, in Resident 63's room, the ADON stated Resident 63's side rails were not padded. The facility did not follow Resident 63's Physician Order for padded side rails. The ADON stated it was important to follow the plan of care for Resident 63 to provide padded side rails to ensure safety of the resident.During a review of the facility's Policy and Procedure (P&P) titled, Safety of Residents, dated 6/27/2022, the P&P indicated, to provide a safe environment for residents and facility staff.

Based on interview and record review, the facility failed to notify the physician of a significant weight loss (weight loss greater than 5 percent ([% metric unit of measurement] in one month, greater than 7.5% in three months and greater than 10% in 6 months) for one of four sampled residents (Resident 10).This deficient practice had the potential for a delay in care and services for Resident 10 and placed the resident at risk for further weight loss.Findings:During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 10's diagnoses included End Stage Renal Disease (ESRD, irreversible kidney failure) on dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney (s) have failed), and right leg below knee amputation (a surgical removal of the portion of the leg below the knee).During a review of Resident 10's History and Physical (H&P), dated 6/6/2025, the H&P indicated Resident 10's decision making capacity was intact.During a review of Resident 10's Nutritional Assessment, dated 3/10/2026, the Nutritional Assessment indicated Resident 10's weight was 121.7 pounds (lbs., metric unit of measurement for mass/weight). The Nutritional Assessment indicated Resident 10 had a significant weight loss of 11.2 lbs./8% in one month, 15.2 lbs./11% in 3 months, and 29.5 lbs./20% in 6 months.During a review of Resident 10's Minimum Data Set (MDS, a resident assessment tool), dated 3/27/2026, the MDS indicated Resident 10's cognitive (ability to think and reason) skills for daily decision making was intact. The MDS indicated Resident 10 required supervision or touching assistance from staff for eating and oral hygiene. The MDS indicated Resident 10 had a weight loss of 5% in the last month or 10% more in the last 6 months and not on physician-prescribed weight-loss regimen.During an interview on 7/22/2026 at 2:56 p.m., with the Registered Dietitian (RD), the RD stated it was not her responsibility to notify resident's physician for significant weight loss.During a concurrent interview and record review on 7/22/2026 at 4:15 p.m., with the Director of Nursing (DON), Resident 10's Progress Notes from 3/10/2026 to 3/27/2026 were reviewed. The DON stated there was no documentation to indicate nurses notified the physician of Resident 10's significant weight loss for the month of 3/2026. The DON stated the standard of practice was to notify resident's physician for any change of condition, which included significant weight loss. It was important to notify resident's physician for significant weight loss to rule out the cause of the weight loss and for the physician to make recommendations to prevent further weight loss. The DON stated significant weight loss could lead to malnutrition (the body is not getting enough calories or the right balance of nutrients to stay healthy).During a review of the facility's Policy and Procedure (P&P), titled Weight Management, undated, the P&P indicated, nursing staff will notify the attending physician and family member/responsible party in the event of resident's patterned or significant, unplanned weight loss/gain of at least 2% in a week, 5% in 30 days, 7.5% in 90 days or 10% in 180 days.

Based on interview and record review, the facility failed to monitor the behavior of one of five sampled residents (Resident 114) who were prescribed psychotropic medications (any drug that affects brain activities associated with mental processes and behavior).This deficient practice had the potential to result in inconsistent behavior monitoring and use of unnecessary psychotropic medication that could cause harm to Resident 114. Findings:During a review of Resident 114's admission Record, the admission Record indicated Resident 114 was admitted to the facility on [DATE] with diagnoses including bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), major depressive disorder (MDD, a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (a mental health condition characterized by excessive, persistent, and uncontrolled fear or worry that interferes with daily life).During a review of Resident 114's Physician Order, dated 7/10/2026, the Physician Order indicated to administer Mirtazapine (drug used to treat MDD) 30 milligrams (mg, metric unit of measurement) daily for anxiety disorder.During a review of Resident 114's Physician Order, dated 7/14/2026, the Physician Order indicated to administer buspirone (drug used to treat anxiety) 15 mg daily for anxiety disorder.During a review of Resident 114's Physician Order, dated 7/14/2026, the Physician Order indicated to administer Lurasidone Hydrochloride (drug used to treat bipolar disorder) 120 mg daily for bipolar disorder.During a review of Resident 114's History and Physical (H&P) dated 7/14/2026, the H&P indicated Resident 114 had the capacity to understand and make decisions.During a concurrent interview and record review on 7/23/2026 at 8:50 a.m., with the Assistant Director of Nursing (ADON), Resident 114's Medication Administration Record (MAR, a daily documentation record used by licensed nurse to document medications and treatments given to a resident) from 7/11/2026 to 7/22/2026, was reviewed. The ADON stated the monitoring of Resident 114's behavior for the use of psychotropic medications was not documented. The ADON stated when residents are on psychotropic medications, the licensed nursing staff should monitor for manifested behavior and document the number of behavior episodes every shift (7-3 shift, 3-11 shift, 11-7 shift) on the MAR. The ADON stated monitoring the behaviors was important because the facility could assess how effective the medication treated the resident's mental illness (a health condition that changes how a person thinks, feels, behaves, or manages their mood) and adjust the dose as needed. The ADON stated Resident 114's use of psychotropic medication was not justified because there was no behavior monitoring documentation. The ADON stated when residents on psychotropic medications were not monitored, the psychotropic medications would be considered unnecessary. The ADON stated psychotropic medications were prescribed to residents with behaviors that affect their mood and thoughts and the medications had adverse effects (undesired effect of a drug) such as tremors (involuntary shaking movement in one or more parts of the body), suicidal thoughts, and cardiac abnormalities that could be detrimental to the residents' health conditions.During an interview on 7/23/2026 at 10:35 a.m., with the Director of Nursing (DON), the DON stated for residents prescribed psychotropic medications, monitoring the resident for behaviors was important to ensure that the resident had the behavior and for the facility to attempt a gradual dose reduction (GDR, a structured, stepwise, and monitored decrease in medication dosage to determine if a resident can manage with a lower dose or discontinue the drug entirely). The DON stated the facility had an interdisciplinary team (IDT, team members from different disciplines who come together to discuss resident care) meeting with Resident 114 and the IDT did not ask about Resident 114's behavior manifestation and the reasons why the psychotropic medications were prescribed.During a review of the facility's policy and procedure (P&P), titled Psychotropic Medication Use, dated 6/2021, the P&P indicated psychotropic medications used to treat behaviors would be used appropriately to address specific underlying medical or psychiatric causes of behavioral symptoms. The P&P indicated all medications used to treat behaviors must have a clinical indication and the behavior should be monitored for efficacy.

Based on interview and record review, the facility failed to ensure a baseline care plan was developed for two of two sampled residents (Resident 110 and Resident 114) by failing to:Ensure the language and communication care plan was included in the baseline care plan for Resident 110.Ensure a baseline care plan was developed within 48 hours of admission for Resident 114.These deficient practices had the potential for Resident 110 and Resident 114's initial goals and interventions not being met which could result in a delay in care and services. Findings: 1. During a review of Resident 110's admission Record, the admission Record indicated Resident 110 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), dysphagia (difficulty swallowing), and rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility). During a review of Resident 110's History and Physical (H&P) dated 7/11/2026, the H&P indicated Resident 110 had the capacity to understand and make decisions. During a review of Resident 110's Minimum Data Set (MDS, a resident assessment tool), dated 7/17/2026, the MDS indicated Resident 110's cognition (ability to think and process) was intact. The MDS indicated Resident 110 used a walker and required substantial assistance (helper does more than half the effort) from staff for toileting, showering, lower body dressing and taking off footwear. The MDS indicated Resident 110 required partial assistance (helper does less than half the effort) from staff for mobility and was dependent (helper does all of the effort) on staff for transfers. During a concurrent interview and record review on 7/24/2026 at 7:44 a.m. with the Director of Nursing (DON), Resident 110's medical record was reviewed. The DON stated Resident 110 spoke Spanish, but the baseline care plan did not include measurable objectives, individualized care, or timeframes based on the resident's assessed needs related to language and communication. The DON stated that without a comprehensive, baseline care plan, the facility could not demonstrate that staff implemented interventions and resources, understood expectations, reduced communication barriers, or evaluated outcomes for Resident 110. 2. During a review of Resident 114's admission Record, the admission Record indicated Resident 114 was admitted to the facility on [DATE]. Resident 114's diagnoses included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (a mental health condition characterized by excessive, persistent, and uncontrolled fear or worry that interferes with daily life). During a review of Resident 114's H&P, dated 7/14/2026, the H&P indicated Resident 114 had the capacity to understand and make decisions. During a concurrent interview and record review on 7/23/2026 at 7:55 a.m., with the Minimum Data Set Nurse (MDSN), Resident 114's baseline care plan, dated 7/13/2026, was reviewed. The MDSN stated resident's baseline care plan should be developed upon admission or within 24 hours of admission. The MDSN stated Resident 114's baseline care plan was developed by facility staff 72 hours after admission. The MDSN stated it was important to develop the baseline care plan within the required timeframe in order to manage the resident's initial health conditions. During a record review of the facility's policy and procedure (P&P) titled, Care Plan - Baseline dated 8/25/2021, the P&P indicated the baseline care plan included healthcare information necessary to properly care for a resident, such as initial goals, physician and dietary orders, and therapy and social services. The P&P indicated baseline care plan was developed within 48 hours of a resident's admission. The P&P indicated the baseline care plan included the minimum healthcare information to properly care for a resident including initial goals based on admission orders or physician order.

Based on observation, interview, and record review, the facility failed to cover the foley catheter (a tube used to drain urine) bag for one of six sampled residents (Resident 51)This deficient practice had the potential to affect Resident 51's dignity because other people could see the content of the foley catheter bag.Findings:During a review of Resident 51's admission Record, the admission Record indicated Resident 51 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 51's diagnoses included retention of urine (inability to fully empty the bladder) and benign prostatic hyperplasia (non-cancerous overgrowth of tissue around the prostate).During a review of Resident 51's physician order, dated 7/21/2026, the physician order indicated Resident 51 had an indwelling Foley catheter and staff were to perform foley catheter care every day shift and as needed.During a review of Resident 51's Minimum Data Set (MDS, a resident assessment tool), dated 7/15/2026, the MDS indicated Resident 51's cognition (ability think and process) was severely impaired. The MDS indicated Resident 51 required partial assistance (helper does less than half the effort) from staff for toileting hygiene. The MDS indicated Resident 51 required substantial assistance (helper does more than half the effort) from staff for toilet transfer. The MDS indicated Resident 51 has an indwelling catheter.During a concurrent observation and interview on 7/21/2026 at 9:35 a.m. in Resident 51's room with Licensed Vocational Nurse (LVN) 4, there was no privacy cover over Resident 51's foley catheter bag. LVN 4 stated there should be a privacy cover over the foley catheter bag to protect the resident's privacy and dignity. LVN 4 stated if there is no privacy bag, the catheter bag was exposed and other people could see the contents, which would affect the resident's dignity. During a review of the facility's policy and procedure (P&P) titled, Dignity Residents Rights, dated 10/2025, the P&P indicated, staff were expected to promote dignity and assist residents by helping the resident keep their urinary catheter bags covered.

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool) was completed accurately for one of 24 sampled residents (Resident 10) by failing to encode Venlafaxine (a drug used to treat major depressive disorder [MDD, a mood disorder that causes a persistent feeling of sadness and loss of interest] and other chronic pain conditions) as an antidepressant medication.This deficient practice resulted in the transmission of inaccurate data to the Centers for Medicare and Medicaid (CMS) and had the potential to negatively affect the plan of care and delivery of care and services for Resident 10.Findings:During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 10's diagnoses included End Stage Renal Disease (ESRD, irreversible kidney failure) on dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), and right leg below knee amputation (a surgical removal of the portion of the leg below the knee).During a review of Resident 10's History and Physical (H&P), dated 6/6/2025, the H&P indicated Resident 10's decision making capacity was intact.During a review of Resident 10's Physician Order, dated 2/2/2026, the Physician Order indicated to administer Venlafaxine hydrochloride 37.5 milligrams (mg, metric unit of measurement) by mouth daily for neuropathic pain (nerve pain causing numbness or weakness in the hands and feet).During a review of Resident 10's MDS, dated [DATE], the MDS indicated Resident 10's cognition (ability to think and process) was intact. The MDS indicated Resident 10 required substantial assistance (helper does more than half the effort) from staff with toileting hygiene, upper body dressing, and personal hygiene.During a concurrent interview and record review on 7/23/2026 at 8:08 a.m. with the Minimum Data Set Nurse (MDSN), Resident 10's MDS, dated [DATE], was reviewed. The MDSN stated Resident 10's MDS assessment was completed inaccurately. The MDSN stated there should be a check marked on Section N0415 (High-Risk Drug Classes: Use and Indication) C (Antidepressant). The MDSN stated per the Resident Assessment Instrument (RAI, a guide that nursing home staff use to assess residents and develop care plans) manual coding of medications, the medication should be based on the pharmacological (relating to the use of drugs to treat a condition) classification of the medication, not based on the reason it was being used. The MDSN stated it was important to have an accurate MDS assessment to provide the care needed by the residents. The MDSN stated the MDS was a tool used by the facility for reimbursement and reflected the residents' plan of care.During an interview on 7/23/2026 at 10:13 a.m. with the Director of Nursing (DON), the DON stated the MDS assessment captured the residents' health conditions and if the MDS assessment was not completed accurately, the facility staff would not be able to take care of the residents appropriately.During a review of the facility's policy and procedure (P&P), titled Resident Assessments, dated 10/2023, the P&P indicated all persons who completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information.

Based on observation, interview and record review, the facility failed to provide a minimum of 80 square feet (sq. ft., unit of measurement) per resident for 23 out of 38 resident rooms (rooms 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 22, 23, 24, 28, 29, 30, 31, 32, 33, 35, and 36). The 23 resident rooms consisted of 3 bed capacity rooms. This deficient practice had the potential to negatively impact the quality of care and ability to safely provide care and privacy to the residents. Findings:During an interview on 7/23/2026 at 10:00 a.m., with the Director of Operations (DOO), the DOO stated there were 23 rooms in the facility that did not have the required 80 sq. ft. of space per resident. The facility had a room waiver (a permit approved by Centers for Medicare and Medicaid Services for rooms that did not meet the regulation requirement) in place, and would like to request an additional waiver this year. The DOO stated the room size had no impact on the care and safety of the residents. The DOO stated 20 out of the 23 rooms listed in the 2025 room waiver did not match the residents identified in the 6/13/2026 census.During a review of the facility's Client Accommodations Analysis form, dated 7/23/2026, the form indicated the facility had 23 rooms (rooms 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 22, 23, 24, 28, 29, 30, 31, 32, 33, 35, and 36) that measured less than the required 80 sq. ft. per resident in multiple bed capacity rooms. During a review of the facility's request for room waiver, dated 7/22/2026, the waiver indicated the arrangement of the rooms provided adequate space for nursing care, wheelchair access, and did not adversely affect the health and safety of the residents. The request indicated the following resident bedrooms measured 228 sq. ft. with three residents (76 sq. ft. per resident):Rooms 2, 3, 4, 5, 6, 7, 8, 9, 10,11, 12, 13, 22, 23, 24, 28, 29, 30, 31, 32, 33, 35 and 36. During the survey, from 7/21/2026 to 7/24/2026, there were no observed adverse effects as to the adequacy of space, nursing care, comfort, and privacy of residents. The residents residing in the affected rooms 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 22, 23, 24, 28, 29, 30, 31, 32, 33, 35 and 36 with an application for variance were observed to have enough space to move freely inside the rooms. There was adequate room for the operation and use of wheelchairs, walkers, or canes. The room variance did not affect the care and services provided to the residents when nursing staff were observed providing care to the residents. During a review of the facility's Resident census from the last Health Recertification Survey with exit date of 6/13/2025, the Census indicated the residents that occupied rooms 2, 3, 4, 5, 7, 8, 10, 11, 12, 13, 22, 23, 28, 29, 30, 31, 32, 33, 35, and 36 were not the same residents that occupied the rooms during the current Health Recertification survey from 7/21/2026 to 7/24/2026.

Based on observation, interview, and record review, the facility failed to ensure the annual recertification survey (an unannounced, comprehensive inspection conducted on-site by California Department of Public Health [CDPH, state licensing and certification agency] to evaluate nursing home's compliance with federal health and safety compliance) and abbreviated survey (complaints or facility reported incidents) results for the previous three years were posted in a location readily accessible to the residents and public.This deficient practice placed the residents, family members, and visitors at risk of not knowing the status of the facility's non-compliance outcome results and past performance history.Findings:During an observation on 7/22/2026 at 9:15 a.m. of the facility's hallway consumer bulletin board, a sign indicated the survey binder was at the lobby.During an observation on 7/22/2026 at 9:18 a.m. of the facility's lobby, the survey binder was not found.During a concurrent interview and record review on 7/22/2026 at 9:23 a.m. with the Director of Operation (DOO), the facility's sign and survey binder were reviewed. The DOO stated the survey binder was kept in the Administrator's office and not easily available to the residents, visitors, staff, or the public. The DOO stated there was no survey binder available at the facility's lobby. The DOO stated the survey binder that was available at the Administrator's office did not include the last year's (2025) recertification survey results conducted by the CDPH. The DOO stated the survey binder should be available and easily accessible to the public so they could review the deficiencies identified by the CDPH and the facility's plan of correction to improve resident's quality of care and to avoid future repeat deficiencies.During a review of the facility's policy and procedure (P&P) titled, Examination of Survey Results, dated 4/2017, the P&P indicated survey reports and plans of correction were readily accessible to the resident, family members, resident representatives and to the public.During a review of the facility's P&P titled, Resident Rights, dated 10/2025, the P&P indicated Federal and State laws guarantee basic rights to all residents of the facility which included the right to examine survey results.

Based on interview and record review, the facility failed to ensure one of 3 residents (Resident 1) who suffered weight loss received adequate nutrition by failing to:Carry out the Registered Dietitian's (RD, a licensed healthcare professional specialized in providing nutrition therapy to help residents meet their health needs) nutritional recommendations.Administer the correct gastric tube feeding (GT, a tube surgically placed directly into the stomach to administer liquid feeding and medications) formula, as recommended by the RD.These failures had the potential to result in the resident's continued weight loss, leading to complications like malnutrition, dehydration, including hospitalization.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 's diagnoses included gastrostomy tube (GT, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), muscle weakness, anemia (low iron in the blood) and hypotension (low blood pressure). During a review of Resident 1 's History and Physical undated the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident1 's Orders Summary Report dated 6/9/2026 to 6/30/2026, the Order Summary Report indicated on 6/9/2026, the GT feeding order of Jevity 1.2 was 50 milliliters (ml, unit of measurement) per hour (ml/hr) to provide 1200 calories in 24 hours. On 6/30/2026, the order was changed to Jevity 1.5 at 65 ml/hr to provide 1949 calories in 24 hours. During a review of Resident 1's Care Plan titled, Resident has an enteral (GT) feeding tube to meet nutritional needs (dysphagia [difficulty swallowing]), initiated on 6/10/2026, the interventions indicated dietary evaluation and monitoring. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 6/16/2026, the MDS indicated Resident 1 had severe cognitive impairment. Resident 1 was dependent (Helper does all the effort) with staff for all activities of daily living (dressing, bathing, toileting, and hygiene). Resident 1 was dependent with oral, toileting and personal hygiene, shower/ bathing self, lower body dressing. During a review of Resident 1's Registered Dietitian's (RD) Nutritional assessment dated [DATE], the assessment indicated Resident 1's enteral feeding order was Jevity 1.2 was at 50 cc/hr. The assessment indicated that the RD recommended to change GT feeding to Jevity 1.5 at 65 ml/hr to provide 1949 calories in 24 hours due to underweight and the current GT feeding could not meet the resident's nutritional needs for weight gain, Pro-Stat (a concentrated liquid protein supplement) 30 ml 3 times per day, Feso4 (Iron supplement) 325 mg daily, Zinc (vitamin supplement) 50mg daily, Vitamin C (vitamin supplement) 250 mg daily, Juven (a nutritional supplement used for wound healing) 2 packets daily and a multivitamin. During a review of Resident 1's RD progress notes dated 6/23/2026 at 2:04 p.m. (one week after), the progress note indicated Resident 1's GT feeding was still Jevity 1.2 rate at 50 ml/hr. due to formula shortage (Jevity 1.5). RD's progress notes indicate Resident 1 remained underweight. During a review of Resident 1's RD progress notes dated 6/30/2026 at 11:44 a.m., the progress notes indicated Resident 1 remained underweight. During concurrent interview and record review on 6/16/2026 at 11:00 a.m., with the RD, the dietary recommendations dated 6/16/2026 and 6/23/2026 were reviewed. The RD stated the RD recommendations dated 6/16/2026 (Jevity 1.5 at 65 ml/hr) were not carried out and fell through the cracks (missed). The nurse assigned to carry out the RD recommendations was on vacation. During a concurrent interview and record review on 6/15/2026 at 2:00 p.m., with the Director of Nurses (DON), Resident 1's Nutrition Progress Notes and Order Summary for June 2026, were reviewed. The DON stated that the RD's recommendation to increase the GT feeding and supplements were not ordered and were not followed up or ordered, placing Resident 1 at risk for additional weight loss and nutritional decline. The DON stated not following through a dietary recommendation was against the facility's policy (unspecified). During a review of the facility's Policy and Procedure (P&P) titled, Enteral Nutrition, dated 11/2018, the P&P indicated, enteral nutrition was ordered by the provider based on the recommendations of the dietitian. The nurse should confirm that orders for enteral nutrition are complete. The P&P indicated the Central supply was responsible for ordering all tube feeding supplies. Staff may use products from a basic formulary until specialized products are delivered.

Based on observation, interview and record review, the facility failed to ensure, one of three sample residents' (Resident 1), received the therapeutic diet (meal plan prescribed by a healthcare professional [doctor or dietitian] to manage a specific medical condition, treat an illness, or improve overall health) ordered by the physician. This deficient practice resulted in Resident 1's high blood sugar levels, placing the resident at risk for complications like diabetic coma (life-threating, temporary state of unconsciousness caused by extreme high blood sugar levels).Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included type 2 diabetes mellitus (DM, chronic condition where the body resists insulin or fails to produce enough, causing high blood sugar levels) and muscle weakness. During a review of Resident 1's History and Physical (H&P) dated 11/27/2025, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 4/10/2026, the MDS indicated Resident 1 was able to understand and be understood by others. The MDS indicated Resident 1 was independent for eating, oral hygiene and toileting hygiene. Resident 1 required supervision (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with shower and bathing self. Resident 1 required setup or clean up assistance (helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity.) with upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. Resident 1 required set up or clean up assistance with rolling from left to right, and supervision from sitting to lying position, lying to sitting on side of the bed. Resident 1 required setup or clean up assistance for sitting to stand, chair/bed to chair transfer, and supervision for toilet transfer, tub/shower transfer, walk 10 feet, and walk 50 feet with two turns. During a review of Resident 1's Order Summary dated 6/8/2026, the Order Summary indicated Carbohydrate Controlled Diet (CCHO, meal plan designed to manage blood sugar, especially for diabetes, by eating roughly the same amount of carbohydrates at the same time each day), Regular Texture (normal, everyday food, no blending or chopping needed,) thin consistency (regular liquids that flow freely), vegetarian (a selection of food and drink that excludes all animal flesh, including meat, poultry, and seafood). During a review of Resident 1's Care Plan titled, Insulin therapy, dated 6/20/2026, the interventions included to encourage compliance with prescribed diet, medications and blood glucose monitoring. During a concurrent observation and interview on 7/1/2026 at 12:10 p.m., with Resident 1, in Resident 1's room, the meal ticket on the breakfast and lunch tray dated 7/1/2026 was observed. The breakfast meal ticket did not indicate the ordered CCHO, regular texture, thin consistency, vegetarian diet (lacto [(lactose) relating to milk]/ovo [plant-based diet that excludes all meat, poultry, seafood, and dairy products, but allows the consumption of eggs]). The breakfast tray had breakfast slider, two fried eggs, and hashbrowns. The lunch tray had brown rice, green beans, tofu with sliced carrots and one white cake with jelly. Resident 1 stated she asked the kitchen not to give her potatoes because of too many carbohydrates. Resident 1 stated her meal ticket did not indicate no potatoes today. During a concurrent interview and record review on 7/1/2026 at 1:11 p.m. with Dietary Manager, the Dietary Manager stated the Order Listing Report dated 7/1/2026 indicating CCHO diet regular texture, thin consistency, vegetarian (lacto/ovo) did not reflect in the breakfast and lunch meal tickets on 7/1/2026. The Dietary Manager stated the order listed and the meal tickets did not match. The Dietary Manager stated the information entered in their system was not printing both diets in the resident's meal ticket. During interview on 7/1/2026 at 2:45 p.m., Licensed Vocational Nurse (LVN 1), LVN 1 stated Resident 1's blood sugars for the month of July, before meals and at nighttime, ranged from 105 milligram/deciliter (milligram [mg]/deciliter [dL] unit of measure) to 400 mg/dL (normal range 70 to 99 mg/dL). LVN 1 stated Resident 1 did not receive the prescribed CCHO diet had led to elevated blood sugar levels. If Resident 1's blood sugar was not managed properly, it could lead to diabetic coma. During a concurrent interview and record review on 7/2/2026 at 11:45 p.m., with Registered Dietitian (RD), the breakfast and lunch meal tickets dated 7/1/2026, Order Listing dated 7/1/2026 and Therapeutic Spreadsheet week 4, was reviewed. RD stated the spreadsheet indicating CCHO diet indicated no hashbrown should be served. RD stated Resident 1's meal ticket did not reflect the physician's orders per the Order Listing and Resident 1 was not served CCHO servings as per Therapeutic Spreadsheet. RD stated the increase of carbohydrates could lead to elevated blood sugar levels. During a review of the facility's Policy & Procedure titled, Therapeutic Diets, dated 10/2017, the P&P indicated the facility therapeutic diets are prescribed by the Attending Physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. A therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet such as diabetic/calorie-controlled diet. The P&P indicated diet order should match the terminology used by the food and nutrition services department.

Based on interview and record review, the facility failed to implement its Policy and Procedure (P/P) titled, Emergency Procedure -Cardiopulmonary Resuscitation (CPR- an emergency procedure to restart a person's heart and breathing after one or both suddenly stop) which indicated staff are trained to initiate CPR, BLS (Basic life Support-medical care for residents experiencing cardiac arrest [when the heart stops beating] or respiratory distress [difficulty in breathing), and defibrillation ([Automated External Defibrillation (AED)- an electrical current to help your heart return to a normal heart beat in someone experiencing cardiac arrest or severe arrhythmias [improper beating of the heart), for one of one sampled Resident (Resident 1), who had a full code status (when a medical personnel performs life-saving measures in a medical emergency), was observed unresponsive in bed as evidenced by: 1. On [DATE] at 4:10 p.m., a Certified Nursing Assistant (CNA) 1 observed Resident 1 was not breathing, and left the resident unattended in the resident's room, to notify the Registered Nurses (RN) 1 and 2. 2. CNA 1 did not activate code blue (emergency code that alerts staff that a resident is experiencing a life-threatening medical emergency such as a cardiac arrest) as soon as he (CNA 1) observed Resident 1 unresponsive. 3. CNA 1 did not check Resident 1's vital signs including the resident's pulse when the resident was found unresponsive. 4. RN 2 and Licensed Vocational Nurse (LVN) 1 initiated CPR on Resident 1 but did not use the defibrillator. 5. RN 1 was not knowledgeable on how to use the defibrillator. These deficient practices resulted in Resident 1's death and placed 86 residents who had full code statuses, at risk of not receiving timely life saving measures. On [DATE] at 5:31p.m., the Administrator (ADM), and Director of Nursing (DON) were notified of an Immediate Jeopardy (IJ- a situation on which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm impairment, or death to a resident) was called for the facility's failure to implement its P/P during a medical emergency (cardiac arrest) for Resident 1 . The ADM and DON were notified of the seriousness of all residents' health and safety were at risk due to staff's failure to implement their P/P titled, Emergency Procedure-CPR during a code situation. The facility needs a system in place to ensure: 1. Staff are trained and aware of all emergency procedures including the use of a defibrillator when a resident becomes unresponsive. 2. Staff are knowledgeable on how to care for a full code resident who becomes unresponsive. 3. Staff initiates code blue as soon as a resident is observed unresponsive. An IJ removal plan (an intervention to immediately correct the deficient practices) was requested. On [DATE] at 1:14 p.m., the facility submitted an acceptable IJ removal plan. After onsite verification if the IJ Removal Plan was implemented through interviews, and record reviews, the IJ was removed on [DATE] at 2:43 pm, in the presence of the ADM and the DON. The IJ Removal Plan included the following: 1.On [DATE] the DON provided a 1:1 in-service (an instructor provides one on one instruction and education to a staff on a specific topic or skill) to CNA 1 on the P/P on Emergency Procedure -CPR with emphasis on not leaving resident unattended during a code blue, activating a code blue as soon as a resident is observed unresponsive, and checking vital signs including BP, O2 Sat when a resident is observed unresponsive. 2.On [DATE] the DON provide a 1:1 in-service to RN 2 on the P/P on Emergency Procedure - CPR with emphasis on not leaving resident unattended during a code blue, activating a code blue as soon as a resident is observed unresponsive, checking vital signs including BP, O2 Sat and blood sugar levels for diabetic (someone who has diabetes mellitus [DM]- a disorder charactered by difficulty in blood sugar control and poor wound healing) residents. 3.On [DATE] the DON provide a 1:1 an in-service to LVN 1 on the P/P on Emergency Procedure - CPR with emphasis on not leaving resident unattended during a code blue, activating a code blue as soon as a resident is observed unresponsive, checking vital signs including BP, O2 Sat and blood sugar levels for diabetic residents. 4.On [DATE], the DON initiated an in-service to licensed nurses on the P/P on Emergency Procedure - CPR with emphasis on not leaving resident unattended during a code blue, activating a code blue as soon as a resident is observed unresponsive, checking vital signs including blood pressure BP, O2 Sat and blood sugar levels when a resident is observed unresponsive. 5.DON/Designee will review the daily assignment sheet of each shift to ensure each licensed nurse has been in-serviced with the P/P on Emergency Procedure-CPR and the skills competency for CPR prior to start of their shift. All in-services will be completed by [DATE]. 6.On [DATE], the DON initiated an in-service to CNAs on the P/P on Emergency Procedure- CPR with emphasis on not leaving resident unattended during a code blue, activating a code blue as soon as a resident is observed unresponsive and to initiate to check vital signs including blood pressure, O2 Sat when a resident is observed unresponsive. 7.On [DATE], a licensed clinical CPR instructor will train and certify the CNAs for CPR. All CNAs will be CPR certified by [DATE]. 8.DON/Designee will track the licensed nurses and CNAs that have been in-serviced based on the daily assignment sheet of each shift to ensure each licensed nurse and CNA have been in-serviced. 9.On [DATE] and ongoing, the DON provided an in-service to licensed nurses on the P/P on Emergency Procedure-CPR with the use of AED (defibrillator). 10.Licensed nurses and CNAs who are off, on leave of absence, and on vacation, will be in-serviced prior to the start of their scheduled shift. 11.The DON/Designee will utilize the active roster list for licensed nurses and CNAs to check if they have been in-serviced. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included DM with ketoacidosis (a life-threatening complication of DM in which acids build up in the blood) and hyperglycemia (a condition where the level of sugar in the blood is too high), Hypertension (HTN-high blood pressure) and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 1's Physician order for life sustaining treatment ([POLST] a written medical order from a physician, nurse practitioner or physician assistant that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness) dated [DATE], the POLST indicated Resident 1 was Full Code. POLST indicated to attempt resuscitation/CPR with full treatment with primary goal of prolonging life by all medical effective means. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated [DATE], the MDS indicated Resident 1's had the ability to make self-understood and to understand others. The MDS indicated Resident 1 required partial/moderate assistance (staff lifts, holds, or supports trunk or limbs but provides less than half the effort) for activities of daily living (ADLs-routine tasks/activities) such as toileting hygiene, showering/bathing and lower body dressing. During a review of Resident 1's LAFD (Los Angeles Fire Department) Patient Care Record dated [DATE] at 4:16 p.m., the record indicated paramedics (EMS-Emergency Medical Services) were dispatched to the facility on [DATE] at 4:18 p.m., for Resident 1 who was in cardiac arrest and EMS arrived on scene at the facility on [DATE] at 4:25 p.m. The record indicated Resident 1 was found not breathing, without a pulse and facility staff performed chest compressions without using an AED for Resident 1 prior to EMS arrival. The record indicated, Resident 1's blood sugar level was high at 500 milligrams per liter ([mg/dl] unit of measurement [reference target range 80-180 mg/dl]). The record indicated Resident was pronounced dead on [DATE] at 4:47 p.m. During a review of Resident 1's Progress Notes, dated [DATE] at 4:47 p.m., the Progress Notes indicated on [DATE] at 4:10 p.m., CNA 1 went to Resident 1's room and observed Resident 1 was not breathing, and CNA 1 notified RN 1 and RN 2 (at the nurse's station). The Progress Notes indicated RN 2 initiated CPR on Resident 1, and the paramedics arrived at the facility around 4:17 p.m. During an interview on [DATE] at 10:03 a.m., with EMS staff (EMS 1), EMS 1 stated, when the EMS team responded to the facility's emergency call for Resident 1 who suffered a cardiac arrest, RN 1, could not provide the last set of vital signs and blood sugar level taken during the code blue for the resident and staff did not use the AED. During a telephone interview, on [DATE] at 2:46 p.m. with RN 1, RN 1 stated, CNA 1 came to the nurse's station and told him (RN 1) that Resident 1 was not breathing. RN 1 stated he sent RN 2 and LVN 1 who were also at the nurse's station to go and assess Resident 1. RN 1 stated he (RN 1) activated the code blue system and called 911. RN 1 stated he did not perform CPR on Resident 1 but other staff did. RN 1 stated he did not see facility staff (RN 2, LVN 1 and CNA 1) using the AED for Resident 1. RN 1 stated he did not know how to use the AED, and he had not been trained on how to use AED during CPR. During an interview on [DATE] at 3:35 p.m., with RN 2, RN 2 stated, on [DATE] at around 4:00 p.m., while he was at the nurse's station, CNA 1 came and said Resident 1 was not breathing, RN 2 stated he (RN 2) went to Resident 1's room with LVN 1, and he (RN 2) assessed the resident. RN 2 stated, Resident 1 had no pulse and was not breathing, so he (RN 2) started chest compressions (part of CPR performed when someone's heart stops beating) on Resident 1, while another staff (LVN 1) was assisting with the Ambu bag (a hand-held device used to provide ventilation [moving air into and out of the lungs] to someone who are struggling to breathe or have stopped breathing). RN 2 stated the paramedics arrived at around 4:17 pm and pronounced Resident 1 dead at around 4:47 pm. RN 1 stated the facility staff did not remember to use the AED on Resident 1 during CPR. During an interview on [DATE] at 4:40 p.m., with CNA 1, CNA 1 stated he was on his way to Resident 1's room, when Resident 1's roommate came out of the room and told him (CNA 1) to look at Resident 1, because the resident was not looking good. CNA 1 stated he observed Resident 1 was not breathing. CNA 1 stated he left Resident 1 in bed, did not activate code blue and went to the nurse's station to inform the RN supervisor (RN 1). CNA 1 stated he returned to Resident 1's room and assisted other staff perform CPR on Resident 1. CNA 1 stated staff did not use the AED on Resident 1 during the code blue. During a concurrent interview and record review on [DATE] at 10:03 am with the DON, Resident 1's Weights and Vitals Summary was reviewed. The DON stated staff were required to assess residents during a code blue including the complete vital signs as well as the blood sugar, especially if the resident was diabetic. The DON stated the last documented pulse, BP and respiration for Resident 1 were on [DATE] at 9:58 a.m., [DATE] at 9:59 a.m. and [DATE] at 1:30 p.m. sequentially. The DON stated the last blood sugar check was done on [DATE] at 9:51 p.m. During a subsequent interview on [DATE] at 10:00 a.m. with the DON, the DON stated any staff who found a resident in bed unconscious or not breathing should not leave the resident unattended, should immediately call for help from the resident's room, initiate code blue and start CPR. The DON also stated staff in the facility were not trained in the use of an AED and did not use it when performing CPR on Resident 1 on [DATE]. During a review of the facility's P/P titled, Emergency Procedures- Cardiopulmonary Resuscitation dated 2001, the P/P indicated Personnel have completed training on the initiation of CPR and BLS, including defibrillation, for victims of cardiac arrest. The P/P indicated all clinical staff members should obtain and maintain certification in BLS/CPR that adheres to the American Heart Association guidelines. The P/P indicated Adult BLS Sequence for Healthcare Providers included to: 1.Ensure scene safety 2. Check for response 3.Shout for nearby help/activate the resuscitation team (Code Blue) a. The provider can activate the resuscitation team at this time or after checking for breathing and a pulse. 4. Check for no breathing or only gasping and check pulse (ideally simultaneously) 5. Immediately begin CPR. 6. When the second rescuer arrives, provide 2-rescuer CPR.

Based on interview and record review the facility failed to ensure one of three sampled residents (Resident 1) was free from sexual abuse. On 8/23/2023, Resident 2 was found by Certified Nurse Assistant (CNA) 2, inside Resident 1's room, touching Resident 1 on her thighs and Resident 1 stated Resident 2 touched her (Resident 1) vagina. This failure resulted in Resident 2 going into Resident 1's room and touched Resident 1 on her thighs and vagina. Resident 1 felt scared, anxious, had trouble sleeping, had difficulty relaxing, and does not feel safe at the facility. Findings: a. During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's diagnoses included epilepsy (a sudden alteration of behavior due to temporary changes in the electrical functioning in the brain), legal blindness (eyesight is diminished and not able to see), hemiplegia right side (paralysis that affects only one side of your body). During a review of Resident 1's History and Physical (H&P), dated 7/31/2023, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS] a comprehensive assessment and care-screening tool), dated 8/2/2023, the MDS indicated Resident 1's cognitive (ability to learn, reason, remember, understand, and make decisions) skills was moderately impaired. The MDS indicated Resident 1 did not exhibit hallucinations (a false perception of objects or events involving your senses) and delusional (something a person believes and want to be true, when it is not true) behaviors. The MDS indicated Resident 1 required extensive assistance for activities of daily living (ADL) including eating, personal hygiene, and dressing. During an interview on 8/25/2023 at 9:15 a.m., with Resident 1, Resident 1 stated Resident 2 came into her room about a week ago (unable to recall exact date and time) touched her feet and heard her (Resident 2) talking and mumbling words. Resident 1 stated there was another incident (on 8/23/2023) while Resident 1 was sleeping, Resident 1 stated I felt her (Resident 2's) finger in my vagina. Resident 1 stated, she was legally blind and can only see shadows but heard Resident 2's voice while she was touching her vagina, and it was the same voice of the person who touched her feet. Resident 1 stated, she was scared, shouted for help and someone (CNA 2) came and removed Resident 2 from her room. Resident 1 stated, she had trouble sleeping and it was hard to relax, since the lady (Resident 2) came into her room and inappropriately touched her. During a concurrent interview and record review on 8/25/2023 at 10:50 a.m., with the Social Worker (SW), Resident 1's SW Progress Notes, dated 8/23/2023 was reviewed. The SW Progress Notes indicated on 8/23/2023, the SW checked in with Resident 1 regarding a report of abuse. The SW progress note indicated Resident 1 verbalized feeling anxiety about the situation (Resident 2 touching Resident 1 inappropriately). The SW progress note indicated Resident 1 does not know if she feels safe at the facility. The SW stated, Resident 2 had severe dementia (the loss of thinking, remembering, and reasoning), known to be a wanderer (someone who often travels from place to place, especially without any clear aim or purpose), and goes into residents' rooms. The SW stated, Resident 2 required one to one supervision since Resident 2 touched Resident 1. The SW stated it was important to make sure residents who were wandering were kept safe, and ensure other residents were kept safe from resident who were wandering around. During a concurrent interview and record review on 8/25/2023 at 2:00 p.m., with the Director of Nursing (DON), Resident 1's Change of Condition ([COC] a clinical deviation from a resident's baseline) dated 8/23/2023 was reviewed. The COC indicated on 8/23/2023, Resident 1 had a changed in condition and verbalize having anxiety related to a situation, Resident 2 touched Resident 1 on her thighs without consent. The DON stated, on 8/23/2023 Resident 2 entered Resident's 1 room and touched Resident 1 without her consent. The DON stated CNA 2 reported she found Resident 2 touching Resident 1 on top of the blanket over Resident 1's body. The DON stated Resident 1 was upset that Resident 2 was touching her without her consent. The DON stated Resident 2 was not being closely monitored and the facility needed to keep a closer watched on Resident 2 to prevent her from roaming into other residents' rooms and to prevent non-consensual touching of another resident. The DON stated, Resident 1 was scared after Resident 2 touched Resident 1 without consent. During an interview on 8/25/2023 at 3:00 p.m., with CNA 2, CNA 2 stated on 8/23/2023 she was in the hallway and heard screaming from Resident 1's room. CNA 2 stated she went inside Resident 1's room and saw Resident 2's hands on top of the blanket of Resident 1 and was touching Resident 1's thighs. CNA 2 stated Resident 1 called her husband and was very upset about what had occurred. CNA 2 stated Resident 1 had informed her that Resident 2 came into her room and touched her vagina. CNA 2 stated Resident 2 was a wanderer and there had been a huddle (meeting) on 8/19/2023 to keep a close watch on Resident 2 and ensure Resident 2 does not go into residents' rooms. During an interview on 8/25/23 at 3:30 p.m., with Administrator (ADM), the ADM stated, Resident 2 went into Resident 1's room on 8/23/2023 and touched Resident 2's thighs on top of the blanket without permission. The ADM stated we failed to keep track of Resident 2 whereabouts to prevent Resident 2 from going into Resident 1's room and touching Resident 1 without consent. During an interview on 8/30/23 at 1:00 p.m., with the family member (FM), the FM stated, he received a call from Resident 1, and she was crying hysterically. The FM stated Resident 1 told him that a woman put her fingers in her vagina. The FM stated Resident 1 was in her right mind, and she would have no reason to lie about the events that occurred. The FM stated Resident 1 was blind but understands what was going on. During a review of Resident 2's Admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses included dementia, anxiety (persistent worry and fear about everyday situations), metabolic encephalopathy (an alteration in consciousness caused due to brain dysfunction). During a review of Resident 2's H&P, dated 8/14/2023, the H&P indicated Resident 2 cannot make decisions but can make needs known. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognition was severely impaired. The MDS indicated Resident 2 required supervision for ADL including bed mobility, walking in room, walking in corridors, and required limited assistance in locomotion on and off unit. The MDS indicated Resident 2 had wandering behavior that occurred daily, the wandering behavior placed Resident 2 at significant risk of getting to a potentially dangerous place, and the wandering significantly intruded on the privacy or activities of others. Resident 2's behavior status, care rejection, or wandering compared to prior assessment was worse. During a review of Huddle form, dated 8/19/2023, the Huddle form indicated to monitor Resident 2 and prevent resident from going into another resident room. During a review of Huddle form dated 8/20/2023, the Huddle form indicated to monitor Resident 2 from going into another resident's room. During a review of Resident 2's Care Plan for resident wandered into another resident room, date initiated 8/19/2023, the Care plan indicated a goal of staff supervision and redirecting Resident 2 to common areas. The Care Plan indicated to assist Resident 2 to common areas, redirect as much as possible, engage resident in activities of interest and consider 1:1 direct supervision if behavior repeats. During a review of Resident 2's COC evaluation, dated 8/23/2023, the COC indicated on 8/23/2023 Resident 2 was alleged an aggressor towards Resident 1. The COC indicated Resident 2 was placed on one to one (1:1-when an individual staff member is assigned to directly supervise no more than one resident and the staff shall stay within very close proximity to ensure constant supervision and immediate intervention if needed for safety reasons) sitter/ nurse to ensure she was monitored after the incident. During a review of Resident 2's Follow-up Documentation (facility report to describe the results of the abuse investigation), dated 8/23/2023, the document indicated, CNA 2 saw Resident 2 going inside Resident 1's room, and shortly after, Resident 1 started screaming and CNA 2 found Resident 2 touching Resident 1. The document indicated CNA 2 assisted Resident 2 out of the room. There was no documentation indicating Resident 2 was on one to one supervision or was being monitored. During a review of Resident 2's Interdisciplinary Meeting (IDT), dated 8/23/2023, the IDT indicated, Resident 2 touched another resident (Resident 1) without her consent and had tendency to wander around. During an interview on 8/25/23 at 1:00 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, Resident 2 was a wanderer and would wander all day and night. LVN 1 stated, there was a huddle on 8/19/2023 and 8/20/2023 to keep a close watch on Resident 2 due to Resident 2 went into Resident 1's room and was found touching Resident 1 on thigh area. During a review of facility's policy and procedure (P&P) titled, Abuse Prohibition, dated 2/23/2021, the P&P indicated, Healthcare Centers prohibit abuse .Instances of abuse of all patients, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish .It includes sexual abuse .Sexual Abuse is a non-consensual sexual contact of any type with a resident .It includes but is not limited to sexual harassment, sexual coercion or sexual assault. During a review of the facility's policy and procedure (P&P) titled, Dignity, undated, P&P indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feeling of self-worth and self-esteem .Staff promote, maintain and protect resident privacy. During a review of facility's policy and procedure (P&P) titled, Resident Rights, dated 12/2021, the P&P indicated, Federal and state laws guarantee certain basic rights to all residents of this facility .a dignified existence .be treated with respect, kindness, and dignity .be free from abuse and neglect.

Based on interview and record review, the facility failed to ensure one of 31 residents (Resident 7) received and consumed foods in appropriate form and texture as prescribed by the physician. Resident 1 was receiving a dysphagia ( difficulty in swallowing food or liquid) advanced texture diet (foods that are hard to chew are chopped, ground, shredded, cooked, or altered to make them easier to chew and swallow and any foods that are very hard, sticky, chewy or crunchy should be avoided) as recommended by the Speech Therapist ([ST] specialist trained to help people with speech and language problems to speak more clearly)'s (ST 1) recommendations. Licensed Vocational Nurse (LVN) 1 provided Resident 1 food items that were inappropriate for a dysphagia advanced diet, a peanut butter and jelly sandwich and graham cracker. This deficiency resulted in Resident 1 being found unresponsive and cyanotic (bluish or grayish color of the skin, nails, lips, or around the eyes), by Certified Nurse Assistance (CNA) 1, on [DATE] at 8:20 p.m., with food particles in his mouth and subsequently was pronounced deceased at 8:43 p.m. on [DATE]. On [DATE] at 2:53 p.m., the Administrator (ADM), Director of Nursing (DON), Clinical Resource (CR), and [NAME] President of Operation (VPO) were notified an Immediate Jeopardy ([IJ], a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident was called for the facility's failure to follow the prescribed diet order to provide food items that were consistent with a dysphagia advanced texture. The facility's ADM, DON, CR, and VPO were notified of the seriousness of all residents' health and safety being threatened by staff not following the prescribed diet orders. An IJ Removal Plan was requested. On [DATE], the facility submitted an acceptable IJ Removal Plan. On [DATE] at 3:33 p.m., the ADM, DON, CR and VPO were notified the IJ Removal Plan was approved and at 3:33 p.m., the ADM, DON, CR and VPO were notified the IJ was removed after review and on-site validation of the IJ Removal Plan via observations, interviews, and record review of the following: 1) Licensed Vocational Nurse (LVN) 1 was suspended on [DATE] and employment was terminated on [DATE]. 2) In-Services were initiated to staff by the VPO, Regional Quality Assurance (QA) Nurse, and DON on [DATE] regarding appropriate diet orders and staff to check residents' diet for correct order prior to giving resident a meal, snack, or hydration. 3) Staff that were absent, on leave or part time, will be in-serviced by Administrator, or DON or Designee prior to start of next scheduled shift. 4) On [DATE], the Infection Prevention (IP) nurse began receiving new physician orders for the identified 31 residents for ST to evaluate as indicated. 5) ST recommendations will be followed up and referred to the physician by the charge nurse for necessary new physician orders via internal communication system and will be followed up during next clinical meeting. Upon receipt of new physician orders, residents plan of care will be updated to reflect any changes. 6) On [DATE], Medical Records Director initiated an audit on the 31 identified residents to make sure ST recommendations were followed up on and carried out and/or implemented. 7) On [DATE], [DATE], and [DATE], Administrator, DON, MDS, and IP Nurse visually observed resident breakfast, lunch, and/or dinner to make sure residents diet texture was prepared and provided and is correctly followed during meal services. Snacks distribution, including bedtime (HS) snacks, was also visually observed on [DATE], [DATE], and [DATE] by the Administrator, DON, MDS, and IP Nurse and appropriate diet orders were followed by staff. 8) Licensed Nurses will visually check all three meals, breakfast, lunch, and dinner, and will compare to residents' diet orders daily to make sure meals served are appropriate per physician order. 9) Charge Nurses will review all snacks assigned to residents and will compare to residents' diet orders daily to make sure snacks served are appropriate per physician order. 10) Administrator and or designee will present findings of the meal and snack observation to the QA committee for further evaluation and recommendation monthly. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated the facility originally admitted Resident 1 on [DATE] and readmitted Resident 1 on [DATE] with diagnoses that included cerebral infarction (a stroke, disrupted blood flow to the brain causing parts of the brain become damaged or die) with dysphagia, aphasia (a language disorder that affects a person's ability to communicate), and dementia (a term for a range of conditions that affect the brain's ability to think, remember, and function normally). During a review of Resident 1's History and Physical Examination (H&P), dated [DATE], the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated [DATE], the MDS indicated the resident had severely impaired cognition (ability to think and reason) for daily decision making. The MDS indicated Resident 1 required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) with eating, and extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility, transfer, dressing, toilet use and personal hygiene. During a review of Resident 1's Physician Order, dated [DATE], indicated Resident 1's diet was changed from regular texture to dysphagia advance texture. During a review of Resident 1's Speech Therapy Treatment Encounter Note (ST Note), dated [DATE], the ST Note indicated Resident 1 had a change of condition due to choking and the Heimlich maneuver (a first aid procedure used to treat upper airway obstructions [or choking] by foreign objects) was performed. The ST Note indicated Resident 1 demonstrated holding food in the mouth/cheeks or residual food in the mouth after meals and coughing or choking during meals. During a review of Resident 1's ST Note, dated [DATE], the ST Note indicated Resident 1 was observed with a dysphagia advanced meal tray and he responded well to verbal prompts to slow pace and finished bites before taking another. The ST Note indicated Resident 1 continued to benefit from One-to-One (1:1 monitoring- when an individual staff member is assigned to directly supervise no more than one resident and the staff shall stay within very close proximity to ensure constant supervision and immediate intervention or assistance if needed for safety reasons) supervision for verbal prompts. The ST Note also indicated Resident 1 and nursing staff made aware and agreed. During a telephone interview on [DATE], at 10:54 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated at approximately 8:20 p.m. on [DATE], when she was going into the room adjacent to Resident 1's room, she saw Resident 1's upper body was lying on the foot of bed with his face on the bed and feet on the floor. CNA 1 stated she called Resident 1's name several times, but Resident 1 did not respond or move. CNA 1 stated she called for help immediately, then, LVN 1 and Registered Nurse (RN) 1 came to check on Resident 1. CNA 1 stated LVN 1 turned Resident 1 over and swept the resident's mouth with her finger. CNA 1 stated cardiopulmonary resuscitation (CPR, emergency procedure that combines chest compressions often with artificial ventilation to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person who is in cardiac arrest) was initiated on Resident 1. During a telephone interview on [DATE], at 1:44 p.m., with LVN 1, LVN 1 stated at approximately 8:00 p.m. on [DATE], she passed by Resident 1's room and saw the resident sitting on his bed and pulling on the bed curtain, making grunting sound. LVN 1 stated she asked Resident 1 if he was hungry and would like to have something to eat. Resident 1 nodded and grunted as a yes. She grabbed a peanut butter and jelly sandwich, some graham crackers and a house shake from the bedtime snack tray at the nursing station and provided the food items to Resident 1 without checking Resident 1's diet order at 8:10 p.m. on [DATE]. LVN 1 stated the peanut butter and jelly sandwich, graham crackers and house shake were not labeled with any resident's name, and the snacks and food items were pre-prepared in case if any resident would like additional bedtime snacks. LVN 1 stated she thought Resident 1 was on a regular texture diet. LVN 1 stated she assisted Resident 1 to sit at the corner of the foot of bed and placed his bedside tray table in front of him. LVN 1 stated she observed Resident 1 take a few bites of the peanut butter and jelly sandwich and left the room to tend another resident. LVN 1 stated at approximately 8:20 p.m. on [DATE], she heard CNA 1's call for help. LVN 1 stated she went to Resident 1's room and saw Resident 1 was facing down on the bed and unresponsive. LVN 1 stated she checked Resident 1's pulse, patted his back and saw him turning blue. LVN 1 stated there were food particles in Resident 1's mouth, so she swept Resident 1's mouth with her finger and removed a spoonful of mashed food from his mouth. LVN 1 stated RN 1 performed the Heimlich maneuver and saw Resident 1 take one breath and his color was improving. LVN 1 stated Resident 1 was not breathing on his own after that breath, then, RN 1 started CPR. LVN 1 stated emergency response was requested at approximately 8:25 p.m. and paramedics arrived at the facility at 8:36 p.m. on [DATE]. LVN 1 stated CPR was ceased when Resident 1's code status was found Do-Not-Resuscitate (DNR, means a person does not want any life-saving measures). LVN 1 stated the paramedic pronounced Resident 1 expired at 8:43 p.m. on [DATE]. LVN 1 stated Resident 1 tended to eat fast, and she was aware that he required supervision while eating. LVN 1 stated a peanut butter and jelly sandwich, and graham crackers were not considered as appropriate for Resident's dysphagia advance diet. LVN 1 stated Resident 1 was at risk for aspiration, and she should have checked Resident 1's diet order and provide supervision during eating. During a review of LVN 1's Written Declaration, dated [DATE], at 3:30 p.m., the declaration indicated LVN 1 provided a peanut butter and jelly sandwich and graham crackers to Resident 1 without checking the diet order at 8:10 p.m. on [DATE]. During an interview on [DATE], at 4:33 p.m., with ST 1, ST 1 stated she saw Resident 1 on [DATE] and Resident 1 was on a modified diet, for example, chopped food items, ground meat, rice, and cut pasta, but no toasted bread. ST 1 stated she did not evaluate if Resident 1 could tolerate a peanut butter and jelly sandwich. ST 1 stated it would not be safe for Resident 1 to eat a whole peanut butter and jelly sandwich. During a telephone interview on [DATE], at 11:22 a.m., with CNA 2, CNA 2 stated Resident 1 had an episode of choking some time ago. CNA 2 stated it was important to check Resident 1's diet order to prevent choking and ensure his safety. During an interview on [DATE], at 12:19 p.m., with the Registered Dietitian (RD), the RD stated Resident 1 was on a dysphagia advanced diet. The RD stated Resident 1 should have received food that had a soft texture and was chopped. The RD stated graham crackers were not allowed for residents on a dysphagia advanced diet. The RD stated the facility had creamy peanut butter in stock on [DATE], so the peanut butter and jelly sandwich which was provided to Resident 1 was made from the creamy peanut butter. The RD stated a ST evaluation was required to evaluate if a resident could tolerate creamy peanut butter before providing a peanut butter and jelly sandwich. The RD stated LVN 1 should have checked Resident 1's diet order and made sure each food item provided to Resident 1 was consistent with the food texture as the physician's diet order. During an interview on [DATE], at 1:59 p.m., with the DON, the DON stated Resident 1 had a choking episode while eating dinner in his room on [DATE], then, his diet was changed from regular texture to dysphagia advance diet on [DATE]. The DON stated the ST evaluation was ordered and the ST initiated the evaluation on [DATE]. The DON stated the ST 1 made recommendations on [DATE], indicating Resident 1 was on dysphagia advance diet and required 1:1 supervision with verbal prompts on Resident 1 while eating. The DON stated through the facility's investigation, the facility found LVN 1 provided a peanut butter and jelly sandwich to Resident 1 without checking Resident 1's diet order on [DATE]. The DON stated LVN 1 should have checked Resident 1's diet order to make sure each food item was appropriate for Resident 1's dysphagia advanced diet, and LVN 1 should have followed the ST's recommendation. The DON stated LVN 1's action placed Resident 1 at risk for aspiration and choking. During a telephone interview on [DATE], at 4:10 p.m., with Resident 1's physician (MD) 1, MD 1 stated as to his knowledge, a peanut butter and jelly sandwich might not be appropriate for Resident 1 because of the stickiness and the chunkiness of the peanut butter. MD 1 stated he would agree with the ST's recommendation to place Resident 1 on a dysphagia diet and provide supervision during eating. During a review of the facility's policy and procedure (P&P) titled, Diet and Nutrition Care Manual-Dysphagia Advanced (Level 3) Or Mechanical (dental) Soft Diet, dated 2019, the P&P indicated foods that hard to chew are chopped, ground, shredded, cooked, or altered to make them easier to chew and swallow and Any foods that are very hard, sticky, chewy or crunchy should be avoided. The P&P indicated crackers was listed as the foods to avoid. During a review of the facility's P&P titled, Dining and Food Preferences, dated ,d+[DATE], the P&P indicated, the individual tray assembly ticket will identify all food items appropriate for the resident/patient based on diet order, allergies & intolerances, and preferences. During a review of the facility's P&P titled, Therapeutic Diets, dated ,d+[DATE], the P&P indicated, all residents have a diet order, including regular, therapeutic, and texture modification, that is prescribed by the attending physician .Diets are prepared in accordance with the guidelines in the approved Diet Manual and the individualized plan of care.

Based on interview and record review, the facility failed to provide one-to-one (1:1) supervision while eating for one of 31 residents (Resident 1), who was receiving a therapeutic diet (a meal plan that controls the intake of certain foods or nutrients as part of the treatment of a medical condition prescribed by a physician). Resident 1 was receiving a dysphagia (difficulty in swallowing food or liquid) advanced texture diet (foods that hard to chew are chopped, ground, shredded, cooked, or altered to make them easier to chew and swallow and any foods that are very hard, sticky, chewy or crunchy should be avoided) with thin liquids and required supervision while eating as indicated by the Speech Therapist ([ST] specialist trained to help people with speech and language problems to speak more clearly)'s assessment/recommendations after a choking episode on [DATE]. Licensed Vocational Nurse (LVN) 1 provided Resident 1 food items (a peanut butter and jelly sandwich and graham crackers) that were inappropriate for a dysphagia advanced diet as prescribed by the physician and failed to supervise Resident 1 while eating to tend to another resident on [DATE] at 8:10 p.m. This deficiency resulted in Resident 1 being found unresponsive and cyanotic (bluish or grayish color of the skin, nails, lips, or around the eyes), by Certified Nurse Assistant (CNA) 1 on [DATE] at 8:20 p.m., with food particles in his mouth and subsequently was pronounced deceased at 8:43 p.m. on [DATE]. On [DATE] at 2:53 p.m., the Administrator (ADM), Director of Nursing (DON), Clinical Resource (CR), and [NAME] President of Operation (VPO) were notified an Immediate Jeopardy ([IJ], a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called for the facility's staff failure to follow the prescribed diet order to provide food items that were consistent with a dysphagia advanced diet and supervise Resident 1 while eating as recommended. The facility's ADM, DON, CR, and VPO were notified of the seriousness of all residents' health and safety being threatened by staff not following diet orders and supervising residents during meals and snack times. An IJ Removal Plan was requested. On [DATE] the facility submitted an acceptable IJ Removal Plan. On [DATE] at 3:33 p.m., the ADM, DON, CR and VPO were notified the IJ Removal Plan was approved and at 3:33 p.m., the ADM, DON, CR and VPO were notified the IJ was removed after review and on-site validation of the Removal Plan via observations, interviews, and record review of the following: 1) LVN 1 was suspended on [DATE], and employment was terminated on [DATE]. 2) In-Services were initiated to Licensed Nurses by the Regional Quality Assurance (QA) Nurse and DON on [DATE] and the VPO initiated an in-service to department managers on [DATE] regarding the importance of supervision of residents that were at risk for aspiration (an object or fluid enter the airway or lungs). 3) Staff that were absent, on leave or part time, would be in-serviced by the ADM, or DON or Designee prior to start of their next working scheduled shift. 4) New employees would be in-serviced by the Director of Staff Development (DSD) and/or Designee regarding importance of supervision of residents that were at risk for aspiration. 5) On [DATE], the Infection Preventionist (IP) nurse began receiving new physician orders for the identified 31 residents for ST 1 to evaluate as indicated. 6) On [DATE], Medical Records Director (MRD) initiated an audit on the 31 identified residents to make sure ST recommendations were followed up on and carried out and/or implemented. 7) ST recommendations would be followed up on and referred to the physician by the charge nurse for necessary new physician orders via internal communication system and would be followed up during the next clinical meeting. 8) Upon receipt of new physician orders, residents plan of care would be updated to reflect any changes. 9) Other residents identified of being at risk for aspiration during meals, were visually observed by the ADM, DON, MDS, and/or IP nurse on [DATE], [DATE], and [DATE] and confirm appropriate supervision was given to residents by nursing staff. 10) A list of the current diet and required level of assistance would be accessible at each nursing station for reference. This list would be updated as needed for any new diet order and/or change in level of assistance and would be discussed at the daily clinical meeting (Monday-Friday) and at the daily shift huddles. The licensed nurses would monitor and validate accuracy of diet prior to serving food items and would visually check that appropriate level of assistance was provided. 11) ADM and or designee would present findings of the staff observation of residents that require supervision with meals to the QA committee for further evaluation and recommendation monthly. Administrator and or designee would present findings of the staff observation of residents that require supervision with meals to the QA committee for further evaluation and recommendation monthly. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated the facility originally admitted Resident 1 on [DATE] and readmitted Resident 1 on [DATE] with diagnoses that included cerebral infarction (a stroke, disrupted blood flow to the brain causing parts of the brain become damaged or die) with dysphagia (difficulty swallowing foods or liquids), aphasia (a language disorder that affects a person's ability to communicate), and dementia (a term for a range of conditions that affect the brain's ability to think, remember, and function normally). During a review of Resident 1's History and Physical Examination (H&P), dated [DATE], the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated [DATE], the MDS indicated the resident had severely impaired cognition (ability to think and reason) for daily decision making. The MDS indicated Resident 1 required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) with eating, and extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility, transfer, dressing, toilet use and personal hygiene. During a review of Resident 1's Physician's Order, dated [DATE], the order indicated Resident 1's diet was changed from regular texture to dysphagia advanced texture with thin liquids, after a choking episode on [DATE]. During a review of Resident 1's Speech Therapy Treatment Encounter Note (ST Note), dated [DATE], the ST note indicated Resident 1 had a change of condition due to choking. The note indicated the Heimlich maneuver (a first aid procedure used to treat upper airway obstructions [or choking] by foreign objects) was performed. The ST Note indicated Resident 1 demonstrated holding food in the mouth/cheeks or residual food in the mouth after meals and coughing or choking during meals. During a review of Resident 1's ST Note, dated [DATE], the ST Note indicated Resident 1 was observed with a dysphagia advanced meal tray and he responded well to verbal prompts to slow pace and finished bites before taking another. The ST Note indicated Resident 1 continued to benefit from 1:1 supervision for verbal prompts. The ST Note also indicated Resident 1 and nursing staff made aware and agreed. During a review of the facility's Special Needs List, dated [DATE], the special needs list indicated Resident 1 was on the Eating with Supervision list. During a telephone interview on [DATE], at 10:54 a.m., with CNA 1, CNA 1 stated at approximately 8:20 p.m. on [DATE], when she was going into the room adjacent to Resident 1's room, she saw Resident 1's upper body was lying on the foot of bed with his face on the bed and feet on the floor. CNA 1 stated she called Resident 1's name several times, but Resident 1 did not respond or move. CNA 1 stated she called for help immediately, then, LVN 1 and Registered Nurse (RN) 1 came to check on Resident 1. CNA 1 stated LVN 1 turned Resident 1 over and swept the resident's mouth with her finger. CNA 1 stated cardiopulmonary resuscitation (CPR, an emergency life-saving procedure done when someone's breathing, or heartbeat has stopped) was initiated on Resident 1. During a telephone interview on [DATE], at 1:44 p.m., with LVN 1, LVN 1 stated at approximately 8:00 p.m. on [DATE], she passed by Resident 1's room and saw him sitting on his bed and pulling on the bed curtain, making a grunting sound. LVN 1 stated she asked Resident 1 if he was hungry and would like to have something to eat. Resident 1 nodded and grunted as a yes. LVN 1 stated she grabbed a peanut butter and jelly sandwich; some graham crackers and a house shake from the bedtime snack tray at the nursing station and provided the food items to Resident 1 without checking Resident 1's diet order at 8:10 p.m. on [DATE]. LVN 1 stated the peanut butter and jelly sandwich, graham crackers and house shake were not labeled with any resident's name, and the snacks and food items were pre-prepared in case any resident would like additional bedtime snacks. LVN 1 stated she thought Resident 1 was on a regular texture diet. LVN 1 stated she assisted Resident 1 to sit at the corner of the foot of bed and placed his bedside tray table in front of him. LVN 1 stated she observed Resident 1 take a few bites of the peanut butter and jelly sandwich and left the room to tend another resident. LVN 1 stated at approximately 8:20 p.m. on [DATE], she heard CNA 1's call for help for Resident 1. LVN 1 stated she went to Resident 1's room and saw Resident 1 was facing down on the bed and unresponsive. LVN 1 stated she checked Resident 1's pulse, patted his back and saw him turning blue. LVN 1 stated there was food particles in Resident 1's mouth, so she swept Resident 1's mouth with her finger and removed a spoonful of mashed food from his mouth. LVN 1 stated RN 1 performed the Heimlich maneuver and saw Resident 1 take one breath and his color was improving. LVN 1 stated Resident 1 was not breathing on his own after that breath, then, RN 1 started CPR. LVN 1 stated emergency response was requested around 8:25 p.m. and paramedics arrived around 8:36 p.m. on [DATE]. LVN 1 stated CPR was ceased when Resident 1's code status was found Do-Not-Resuscitate (DNR, means a person does not want any life-saving measures). LVN 1 stated the paramedics pronounced Resident 1 expired at 8:43 p.m. on [DATE]. LVN 1 stated Resident 1 tended to eat fast, and she was aware that he required supervision while eating, but she did not stay to supervise Resident 1 finishing his snack and she did not inform other staff to supervise Resident 1 while eating the snack. LVN 1 stated after she left the room, Resident 1 was eating without any supervision from the staff. LVN 1 stated a peanut butter and jelly sandwich was not considered as appropriate for Resident 1's dysphagia advanced diet. LVN 1 stated Resident 1 was at risk for aspiration, and she should have checked Resident 1's diet order and provide supervision during eating. During a review of LVN 1's Written Declaration, dated [DATE], the Declaration indicated LVN 1 provided a peanut butter and jelly sandwich and graham crackers to Resident 1 without checking the diet order and did not provide adequate 1:1 supervision to Resident 1 while eating at 8:10 p.m. on [DATE]. During an interview on [DATE], at 4:33 p.m., with ST 1, ST 1 stated she saw Resident 1 on [DATE]. ST1 stated Resident 1 was on a modified diet, for example, chopped food items, ground meat, rice, and cut pasta, but no toasted bread. ST 1 stated Resident 1 did not request to eat a peanut butter and jelly sandwich during the evaluation in February 2023, so she did not evaluate if Resident 1 could tolerate a peanut butter and jelly sandwich. ST 1 stated it would not be safe for Resident 1 to eat a whole peanut butter and jelly sandwich, without supervision. ST 1 stated she recommended 1:1 supervision for verbal prompts during meals and stated Resident 1 would be at minimum to moderate risk for aspiration and choking without supervision. During a telephone interview on [DATE], at 11:22 a.m., with CNA 2, CNA 2 stated Resident 1 had an episode of choking some time ago. CNA 2 stated after that incident, Resident 1 required staff to supervise and remind him to eat slowly during meals because he liked to put a lot of food in his mouth and ate fast. CNA 2 stated it was important to check Resident 1's diet order and provide supervision while eating to prevent choking and ensure his safety. During an interview on [DATE], at 12:19 p.m., with the Registered Dietitian (RD), the RD stated Resident 1 was on a dysphagia advanced diet and should have received food that had a soft texture and was chopped. The RD stated graham crackers were not allowed for residents on dysphagia advanced diets. The RD stated the facility had creamy peanut butter in stock on [DATE], so the peanut butter and jelly sandwich which was provided to Resident 1 was made from the creamy peanut butter. The RD stated a ST evaluation was required to evaluate if a resident could tolerate creamy peanut butter before providing a peanut butter and jelly sandwich. The RD stated LVN 1 should have check Resident 1's diet order and made sure each food item provided to Resident 1 was consistent with the food texture as the physician's diet order. During an interview on [DATE], at 1:59 p.m., with the DON, the DON stated Resident 1 had a choking episode while eating dinner in the dining room on [DATE], then, the resident's diet was changed from regular texture to dysphagia advance diet on [DATE]. The DON stated the ST evaluation was ordered and ST 1 initiated an evaluation on [DATE]. The DON stated ST 1 made recommendation on [DATE], indicating Resident 1 was placed on dysphagia advance diet and recommendations to provide 1:1 supervision with verbal prompts to Resident 1 while eating. The DON stated the facility put Resident 1 on the Eating with Supervision List which was located at each nursing station to alert the staff that Resident 1 required supervision while eating. The DON stated through the facility's investigation, the facility found LVN 1 provided a peanut butter and jelly sandwich to Resident 1 without checking Resident 1's diet order and left Resident 1 to eat without supervision in the room at 8:10 p.m. on [DATE]. The DON stated Resident 1 was found unresponsive on the bed with food particles in his mouth at approximately 8:20 p.m. on [DATE]. The DON stated a mouth sweep, Heimlich maneuver, and CPR were performed. The DON stated emergency response was called and paramedics arrived on scene at 8:25 p.m. on [DATE], then, paramedics provided suctioning and laryngoscopy (exam of the back of the throat). The DON stated Resident 1 was pronounced deceased at 8:43 p.m. on [DATE]. The DON stated LVN 1 should have checked Resident 1's diet order to make sure the food items were appropriate for Resident 1's dysphagia advance diet. LVN 1 should have followed ST 1's recommendation to provide supervision while eating. The DON stated LVN 1's actions placed Resident 1 at risk for aspiration and choking. During a telephone interview on [DATE], at 4:10 p.m., with Resident 1's physician (MD 1), MD 1 stated as to his knowledge, a peanut butter and jelly sandwich might not be appropriate for Resident 1 because of the stickiness and the chunkiness of the peanut butter. MD 1 stated he would agree with ST 1's recommendation to place Resident 1 on a dysphagia diet and provide supervision during eating. During a review of the facility's undated policy and procedure (P&P) titled, Assistance with Meals, the P&P indicated residents should receive assistance with meals in a manner that meets the individual needs and ensure residents' safety.

Based on interview and record review, the facility failed to develop a comprehensive care plan addressing the risk for aspiration (occurs when food, drink, or foreign objects are breathed into the lungs) for one of 31 sampled residents (Resident 1). Resident 1 had a choking episode on [DATE] and the Speech Therapist ([ST] specialist trained to help people with speech and language problems to speak more clearly) (ST 1) recommended Resident 1 to receive a dysphagia (difficulty in swallowing food or liquid) advance texture diet (foods that hard to chew are chopped, ground, shredded, cooked, or altered to make them easier to chew and swallow and any foods that are very hard, sticky, chewy or crunchy should be avoided) and one-to-one (1:1 monitoring- when an individual staff member is assigned to directly supervise no more than one resident and the staff shall stay within very close proximity to ensure constant supervision and immediate intervention or assistance if needed for safety reasons) supervision while eating. Resident 1's diet was changed from regular texture to dysphagia advanced texture with thin liquids on [DATE], which was not care planned. Resident 1 was provided food items that were inappropriate for a dysphagia advanced diet as prescribed by the physician and was not supervised while eating on [DATE]. This deficiency resulted in Resident 1 being found unresponsive and cyanotic (bluish or grayish color of the skin, nails, lips, or around the eyes), by Certified Nurse Assistant (CNA) 1 on [DATE] at 8:20 p.m., with food particles in his mouth and subsequently was pronounced deceased at 8:43 p.m. on [DATE]. On [DATE] at 2:53 p.m., the Administrator (ADM), Director of Nursing (DON), Clinical Resource (CR), and [NAME] President of Operation (VPO) were notified an Immediate Jeopardy ([IJ], a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called for the facility's failure to develop a comprehensive care plan addressing the risk for aspiration after Resident 1's choking episode on [DATE], ST 1's recommendations and the change in diet order. The facility's ADM, DON, CR, and VPO were notified of the seriousness of all residents' health and safety being threatened by staff not developing a comprehensive care plan for the residents who were at risk for aspiration. An IJ Removal Plan was requested. On [DATE] at 3:33 p.m., the ADM, DON, CR and VPO were notified the IJ Removal Plan was approved and at 3:33 p.m., the ADM, DON, CR and VPO were notified the IJ was removed after review and on-site validation of the IJ Removal Plan via observations, interviews, and record review of the following: 1) In-Services were initiated to Licensed Nurses by Regional Quality Assurance (QA) Nurse and DON on [DATE] and VPO initiated an in service with department managers regarding developing comprehensive care planning addressing the risk for aspiration. 2) Staff that were absent, on leave or part time, will be in-serviced by the ADM or DON or Designee prior to start of their next scheduled working shift. 3) New employees will be in-serviced by the Director of Staff Development (DSD) and/or Designee regarding developing comprehensive care planning addressing the risk for aspiration. 4) On [DATE], the Infection Preventionist (IP) nurse began receiving new physician orders for the identified 31 residents for ST to evaluate as indicated. 5) ST recommendations will be followed up on and referred to the physician by charge nurse for necessary new physician orders via internal communication system and will be followed up during the next clinical meeting. 6) Upon receipt of new physician orders, residents plan of care will be updated to reflect any changes. 7) On [DATE], the Medical Records Director (MRD) initiated an audit on the 31 identified residents to make sure ST recommendations were followed up on and carried out and/or implemented. 8) On [DATE], the MRD and Medical Records Assistant (MRA) initiated and completed an audit of the 31 identified residents with mechanically altered diet to confirm comprehensive care plans are in place for aspiration. 9) The DON initiated and completed comprehensive care plan for risk for aspiration for the identified residents on [DATE]. Residents identified with mechanically altered diet a comprehensive care plan was initiated for aspiration on [DATE] by Regional QA Nurse. 10) On [DATE], the DON initiated an in-service with licensed nurses regarding changes in the plan of care for the 24 identified residents regarding risk for aspiration. On [DATE], the ADM initiated an in-service with the Dietary, Housekeeping, Laundry, Therapy, Department Managers, and assistance regarding changes in the plan of care for the 24 identified residents regarding risk for aspiration. 11) New Physician Orders will be reviewed by the DON and/or Designee 5 times a week (Monday- Friday) during facility clinical meeting. For changes in residents' diet, the care plan will be reviewed by the Interdisciplinary Team (IDT, group of different disciplines working together towards a common goal of a resident) and will confirm At Risk for Aspiration is being addressed. On Saturdays and Sundays, the Registered Nurse (RN) Supervisor will review changes in resident diet orders to confirm residents on mechanically altered diets care plans are addressing residents being at risk for aspiration. 12) MRD and or designee will present findings of the Comprehensive Care Plan audits to the QA committee for further evaluation and recommendation monthly. The QA committee will continue to review the Comprehensive Care Plan Audit deficiency and has been proven to be resolved for 3 consecutive months and /or advised by the QA committee. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated the facility originally admitted Resident 1 on [DATE] and readmitted Resident 1 on [DATE] with diagnoses that included cerebral infarction (a stroke, disrupted blood flow to the brain causing parts of the brain become damaged or die) with dysphagia (difficulty swallowing foods or liquids), aphasia (a language disorder that affects a person's ability to communicate), and dementia (a term for a range of conditions that affect the brain's ability to think, remember, and function normally). During a review of Resident 1's History and Physical Examination (H&P), dated [DATE], the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated [DATE], the MDS indicated the resident had severely impaired cognition (ability to think and reason) for daily decision making. The MDS indicated Resident 1 required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) with eating, and extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility, transfer, dressing, toilet use and personal hygiene. During a review of Resident 1's Physician Order, dated [DATE], the order indicated Resident 1's diet was changed from regular texture to dysphagia advance texture. During a review of Resident 1's Speech Therapy Treatment Encounter Note (ST Note), dated [DATE], the ST note indicated Resident 1 had a change of condition due to choking and the Heimlich maneuver (a first aid procedure used to treat upper airway obstructions [or choking] by foreign objects) was performed. The ST note indicated Resident 1 demonstrated holding food in the mouth/cheeks or residual food in the mouth after meals and coughing or choking during meals. During a review of Resident 1's ST Note, dated [DATE], the ST Note indicated Resident 1 was observed with a dysphagia advanced meal tray and he responded well to verbal prompts to slow pace and finished bites before taking another. The ST Note indicated Resident 1 continued to benefit from 1:1 supervision for verbal prompts. The ST Note also indicated Resident 1 and nursing staff made aware and agreed. During a review of the facility's Special Needs, dated [DATE], indicated Resident 1 was on the Eating with Supervision list. During a telephone interview on [DATE], at 10:54 a.m., with CNA 1, CNA 1 stated at approximately 8:20 p.m. on [DATE], when she was going into the room adjacent to Resident 1's room, she saw Resident 1's upper body was lying on the foot of bed with his face on the bed and feet on the floor. CNA 1 stated she called Resident 1's name several times, but Resident 1 did not respond or move. CNA 1 stated she called for help immediately, then, Licensed Vocational Nurse (LVN) 1 and RN 1 came to check on Resident 1. CNA 1 stated LVN 1 turned Resident 1 over and swept the resident's mouth with her finger. CNA 1 stated cardiopulmonary resuscitation (CPR, an emergency life-saving procedure done when someone's breathing or heartbeat has stopped) was initiated on Resident 1. During a telephone interview on [DATE], at 1:44 p.m., with LVN 1, LVN 1 stated at approximately 8:00 p.m. on [DATE], she passed by Resident 1's room and saw him sitting on his bed and pulling on the bed curtain, making a grunting sound. LVN 1 stated she asked Resident 1 if he was hungry and would like to have something to eat. Resident 1 nodded and grunted as a yes. LVN 1 stated she grabbed a peanut butter and jelly sandwich; some graham crackers and a house shake from the bedtime snack tray at the nursing station and provided the food items to Resident 1 without checking Resident 1's diet order at 8:10 p.m. on [DATE]. LVN 1 stated the peanut butter and jelly sandwich, graham crackers and house shake were not labeled with any resident's name, and the snacks or food items were pre-prepared in case any resident would like additional bedtime snacks. LVN 1 stated she thought Resident 1 was on a regular texture diet. LVN 1 stated she assisted Resident 1 to sit at the corner of the foot of bed and placed his bedside tray table in front of him. LVN 1 stated she observed Resident 1 take a few bites of the peanut butter and jelly sandwich and left the room to tend another resident. LVN 1 stated at approximately 8:20 p.m. on [DATE], she heard CNA 1's call for help for Resident 1. LVN 1 stated she went to Resident 1's room and saw Resident 1 was facing down on the bed and unresponsive. LVN 1 stated she checked Resident 1's pulse, patted his back and saw him turning blue. LVN 1 stated there were food particles in Resident 1's mouth, so she swept Resident 1's mouth with her finger and removed a spoonful of mashed food from his mouth. LVN 1 stated RN 1 performed the Heimlich maneuver and saw Resident 1 take one breath and his color was improving. LVN 1 stated Resident 1 was not breathing on his own after that breath, then, RN 1 started CPR. LVN 1 stated emergency response was requested around 8:25 p.m. and paramedics arrived around 8:36 p.m. on [DATE]. LVN 1 stated CPR was ceased when Resident 1's code status was found Do-Not-Resuscitate (DNR, means a person does not want any life-saving measures). LVN 1 stated the paramedics pronounced Resident 1 expired at 8:43 p.m. on [DATE]. LVN 1 stated Resident 1 tended to eat fast, and she was aware that he required supervision while eating, but she did not stay to supervise Resident 1 finishing his snack and she did not inform other staff to supervise Resident 1 while eating the snack. LVN 1 stated after she left the room, Resident 1 was eating without any supervision from the staff. LVN 1 stated a peanut butter and jelly sandwich was not considered as appropriate for Resident 1's dysphagia advanced diet. LVN 1 stated Resident 1 was at risk for aspiration, and she should have checked Resident 1's diet order and provide supervision during eating. During a review of LVN 1's Written Declaration, dated [DATE], at 3:30 p.m. the Declaration indicated LVN 1 provided Resident 1 a peanut butter and jelly sandwich and graham crackers to Resident 1 without checking the diet order and did not provide adequate supervision to Resident 1 while eating at 8:10 p.m. on [DATE]. During an interview on [DATE], at 4:33 p.m., with the ST 1, the ST 1 stated she saw Resident 1 in February 2023 and Resident 1 was on a modified diet, for example, chopped food items, ground meat, rice, and cut pasta, but no toasted bread. ST 1 stated it would not be safe for Resident 1 to eat a whole peanut butter and jelly sandwich without supervision. ST 1 stated she recommended 1:1 supervision for verbal prompts during meals and stated Resident 1 would be at minimum to moderate risk for aspiration and choking without supervision. During a telephone interview on [DATE], at 11:22 a.m., with CNA 2, CNA 2 stated Resident 1 had an episode of choking some time ago. CNA 2 stated after that incident, Resident 1 required staff to supervise and remind him to eat slowly during meals because he liked to put a lot of food in his mouth and eat fast. CNA 2 stated it was importance to check Resident 1's diet order and provide supervision while eating to prevent choking and ensure his safety. During an interview on [DATE], at 1:59 p.m., with the DON, the DON stated Resident 1 had a choking episode while eating dinner in his room on [DATE]. The DON stated after the choking episode, Resident 1's diet was changed from regular texture to dysphagia advance diet on [DATE]. The DON stated an ST evaluation was ordered and ST 1 initiated the evaluation on [DATE]. The DON stated the ST made recommendations on [DATE], indicating to provide 1:1 supervision with verbal prompts to Resident 1 while eating. The DON stated the facility placed Resident 1 on the Eating with Supervision List which was located at each nursing station to alert the staff that Resident 1 required supervision while eating. During a concurrent interview and record review, on [DATE], at 3:00 p.m., with the DON, Resident 1's care plans were reviewed. Resident 1's care plans indicated there was no comprehensive care plan addressing the resident's risk for aspiration. The DON stated the facility staff did not develop a care plan to address Resident 1's risk for aspiration after Resident 1's choking episode on [DATE], the change of diet order on [DATE], and the ST's recommendation on [DATE]. The DON stated a comprehensive care plan was very important because it indicated the goals of care and the interventions to address a resident's identified problems. The DON stated the facility staff could provide quality of care and ensure residents' safety more effectively by following an individualized comprehensive care plan. During a review of the facility's policy and procedure (P&P) titled, Care Plan-Interdisciplinary Team, dated [DATE], the P&P indicated an individualized comprehensive care plan should be developed for each resident to meet the resident's needs.

Based on observation, interview and record review, the facility failed to ensure two of two sampled residents (Resident 1 and 2) were free from physical abuse. The facility failed to: 1.Ensure Resident 2 was not physically abused by Resident 1. Resident 2 was pushed by Resident 1 and fell hitting his nose and right shoulder. 2. Ensure Resident 1 was not physically abused by Resident 2. Resident 1 was hit in the jaw by Resident 2. Resident 1 was having conflicts with Resident 2 and asked the Social Services Director (SSD), for a room change. 3. Adhere to its policy and procedure titled, Abuse Prohibition dated 10/24/2022, that indicated, the facility will provide adequate supervision when the risk of resident-to-resident altercation was suspected. It also indicated an option for room changes will be provided based on the situation. This deficient practice resulted in Resident 1 physically assaulting Resident 2. Resident 2 complained of right arm pain which resulted in a closed fracture (broken) of the right shoulder. Resident 2 assaulted Resident 1 with no injuries. Findings: During a review of Resident 2's face sheet (admission record), the face sheet indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnosis included depression, generalized muscle weakness and hypertension ([HTN] high blood pressure). During a review of Resident 2's History and Physical (H&P) dated 2/24/2022, the H&P indicated Resident 2 had normal judgment and insight. During a review of Resident 2's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 8/22/2022, the MDS indicated Resident 2 was able to understand and be understood by others. The MDS indicated Resident 2 required staff supervision with bed mobility, transfer, walking, dressing, eating, toilet use and personal hygiene. During a review of Resident 2's Change of Condition ([COC] internal communication tool) dated 10/20/2022, the COC indicated Resident 2 had an altercation with Resident 1. The COC indicated during the altercation, Resident 2 slipped and fell on his shoulder. The COC indicated Resident 2 complained of severe pain with slight limitation of movement on the right arm and was transferred to a general acute care hospital (GACH). During a review of Resident 2's radiology ([x-ray] process of taking pictures of body parts to diagnose and treat diseases) report of the right humerus (long bone in the upper arm), dated 10/22/2022, the x-ray report indicated Resident 2 sustained a right upper arm facture. During a review of Resident 2's physician's progress notes dated 10/21/2022, the notes indicated Resident 2 was pushed from behind by another resident (Resident 1). The notes indicated Resident 2 fell and hit his nose and shoulder. The notes also indicated, Resident 2's nose was bleeding and the resident complained of right shoulder pain rated at 5/10 (on a scale of 1-10, 10 being the worst pain), especially when Resident 2 was lying down in bed. The notes further indicated Resident 1 threatened Resident 2, two days before the altercation. During a review of Resident 2's GACH Visit Summary report dated 10/22/2022, the summary report indicated Resident 2 had a fracture that required a non-surgical treatment, with a special sling (a flexible strap or belt used in the form of a loop to support or raise a weight) called a shoulder immobilizer, or a splint (a strip of rigid material used for supporting and immobilizing a broken bone when it has been set) or cast (object made by shaping molten (melted) metal or similar material in a mold). The report indicated Resident 2 ' s fracture will take 4 to 6 weeks or longer to heal. The report also indicated Resident 2 should follow up with his primary doctor to make sure the fractured bone was healing. During a review of Resident 2's Medication Administration Record (MAR) dated October 2022, the MAR indicated Resident 2 was to receive Norco from 10/21/2022 to 11/04/2022. The MAR indicated on 10/22/2022, Resident 2 received Norco 5-325 mg by mouth for an 8/10 pain level. During a review of Resident 2's progress notes dated 10/21/2022 at 1:53 p.m., the notes indicated after Resident 2 had an altercation (disagreement) with Resident 1, Resident 2 sustained a closed fracture of the right proximal humerus (towards the top of the upper arm bone). The notes indicated Resident 2 had a splint on the affected site and was receiving an unnamedpain medication. During an interview on 10/31/2022, at 11:53 a.m., in the activity room, Resident 1 stated on 10/20/2022, Resident 2 was repeatedly turning his television (TV) off. Resident 1 stated, he got up from his bed and turned Resident 2's TV off. Resident 1 stated, Resident 2 placed his lunch tray on top of his wheelchair. Resident 1 stated, he took the tray and tossed it on top of Resident 2's bed. Resident 1 stated, he then went outside of the room with Resident 2, and Resident 2 hit him on the right side of his face. Resident 1 stated, Resident 2, hit himself on the nose and fell to the floor. Resident 1 stated, he was arguing with Resident 2 for months, before the incident. Resident 1 stated he asked the SSD, to be moved to another room. Resident 1 stated, the SSD stated there was no other room Resident 1 could be moved to. During concurrent observation and interview on 10/31/2022, at 12:28 p.m., Resident 2 was observed outside of his room, walking in the hallway. Resident 2 had a white cast from the right elbow to the right hand, resting on a sling. Resident 2 stated, on 10/20/2022, as he was coming out from the room, on his wheelchair, Resident 1 pushed him and he fell face down, and cut his nose. Resident 2 stated, he was having problems with Resident 1, for a couple of days before the incident. Resident 2 stated, Resident 1 liked to keep his TV loud, and he asked Resident 1 to please put the volume down. Resident 2 stated, he informed the Activity Assistance (AA) 1 that they (Resident 1 and 2) were having problems and arguing, and the AA 1 told him to just ignore Resident 1. During an interview on 10/31/22 at 1:56 p.m., AA 1 stated, a month ago Resident 2 informed her (AA 1) that he was the only person who could stop Resident 1's behavior. AA 1 stated, Resident 2 had called Resident 1 a Fat pig. AA 1 stated, about three weeks ago, AA 1 told the SSD about the arguments and requested a room change for Resident 1. Resident 1 had asked several times for a room change. AA 1 stated, he knew Resident 1 and Resident 2 had problems for about a month but was not sure if it was documented in both residents' charts. AA 1 stated the incident could have been avoided had Resident 1 been moved to another room as requested. During a review of Resident 1's Face Sheet, the face sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnosis included depression (mood disorder that causes a persistent feeling of sadness and loss of interest with daily activities), generalized muscle weakness and HTN. During a review of Resident 1's medical records, the initial H&P dated 12/27/2021, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's care plan titled Resident has an episode of physical altercation with another resident dated 7/31/2022, the care plan's interventions indicated the staff will do the following: 1. Perform frequent visual checks. 2. Evaluate the nature and circumstances of physical behavior with others. 3. Encourage the resident to seek staff support for distress mood. 4. Observe Resident 1 for non-verbal signs of physical aggression and remove the resident from the environment, if needed. During a review of Resident 1's MDS dated [DATE], the MDS indicated Resident 1 was able to understand and be understood by others. The MDS indicated Resident 1 required staff supervision with bed mobility, transfer, eating, and in personal hygiene. The MDS indicated Resident 1 required a one person assist walking, dressing and in toilet use. The MDS indicated Resident 1 used a walker or wheelchair for mobility. During a review of Resident 1's COC dated 10/20/2022, the COC indicated Resident 1 had an altercation with his roommate, Resident 2 and Resident 1 was allegedly punched in the face and fell on the floor. During a review of Resident 1's Progress Notes dated 10/21/2022 at 11:22 a.m., the notes indicated Resident 1 reported he got into an altercation with Resident 2 when Resident 2 placed his food tray on his (Resident 1's) wheelchair. The progress notes indicated Resident 1 stated Resident 2 hit him on his right jaw. During a review of Resident 1's psychological consult notes dated 10/4/22, the notes indicated Resident 1 endorsed feeling depressed, and anxious from multiple stressors. The notes indicated staff reported that the resident had mood swings and agitation. The notes indicated the staff will continue with Resident 1's treatment to decrease agitation, angry outburst and increase calm. During a review of Resident 1's psychological consult notes dated 10/11/22, the notes indicated Resident 1 endorsed feeling depressed, anxious, on edge and tensed from multiple stressors. The notes indicated staff reported that the resident had mood swings and agitation. The notes indicated staff will continue Resident 1's treatment to address the resident's physical challenges, reduce pain intensity and dysphoric mood (a consistent state of profound unhappiness and dissatisfaction). During an interview on 10/31/2022 at 2:22 p.m., with the SSD, the SSD stated, he did not recall Resident 1 requested for a room change. The SSD stated, Resident 1 complained that Resident 2 snored very loud, but he did not ask for a room change. The SSD stated, he was not informed Resident 1 and Resident 2 were arguing before the incident. He (SSD) would have moved Resident 1 to another room, to prevent any physical altercations and emotional distress. During an interview on 10/31/2022 at 4:21 p.m., with the Administrator (ADM), the ADM stated, when the staff reported that Residents 1 and 2 were not getting along, one of them (Resident 1 and 2) should have been moved to another room to prevent any issues down the road. The ADM stated, Resident 1 and Resident 2 could be emotionally damaged if the arguments continued. During a review of the facility's policy and procedure titled, Abuse Prohibition dated 10/24/2022, the policy indicated, the facility will provide adequate supervision when the risk of resident-to-resident to altercation was suspected. It also indicated an option for room changes will be provided based on the situation. During a review of the facility's Policy and procedure titled, Room Transfers dated, 3/9/2020, the policy indicated, staff may initiate room changes based on efforts to comply with room change requests from residents and/or family members: or to facilitate appropriate patient care, to provide for the safety and wellbeing of residents During a review of the facility's Policy and procedure titled, Social Services Director dated, 4/1/2011, the policy indicated, staff were to advocate for residents' rights, promote actions that maintained each resident's dignity, individual needs, preferences, and choices.

Based on interview and record review the facility failed to ensure one of three sampled residents (Resident 1) who required a two-person assistance with bed mobility and toilet use received adequate assistance while being changed. CNA 3 changed Resident 1 without assistance and Resident 1 fell on to the floor. According to the facility Resident 1 was lowered to the ground by CNA 3 This deficient practice resulted in an avoidable fall for Resident 1. Resident 1 fell from the bed, sustained a right [CONDITION(S)] (broken bone), and required admission to the General Acute Care Hospital (GACH) for right hip surgery. Findings: During a review of Resident 1 ' s admission record, the admission record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 ' s diagnoses included right [CONDITION(S)] (paralysis of one side of the body) and [CONDITION(S)] (weakness or inability to move on one side of body), muscle weakness, and [CONDITION(S)] (loss of ability to understand or express speech). During a review of Resident 1 ' s History and Physical (H&P) dated 3/18/2022, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set ([MDS]), a standardized assessment and care planning tool), dated 5/26/2022, the MDS indicated Resident 1 was usually able to make self-understood and usually able to understand others. The MDS indicated Resident 1 required a two or more-person physical assist with bed mobility and toilet use. During a review of Resident 1 ' s right femur (thigh bone) Radiology (uses medical imaging to diagnose diseases) Result dated 6/15/2022, the radiology result indicated minimally displaced subtrochanteric (area of the hip) fracture (broken bone). During a review of Resident 1 ' s GACH History and Physical/Orthopedic Consult (H&P/OC), dated 6/18/2022 and timed at 11:42 a.m., the H&P/OC indicated Resident 1 had a right intertrochanteric (between the bony protrusions of the thigh bone) femur fracture which required surgery and placement of right femur cephalomedullary (surgical repair of the broken bone) nail on 6/18/2022. During an interview on 6/28/2022, at 11:33 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated, Resident 1 could not get up by herself and required a two (2) person assist for activities of daily living ([ADL], term used to collectively describe fundamental skills required to independently care for oneself) because Resident 1 has right sided weakness and cannot move side to side on her own. CNA 1 stated Resident 1 did get out of bed to the wheelchair but required a Hoyer lift (assistive device used to transfer residents from a bed to a chair). During a concurrent interview and record review, on 6/28/2022, at 11:40 a.m., with Licensed Vocational Nurse (LVN) 1, Resident 1 ' s Situation Background Assessment Recommendation ([SBAR], a communication tool for the health care team about a resident ' s condition), was reviewed. The SBAR for Resident 1 indicated, on 6/15/2022, at 5:10 a.m., CNA 3 was changing Resident 1, CNA 3 rolled Resident 1 to her left side, but the bed was too slippery, and Resident 1 fell off the side of the bed. LVN 1 stated, Resident 1 fell from the left side of the bed while CNA 3 changed Resident 1. During concurrent interview and record review of Resident 1 ' s Fall Care Plan ([CP]), correctly identifies residents existing needs and recognizes potential needs or risks), on 6/28/2022, at 12:00 p.m., with Registered Nurse Supervisor (RN) 1, Resident 1 ' s CP was reviewed. The CP for Resident 1 created on 10/26/2021, indicated Resident 1 was a fall risk. RN 1 stated she was aware Resident 1 was a high fall risk due to Resident 1 ' s right sided weakness, immobility, and prior fall on 3/5/2022. RN 1 stated all staff are responsible to ensure residents did not fall. During a concurrent interview and record review of Resident 1 ' s Interdisciplinary Team ([IDT], approach to healthcare that integrates multiple disciplines through collaboration that ensure residents receive the best care), on 6/28/2022, at 12:05 p.m., with Director of Nursing (DON), Resident 1 ' s IDT notes were reviewed. The IDT for Resident 1 dated, 6/17/2022, at 10:56 a.m., indicated on 6/15/2022, CNA 3 was providing care to Resident 1, while CNA 3 was removing dirty linens from the resident ' s bed, the motion of removing the dirty linen under the resident ' s right hip and leg caused Resident 1 ' s hip to be displaced off the side of the bed. DON stated the IDT notes were written by her (DON) after interviewing CNA 3. DON stated CNA 3 was changing Resident 1 alone when incident occurred. During an interview on 6/30/2022, at 3:32 p.m., with CNA 3, CNA 3 stated Resident 1 had an episode of loose stool, and she (CNA 3) was cleaning Resident 1. CNA 3 stated, she raised Resident 1 ' s bed to the level of her (CNA 3) waist to clean Resident 1 and was standing on the right side of Resident 1 ' s bed, behind Resident 1. CNA 3 stated while cleaning Resident 1, she (CNA 3) pulled Resident 1 towards her, but Resident 1 ' s bed was so slippery due to the air mattress (special mattress use to prevent pressure ulcers) and draw sheet, Resident 1 ended up rolling off the left side of the bed. CNA 3 stated she ran to the left side of the bed and caught Resident 1, then used her (CNA 3) body to guide Resident 1 to the floor. CNA 3 stated Resident 1 was approximately three to four feet from the ground. CNA 3 stated it could have been safer had another staff assisted in repositioning Resident 1, as she (CNA 3) was alone while cleaning Resident 1. CNA 3 stated Resident 1 ' s bed did have assistance rails; though the rails were not high enough to protect Resident 1 from falling. CNA 3 stated Resident 1 could barely reach the rail since it was at the same level as the top of the air mattress. During a concurrent interview and record review of Resident 1 ' s Physical Therapy Notes (PTN), on 7/19/2022, at 9:57 a.m., with Assistant Director of Rehabilitation (ADR), Resident 1 ' s PTN were reviewed. The PTN for Resident 1 indicated, on 6/8/2022, Resident 1 required total assistance for bed mobility rolling left to right. The ADR stated Resident 1 was a full assist, required two or more persons to roll left to right and Resident 1 could not roll left to right by herself. The ADR stated Resident 1 was a fall risk because the air mattress was slippery especially when repositioning the resident. ADR stated the air in the air mattress was unsteady. ADR also stated that Resident 1 had sustained a right femur fracture on 3/5/2022, was making progress with PT but Resident 1 had another fall on 6/15/2022, that resulted in a decline in the resident ' s ability to continue with PT. ADR stated if Resident 1 had not sustained another fall, Resident 1 could have had so much more progress rather than having to start all over again with PT. During a concurrent interview and record review of Resident 1 ' s MDS on 7/19/2022, at 11:35 a.m., with MDS Nurse (MDSN), Resident 1 ' s MDS and CPs were reviewed. The MDS dated [DATE], indicated Resident 1 required a two person assist with activities of daily living. There was no care plan prior to the fall noted in the resident ' s record. The CP Resident at Exhibits/Risk for fractures dated 6/15/2022, indicated Resident 1 requires a two-person assist for care and ADLs. MDSN 1 stated Resident 1 ' s CP was developed after the fall and there was no prior CP regarding two person assist. MDSN further stated a CP should have indicated the resident should have been a two person assist prior to the fall. MDSN 1 stated based on Resident 1 ' s history of falls and right sided weakness, the resident should always have two-person assistance with bed mobility, for safety reasons. MDSN 1 stated if Resident 1 ' s CP was updated per the MDS on 5/26/2022, then nursing could have informed care staff (CNAs and other team members) that Resident 1 required a two-person assistance with ADLs to prevent Resident 1 from falling. MDSN stated Resident 1 ' s fall should not have happened and could have been avoided. During a review of the facility ' s Certified Nursing Assistant Job Description, revised 6/27/2017, the CNA Job Description indicated responsibilities and accountabilities include participation in the care planning process and implementing care according to the care plan. During a review of the facility ' s Policy and Procedure (P/P), titled Fall Management, dated 5/26/2021, the P/P indicated patients will be assessed for fall risk as part of the nursing assessment process, those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury, to communicate patient ' s fall risk status to caregivers, update care plan to reflect new interventions.

Based on interview and record review, the facility failed to provide pressure ulcer care, treatment, and services for one of three sampled residents (Resident 1) to address and meet the resident's needs. This deficient practice resulted in Resident 1, who was admitted with no pressure ulcer developing an infected Stage 4 pressure ulcer (full thickness extends deep into the muscle, tendons, ligaments, or bones) on the sacrococcyx (tail bone) measuring 4.6 centimeter ([cm] units of measurement) in length, 4.5 cm width, and 0.3 cm deep with moderate fluid, slough ([shedding of dead tissue], and black eschar [a dry, dark scab of dead skin]) and experiencing pain. Resident 1 was receiving [MEDICATION(S)] (strong opioid used to treat pain) 5 micrograms ([mcg] unit of measurement)/hour (hr) patches for pain and was found to have 3 patches on her body (leg, buttocks, and shoulder) on 6/15/2021 at the general acute care hospital (GACH). Resident 1 had an order to receive only one patch. The old patches were not removed. This deficient practice had the potential to result in [MEDICATION(S)] toxicity (poisonous) and overdose (an excessive amount of medication) which could lead to uneven heartbeats, sedation (decreased awareness and responsiveness), coma (state of unconsciousness), respiratory depression or failure (breathing stops), and death. On 6/23/2021 at 4:22 p.m., the Administrator (ADM) and the Director of Nursing (DON), were notified of an Immediate Jeopardy ([IJ], a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) due to the facility's inability to assess, identify, treat and monitor daily the development of Resident 1's pressure ulcer. The facility's ADM and DON were notified of the immediacy and seriousness of the residents' health and safety being threatened. On 6/24/2021, at 3 p.m., the ADM submitted an acceptable Plan of Action (POA) for the correction of the IJ which included: 1. Resident 1 no longer reside in the facility as of 6/14/2021. A licensed nurse performed a skin sweep (skin check) to all in-house residents on 6/23/2021 and 6/24/2021 and identified six residents with new skin injury (Resident 6, 7, 8, 9, 10, 11). The residents identified were assessed, and their physician and responsible party were informed of the changes. Should Resident 1 return to the facility, the facility would ensure the accuracy of any medication patch order to include the site of administration with site rotation orders, duration and time of administration and removal and proper dosage of medicated patches. 2. Skilled wound care physician assessed and evaluate identified pressure injuries (of Resident 6, 7, 8, 9, 10, 11) on 6/24/21 for treatments and management. 3. The nurse educator initiated an in-service for certified nurse assistants (CNAs) on 6/23/2021, 6/24/2021 and to be completed 100% by 6/28/2021 about utilizing the Daily Body Check Form related to the following: a. Pressure injury identification. b. Pressure injury report d. Pressure injury management 4. The nurse educator initiated an in-service for licensed nurses on 6/23/2021 and 6/24/2021 and to be completed 100% by 6/28/2021 related to the following: a. Skin management policies and procedures. b. Pressure injury identification and reporting utilizing daily body check form. c. Pressure injury skin assessment accuracy related location, appearance, and measurements. d. Person center care planning interventions and implementation. e. Change of condition initiation and notification process. f. Wound documentation and treatments. 5. The Vice President Clinical Operations provided an in-service education to the interdisciplinary team ([IDT] a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident) on 6/24/2021 related to the following: a. IDT review and evaluation process b. Individualized care planning process and evaluation 6. The CNAs will submit a daily body check form by the end of shift to their individual charge nurse and the charge nurse will assess any identified skin issues initiating a change of condition and care plans. 7. The DON will discuss any identified pressure injury during daily stand up meeting Monday through Friday for further review and interventions. 8. A licensed nursing staff and or designee will perform skin inspection twice a month and as needed to all residents to capture new and or declining skin breakdown. Findings will be reported to the DON and or designee for further review and management. Findings will be presented to the quality assurance ([QA] is the coordinated application of one reinforcing aspects of a quality management system) committee for review and further evaluation and recommendation monthly. The QA committee will continue to review the results until it has been proven to be resolved for three consecutive months and or advised by the QA committee, the skin inspections will be performed on an as needed basis. 9. The IDT will conduct team discussion on any reported pressure injuries and or wounds to capture root cause and develop individualized plan of interventions to manage risk outcomes. 10. The DON or designee will discuss patterns and concerns regarding skin management to the QA committee meeting month, for three months, for further recommendation and interventions and will be re-evaluated thereafter for continued compliance. 11. Licensed Nurses will use a body diagram provided by consulting pharmacy to indicate the site and date of administration; nurses will use topical (skin area) patch administration record to sign for the application of a new patch and the removal of a used medication patch. 12. The facility nurse educator had initiated in-services starting on 6/23/2021 with the licensed nurses on medicated patch administration and removal. a. Write on the patch the time, date, and who administered the patch. b. Follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . c. Adherence to policy and procedure on Patch Medication Administration. d. Licensed nurses will utilize the Monthly Administration Record for topical patches and Topical Patch Medication Administration Count sheet for narcotic patches. The nurse educator would complete in-service of all licensed nurses 100% on or before 6/28/2021. The nurses will not be allowed to perform direct patient care not until he/she has completed this in-service on medication patch administration. On 6/24/2021 at 4:23 p.m., while onsite, the surveyor verified and confirmed the POA was implemented through observation, interviews, and record reviews, including in-services provided to the licensed nurses by the nurse educator, and the IJ was removed. The ADM and DON were notified. Findings: During a review of Resident 1's Admission Record (Face Sheet), the face sheet indicated Resident 1 was admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Braden Scale (assessment tool used for predicting the risk of pressure ulcers) for Predicting Pressure Sore Risk, dated 4/10/2021, the scale indicated Resident 1 had a mild risk to develop a pressure ulcer. During a review of Resident 1's the Skin Integrity Report dated 5/11/2021, the report indicated Resident 1 had a Stage 4 pressure ulcer to the sacrococcygeal measuring 4.6 cm in length, 4.5 cm in width, and 0.3 cm deep with moderate serous (thin watery fluid) sanguineous (blood) fluid, slough, and black eschar in the sacrococcyx. On 6/9/2021 the report indicated Resident 1 had pain, required to be medicated and the pressure ulcer measured 5.2 cm in length, 4.8 cm in width, 0.5 cm in depth, with slough, eschar, moderate fluid. During a review of Resident 1's Progress Notes, dated 5/11/2021 and timed at 1:37 p.m., the note indicated Resident 1 had an open wound on the sacrococcygeal area. On 6/9/2021 and timed at 6:57 p.m., the note indicated Resident 1 had an infection to the sacrococcygeal pressure ulcer with a strong odor and drainage. During a review of Resident 1's Minimum Data Set ([MDS] a standardized care screening and assessment tool), dated 5/18/2021, the MDS indicated Resident 1 was usually able to make herself understood and sometimes was able to understand others. The MDS indicated Resident 1 was totally dependent of a one-person physical assist for locomotion on and off the unit, dressing, and toilet use. The MDS indicated Resident 1 was at risk to develop a pressure ulcer and had an unhealed, Stage 4 pressure ulcer. During a review of Resident 1's Surgical Consult dated 5/19/21, the surgical consult indicated Resident 1 receive management for sacrococcyx wound. The Surgical consult report indicated Resident 1 sacrococcyx wound had an area of slough and necrotic (dead cells) tissue visible along the surface and base of the exposed tissue. The record indicated the sacrococcyx wound measured 4.5 cm in length, 4.3 cm in width and 0.3 cm in depth. The record indicated the sacrococcyx wound was debrided (removal of dead [necrotic] or infected skin tissue). During a review of Resident 1's Order Summary Report dated 5/28/2021, the summary indicated Resident 1 had an order dated 5/11/2021 for a low air mattress (mattress used to prevent and treat pressure ulcers) and pressure ulcer treatment. During a review of Resident 1's COC dated 6/9/2021, indicated Resident 1 had an infection in the sacrococcyx pressure ulcer that contained fluid and a strong odor. During a review of Resident 1's progress notes dated on 6/14/2021 and timed at 3:56 p.m., the note indicated Resident 1's physician requested Resident 1 to be transferred to the GACH. During a review of Resident 1's GACH Emergency Treatment Records (ETR), dated 6/15/2021 and timed 12:31 a.m., the ETR indicated Resident 1 was transferred to the hospital due to inability to eat and drink for one month. The ETR indicated Resident 1 was moaning, thin, and appeared cachectic (condition that causes extreme weight loss and muscle wasting). During a review of Resident 1's GACH progress note dated 6/16/2021 and timed at 11:59 a.m., the note indicated Resident 1 had a severe, unstageable (unable to determine the depth) pressure ulcer (in the sacrococcyx), with superficial infection that was highly concerned for neglect (failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress). The note indicated Resident 1 was evaluated for pressure ulcer surgical intervention, but Resident 1 was unlikely to tolerate the procedure due to her poor nutritional status. During a review of Resident 1's GACH Social Worker Notes, dated 6/16/2021 and timed 3:07 p.m., the note indicated the GACHs' physician reported Resident 1's overall presentation was consistent with neglect. During a review of Resident 1's GACH Wound Consultation, dated 6/17/2021 and timed at 10:42 a.m., the note indicated Resident 1 had a large, unstageable, pressure ulcer wound in the sacral area. The consult plan indicated Resident 1 was expressing pain and performing a surgical procedure to her pressure ulcer would improve her quality of life During an interview on 6/21/2021, at 1:27 p.m., the DON stated Resident 1 was admitted to the facility without a pressure ulcer. The DON stated Resident 1 was sent to the GACH for failure to thrive (syndrome of weight loss, decreased appetite, poor nutrition, inactivity, dehydration, and depressive symptoms). The DON stated Resident 1's sacrococcyx pressure ulcer was infected. During a concurrent interview and review of Resident 1's treatments on 6/21/2021, at 2:36 p.m., the Treatment Nurse (Tx Nurse 1) stated Resident 1 was admitted on [DATE] with no pressure ulcers. Tx Nurse1 stated Resident 1 was identified to have an unstageable pressure ulcer that broke into a Stage 4 pressure ulcer on 5/11/2021. The Tx Nurse stated Resident 1 was frail, could not turn in bed by herself, and did not have an air mattress prior to developing the pressure ulcer. The Tx Nurse stated Resident 1 pressure ulcer could have been prevented if the staff paid more attention to her, reported the pressure ulcer earlier, and repositioned Resident 1 earlier on. During an interview on 6/22/2021 at 2:49 p.m., Licensed Vocational Nurse 6 (LVN 6) stated Resident 1 was small, bed bound, slept a lot and was usually in bed. LVN 6 stated she assessed Resident 1 sacrococcygeal (tailbone) when was first reported and the pressure ulcer looked really bad, unstageable with necrotic tissue and slough. LVN 6 stated she thought Resident 1's pressure ulcer developed overnight but she did not understand how the wound could look so bad without anyone reporting. During an interview on 6/23/2021, at 4:04 p.m., Tx Nurse 1 stated the Certified Nursing Assistants (CNAs) notified her when the residents have something unusual in the skin. TX Nurse 1 stated she did weakly skin assessment when residents had a pressure ulcer. TX Nurse 1 stated when she initially assessed Resident 1 coccygeal pressure ulcer, Resident 1 had necrotic tissue. Tx Nurse 1 stated if staff had turned and checked on Resident 1, they would have prevented Resident 1 from developing a pressure ulcer. During an interview on 6/24/2021, at 12:01 p.m., Family Member (FM 1) stated she received a call from the GACH notifying her Resident 1 was admitted to the GACH on 6/17/2021 and was informed by the GACH's physician he was concerned of the conditions of how Resident 1 had arrived to the GACH and believed the facility neglected Resident 1. FM 1 stated the GACH physician told her the pressure ulcer was deep into the bone and Resident 1 lost all her protein fighting to heal the pressure ulcer. FM 1 stated when the staff turned Resident 1, she screamed in pain. b. During a review of Resident 1 Situation, Background, Appearance, and Review Communication form (internal communication tool) dated 5/11/21, the form indicated the resident's left leg was contracted (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). The form indicated a new order to apply [MEDICATION(S)] transdermal (attaches to the skin) patch 5 mcg/hr to the skin every 7 days. During a review of the Order Summary Report dated 5/28/2021, the report indicated on 5/12/2021 there was an order to apply one [MEDICATION(S)] transdermal patch 5 mcg/hr every 7 days for pain management to Resident 1. The order indicated to rotate the (body) site with every new patch application. The order indicated not to repeat applying the patch to the same site for 21 days and to remove the [MEDICATION(S)] transdermal patch as scheduled. During a review of Resident 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . was applied to the resident. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The location (body site) of the applied and removed transdermal patch was not documented. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's MAR for the month of June 2021 indicated Resident 1 received two [MEDICATION(S)] transdermal patches, on 6/2/2021 and 6/9/2021. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Controlled Drug Record form dated 6/9/2021 at 9 am, the record indicated a [MEDICATION(S)] transdermal patch (number 2) 5 mcg/hr was applied to Resident 1. The record indicated on 6/9/2021 at 8:59 a.m., [MEDICATION(S)] transdermal patch (number 3) 5 mcg/hr. was removed from Resident 1. The record did not show which body part the patches were applied to and removed from. During a review of Resident 1's Situation, Background, Appearance, and Review Communication form ([SBAR] an internal communication tool), dated 6/14/2021, the SBAR indicated Resident 1 had a decline of functional mobility and had no appetite and sustained a significant weight loss. The SBAR form indicated Resident 1 was transferred to GACH (on 6/15/2021). During a review of Resident 1's Progress Note dated 6/14/2021 at 3:56 p.m., the progress note indicated the resident was noted with a change of condition. The notes indicated Resident 1 was noted with functional decline and decreased mobility. The notes dated 6/15/2021 at 10 p.m., Resident 1 was sent to the GACH for failure to thrive (syndrome of weight loss, decreased appetite, poor nutrition, inactivity, dehydration, and depressive symptoms). During a review of Resident 1's GACH History and Physical (H/P), dated 6/15/2021 and timed at 12:55 a.m., indicated Resident 1 was admitted to the GACH for failure to thrive and poor oral intake. The H/P indicated upon arrival, Resident 1 was found to have two [MEDICATION(S)] 5 mcg/hr patches, one patch was dated as 6/9/2021 and the second patch was undated. During a review of GACH's Nursing Progress notes dated 6/15/2021 at 3:01 p.m., the progress notes indicated Resident 1 had two (2) [MEDICATION(S)] transdermal patches 5 mcg/hr. The notes indicated one patch was on the left hip and one patch on the left shoulder. The notes indicated one of the patches (body site was not identified) was dated 6/9/2021. During a review of the GACH Hospitalist Progress Note dated 6/16/2021, and timed at 11:59 a.m., the progress note indicated three different [MEDICATION(S)] 5 mcg patches were still applied to Resident 1's body, only one with a written date of 6/9/21 (body site not specified) and the others were unlabeled and in different locations of the body, including leg, buttocks, and shoulder. The resident's condition was highly concerning for neglect. During a review of the GACH titled Social Worker Notes dated 6/16/2021, and timed 3:07 p.m., the social worker notes indicated the (GACH) physician reported Resident 1 had a severe, unstageable pressure ulcer on her sacral and was found to have three high dose [MEDICATION(S)] patches on her body. The (GACH) physician reported Resident 1's presentation was consistent with neglect. During a review of Resident 1's care plan titled, at risk for alteration in comfort related to immobility revised on 6/16/2021, indicated Resident 1 had an intervention to receive [MEDICATION(S)] patch weekly 5 mcg/hr for pain. The care plan did not provide any instructions for the use of the patch. During an interview on 6/21/2021, at 10:40 a.m., Licensed Vocational Nurse 1 (LVN 1) stated before applying a medication patch to a resident she had to check the order. LVN 1 stated after applying a medication patch to a resident, she had to date, time, and initial, the patch. LVN 1 stated it was important to follow the orders before applying a pain patch medication. LVN 1 stated before applying a patch with pain medication, she had to remove the old patch to prevent the resident from receiving a double dose of the pain medication. LVN 1 stated if the resident pain patch was not removed before applying a new one the resident could have cognitive impairment (ability to think, understand and make daily decisions) and lose appetite. During an interview on 6/21/2021, at 1 p.m., the MDS Assistant stated the facility received a complaint from Resident 1's family members and the hospital alleging Resident 1 was found in the GACH with three pain patches of [MEDICATION(S)]. During an interview on 6/21/2021, at 1:27 p.m., the DON stated Resident 1 was send to the GACH for failure to thrive. The DON stated Resident 1's family came to the facility on [DATE] and stated Resident 1 was found in the GACH with three pain patches. During an interview on 6/22/2021, at 2:26 p.m., in the presence of the DON, the Consultant Pharmacist stated many things could happen to a resident when they have extra patches of [MEDICATION(S)]. The pharmacist consultant stated the used [MEDICATION(S)] patch should be removed before applying a new patch on and the medication administration should follow the manufacture direction. The consultant pharmacist stated [MEDICATION(S)] side effects included confusion, behavior changes, constipation, nausea, and headache. During a review of the facility's policy and procedures titled, Abuse Prohibition, revised 4/9/21, indicated the center prohibited neglect which was defined as the failure of the facility, its employees, or service providers to provide goods and services to a patient that were necessary to avoid physical harm, pain, mental anguish, and emotional distress. The policy indicated a purpose to do all that was within their control to prevent occurrences of neglect for all patients.

Based on interview and record review, the facility failed to follow physician's order, remove transdermal patches (the application of a medicine or drug through the skin, typically by using an adhesive patch, so that it is absorbed slowly into the body) prior to applying a second patch, and document the site and date of transdermal patch application as indicated on the facility's policy and procedures (P/P) for two of three sampled residents (Resident 1 and 2). Resident 1, who had a physician's order for [MEDICATION(S)] (strong opioid [class of highly addictive drugs] used to treat pain) transdermal patch 5 micrograms ([mcg] unit of measurement) per hour (hr) for pain, did not have the patch applied every 7 days and the site of the patch rotated, and ensure the patch was not applied to the same site for 21 days. Resident 1 was found with three [MEDICATION(S)] transdermal patches on her body (legs, buttocks, and shoulder) while at the general acute care hospital (GACH), one of the [MEDICATION(S)] patches was dated 6/9/2021 and the other patches were undated and untimed. Resident 2, who had a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 2 had undated, untimed and without initials [MEDICATION(S)] patch on bilateral (both) knees after 24 hrs. These deficient practices had the potential to result in [MEDICATION(S)] and [MEDICATION(S)] toxicity (poisonous) and overdose (an excessive amount of medication) which could lead to uneven heartbeats, sedation (decreased awareness and responsiveness), coma (state of unconsciousness), respiratory depression or failure (breathing stops), and death. On 6/23/2021 at 4:22 p.m., the Administrator (ADM) and the Director of Nursing (DON), were notified an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) due to the facility's inability to provide the necessary care and services according to the professional standards by administering, assessing, and monitoring Resident 1 and 2, who were administered [MEDICATION(S)] and [MEDICATION(S)] patches. The facility's ADM and DON were notified of the immediacy and seriousness of the residents' health and safety being threatened. On 6/24/2021 at 3 p.m., the ADM submitted an acceptable Plan of Action (POA) for the correction of the IJ which included: 1. Resident 1 is no longer at the facility. Should Resident 1 return to the facility, the facility would ensure the accuracy of any medication patch order to include the site of administration with site rotation orders, duration and time of administration and removal and proper dosage of medicated patches. 2. Licensed Nurses will use a body diagram provided by consulting pharmacy to indicate the site and date of administration; nurses will use topical (skin area) patch administration record to sign for the application of a new patch and the removal of a used medication patch. 3. The facility nurse educator had initiated in-services starting on 6/23/2021 with the licensed nurses on medicated patch administration and removal. a. Write on the patch the time, date, and who administered the patch. b. Follow physician's orders when administering medication but not limited to [MEDICATION(S)] patch. c. Adherence to policy and procedure on Patch Medication Administration. d. Licensed nurses will utilize the Monthly Administration Record for topical patches and Topical Patch Medication Administration Count sheet for narcotic patches. The nurse educator would complete in-service of all licensed nurses 100% on or before 6/28/2021. The nurses will not be allowed to perform direct patient care not until he/she has completed this in-service on medication patch administration. 4. Resident 2 was re-assessed by a licensed nurse on 6/21/2021 for any possible effects of having two [MEDICATION(S)] patches found on the body. Resident 2 had no skin breakdown or skin irritation on the knees where the patches were placed. 5. Resident 2 had a change of condition initiated on 6/21/21 for the prolonged application of [MEDICATION(S)] patches. The attending physician and the Medical Director and Residents 2's responsible party were made aware of the change of condition. 6. Resident 2's physician performed an assessment on the resident on 6/24/2021 and found no adverse effects due to the prolonged application of the [MEDICATION(S)] patches. 7. The facility nurse educator had initiated in-services starting on 6/23/2021 with the licensed nurses on the importance of the following physician orders when administering patch medications. a. Write on the patch the time, date, and initial of when it was applied. b. Following physician's orders when administering medications but not limited to [MEDICATION(S)] patch. c. Adherence to policy and procedure on Patch Medication Administration. The nurse educator will complete in-service of all licensed nurses 100% on or before 6/28/2021. The nurses will not be allowed to perform direct patient care not until he/she has completed this in-service on medication patch administration On 6/24/2021 at 4:23 p.m., while onsite, the Department verified and confirmed the POA was implemented through observation, interviews, and record reviews including in-services provided to the licensed nurses by the nurse educator and the IJ was removed. The ADM and DON were both notified. Findings: a. During a review of Resident 1's Admission Record indicated the resident was admitted to the facility on [DATE] and last readmitted on [DATE]. The Admission Record indicated Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1 Situation, Background, Appearance, and Review Communication form (internal communication tool) dated 5/11/21, the form indicated the resident's left leg was contracted (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). The form indicated a new order to apply [MEDICATION(S)] transdermal patch 5 mcg/hr. to the skin every 7 days. During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening and tool, dated 5/18/2021 indicated Resident 1 was usually able to make self-understood and sometimes understood others. The MDS assessment indicated Resident 1 was totally dependent on one-person for locomotion on and off the unit, dressing, and toilet use. During a review of the Order Summary Report dated 5/28/2021, the report indicated on 5/12/2021 there was an order to apply one [MEDICATION(S)] transdermal patch 5 mcg/hr. every 7 days for pain management to Resident 1. The order indicated to rotate the site with every new patch application. The order indicated not to repeat applying the patch to the same site for 21 days and to remove the [MEDICATION(S)] transdermal patch as scheduled. During a review of Resident 1's MAR for the month of June 2021, the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . was applied to the resident. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . was removed and at 9 a.m. and a new patch applied. The location (body site) of the applied and removed transdermal patch was not documented. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's MAR for the month of June 2021 indicated Resident 1 received two [MEDICATION(S)] transdermal patches, on 6/2/2021 and 6/9/2021. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Controlled Drug Record form dated 6/9/2021 at 9 am, the record indicated number 2 [MEDICATION(S)] transdermal patch 5 mcg/hr. was applied to Resident 1. The record indicated on 6/9/2021 at 8:59 a.m., number 3 [MEDICATION(S)] transdermal patch 5 mcg/hr. was removed from Resident 1. The form record did not show which body part the patches were applied to and removed from. During a review of Resident 1's Situation, Background, Appearance, and Review Communication form ([SBAR] an internal communication tool), dated 6/14/2021, the SBAR indicated Resident 1 had a decline of functional mobility and had no appetite and sustained a significant weight loss. The SBAR form indicated Resident 1 was transferred to GACH (on 6/15/2021). During a review of Resident 1's Progress Note dated 6/14/2021 at 3:56 p.m., the progress note indicated the resident was noted with a change of condition. The notes indicated Resident 1 was noted with functional decline and decreased mobility. The notes dated 6/15/2021 at 10 p.m., Resident 1 was sent to the GACH for failure to thrive (syndrome of weight loss, decreased appetite, poor nutrition, inactivity, dehydration, and depressive symptoms). During a review of the GACH's History and Physical (H/P) assessment form dated 6/15/2021 at 12:55 a.m., the form indicated Resident 1 was admitted to the GACH for failure to thrive and poor oral intake. During a review of GACH's Nursing Progress notes dated 6/15/2021 at 3:01 p.m., the progress notes indicated Resident 1 had two (2) [MEDICATION(S)] transdermal patches 5 mcg/hr. The notes indicated one patch was on the left hip and one patch on the left shoulder. The notes indicated one of the patches (body site was not identified) was dated 6/9/2021. During a review of the GACH Hospitalist Progress Note dated 6/16/2021, and timed at 11:59 a.m., the progress note indicated three different [MEDICATION(S)] 5 mcg patches were still applied to Resident 1's body, only one with a written date of 6/9/21 (body site not specified) and the others were unlabeled and in different locations of the body, including leg, buttocks, and shoulder. During a review of Resident 1's Care Plan at risk for alteration in comfort related to immobility revised on 6/16/2021, the care plan indicated the intervention was to receive [MEDICATION(S)] transdermal patch 5 mcg/hr on a weekly basis for pain. The interventions on the care plan did not provide specific instructions for the use of the patch. During a concurrent interview and record review (the MAR) on 6/21/2021 at 2:11 p.m., Licensed Vocational Nurse 2 (LVN 2) stated she applied the pain patch to Resident 1 once (date not specified), but she took the old [MEDICATION(S)] patch off prior to applying a new patch. LVN 2 stated she did not remember which side of the body the patch was applied to but if the old patch was on the right side of Resident 1's arm, then the new patch was applied to the left side but she could not specifically recall. LVN 2 stated she destroyed the old patch with Registered Nurse 1 (RN 1). LVN 2 stated she documented in the medication sheet and the back of the MAR. LVN 2 stated she did not know the reason why the application of the patch to Resident 1 was not documented in the medication sheet. During an interview on 6/22/2021 at 2:39 p.m., DON stated the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated Resident 1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated no one caught or changed the MAR forms to show the body part the patch was being applied to. b. During a review of Resident 2's Admission Record indicated the resident was admitted to the facility on [DATE] and last readmitted on [DATE]. The Admission Record indicated Resident 2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 2's MDS assessment dated [DATE], the MDS indicated the resident was usually able to make self-understood and was able to understand others. The MDS assessment indicated Resident 2 was totally dependent on one-person physical assist for bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. During a review of Resident's 2 Order Summary Report dated 6/9/2021, the report indicated the resident had an order dated 5/17/2021 for [MEDICATION(S)] patch 5% to be applied to both knees for pain management. The order indicated the [MEDICATION(S)] patch was to be applied to the skin every day for 12 hours (hr) and removed for 12 hours in the 24-hour period. During a review of Resident 2's Care Plan revised on 6/9/2021, the care plan indicated the resident was at risk for alteration in comfort related to immobility. The Care Plan interventions included to administer the medication for pain as ordered. The Care Plan intervention, updated on 6/24/2021, indicated to apply [MEDICATION(S)] patch 5% to bilateral knees topically (over the skin) for pain management every day. The Care Plan intervention indicated to leave the patch on for 12 hours and remove the patch after 12 hours within a 24-hr. period. During a review of Resident 2's MAR for the month of June 2021, the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 6/21/2021 at 10:40 a.m., Licensed Vocational Nurse 1 (LVN 1) stated before applying a medication patch to the resident, she had to check the order. LVN 1 stated after applying a medication patch to a resident, she had to date, time, and initial the patch. LVN 1 stated it was important to follow the orders before applying a transdermal patch medication. LVN 1 stated before applying a new patch, the staff had to remove the old patch to prevent the resident from receiving a double dose of pain medication. LVN 1 stated if the resident's pain patch was not removed before applying a new one, the resident could suffer side effects (a secondary, typically undesirable effect of a drug or medical treatment), such as cognitive impairment (ability to think, understand and make daily decisions) and lose their appetite. During a concurrent observation and interview on 6/21/2021 at 10:53 p.m., Resident 2 stated she had two [MEDICATION(S)] patches, one to her right knee, and one applied to the left knee. During observation, Resident 2's right and left knees had a [MEDICATION(S)] patch 5% that was not dated, timed, and there were no initials to show who applied the patches. Resident 2 stated the patches were applied on 6/20/2021. Resident 2 stated the staff sometimes took the patches off in the evening and sometimes they did not. During an observation and interview on 6/21/2021 at 11:58 a.m., LVN 2 stated she changed Resident's 2 [MEDICATION(S)] patch on 6/21/2021 at around 10:15 a.m. LVN 2 acknowledged Resident 2's [MEDICATION(S)] patches applied to the knees on 6/20/2021 should have been removed on 6/20/2021 at 9 p.m. LVN 2 stated she did not remember if the patch (that was removed) were labeled. LVN 2 stated she applied the new patch and dated it 6/21/2021. LVN 2 stated she did not add the time to the patch as the time was in the MAR. During an interview on 6/21/2021 at 12:04 p.m., LVN 2 stated after she was told about the old [MEDICATION(S)] patches on Resident 2's knees she took them off, threw the old patches out and applied the new patches. LVN 2 stated she knew she could apply a new patch on because after 12 hours the [MEDICATION(S)] patch was ineffective. LVN 2 stated she did not report about Resident 2's [MEDICATION(S)] patches were not removed on 6/20/2021 (at 9 p.m.). During a concurrent observation and interview on 6/21/21 at 12:21 p.m., LVN 3 stated the [MEDICATION(S)] patches and the narcotic patches needed to be removed from the resident before applying a new patch because the resident could receive higher doses of the medication and suffer an overdose. During an interview on 6/21/2021 at 1 p.m., the MDS Assistant stated Resident 1 was sent to the GACH because she had a decrease level of consciousness, was not eating, and was weak. The MDS Assistant stated the staff documented the administration of medication patches in the nurse's notes, which included the body site where it was applied. The MDS Assistant stated when the patch was removed the staff documented it in the narcotic sheet. During an interview on 6/21/21 at 4:15 p.m., the DON stated LVN 4 told him on 6/20/2021 that Resident 2 refused for the [MEDICATION(S)] patch to be removed. The DON stated when the staff found the [MEDICATION(S)] patches on the resident (on 6/21/2021), they had to take the old patch off, complete a change of condition form, notify the family, and the physician. The DON stated LVN 2 should had never applied a new [MEDICATION(S)] patch to Resident 2 (on 6/21/2021) until she had spoken with the physician. During an interview with the facility's Pharmacy Consultant on 6/22/2021 at 2:26 p.m., the Pharmacy Consultant stated many things could happen to the resident when there were extra patches of [MEDICATION(S)] applied to them. When asked what could happen the Consultant Pharmacist stated it was hard to speculate what could happen to the resident. When asked if the resident could continue to receive the medication if the patch was left on the skin, the Consultant Pharmacist stated she did not have that information. The Consultant Pharmacist confirmed the used [MEDICATION(S)] transdermal patch had to be removed before applying a new patch and the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The Consultant Pharmacist stated that some of the side effects when using [MEDICATION(S)] patch included confusion, behavior changes, constipation (hard stool), nausea, and headache. During a review of facility's manufacturer's instructions provided by the facility's Pharmacy Consultants dated 6/22/2021, the instructions indicated [MEDICATION(S)] transdermal patch could cause serious, life threatening, or fatal respiratory depression (a breathing disorder characterized by slow and ineffective breathing). The instructions indicated the elderly with chronic pulmonary disease, cachectic (a general state of ill health involving marked weight loss and muscle loss), or debilitated were at increased risk of life-threatening respiratory depression because they may have altered pharmacokinetics (how the medication moves through the body) or altered clearance compared to younger patients. The instructions indicated to monitor closely especially upon initiation or following a dose increase. The manufacturer's instructions indicated when patients had an overdose the patch must be removed and continued medical monitoring was required because of the possibility of extended effects as [MEDICATION(S)] continues to be absorbed from the skin. The manufacturer's instruction indicated to apply [MEDICATION(S)] exactly as prescribed by the healthcare provider and to not apply more than 1 patch at the same time unless instructed by the healthcare provider. During a review of The DailyMed.gov (a website operated by the U.S. National Library of Medicine to publish up-to-date and accurate drug labels to health care providers and the general public) website, dated 12/14/2020, indicated excessive dosing occur by applying the [MEDICATION(S)] patch to larger areas or for longer than the recommended wearing time could result in increased absorption of [MEDICATION(S)] and high blood concentrations leading to serious adverse effects (a harmful or abnormal result). The [MEDICATION(S)] administration instruction indicated to apply the patch only once for up to 12 hours within a 24-hour period. During an interview on 6/23/2021 at 11:35 a.m., LVN 4 stated that on 6/20/2021 at 9 p.m., the [MEDICATION(S)] patches were not removed from Resident 2. LVN 4 stated she went to Resident 2's room but the resident had her eyes closed so she decided to return later to remove the [MEDICATION(S)] patches. LVN 4 stated she forgot to return to Resident 2 to remove the patches. LVN 4 reviewed Resident 2's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN 4 stated she did not know who documented Resident 2's patches were removed (on 6/20/2021 at 9 p.m.) but she was not the one who documented that in the MAR. LVN 4 confirmed a medication error was when the medication was administered by not following the physician's order and the specific manufacturer's instructions. During a review of the facility's policy and procedure titled Specific Medication Administration Procedures (transdermal patch application), dated 2/23/15 indicated the facility staff would place the patch after identifying the location of the body to be placed and document of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of the facility's policy procedure titled, Medication Administration: General revised on 6/1/2021, indicated the facility would follow accepted standards of practice to administer medication. The policy indicated doses would be administered to patients within one hour of the prescribed time unless otherwise indicated by the prescriber. The policy indicated the facility would document the medication administration in the MAR, the patient's response to the medication, notification of physician, the medications refused by the patient would be circled with the initial with the date and time it was ordered, and the refusal was documented on the back of the MAR.

Based on interview and record review, the facility failed to provide ongoing assessment, treatments, and daily monitoring of pressure ulcers (prolonged pressure on the skin that results in injury to the skin and underlying tissue), and implement interventions to prevent the development and worsening of pressure ulcers for one of three sampled residents (Residents 1). (Cross referenced to F684). Resident 1, who was admitted to the facility without a pressure ulcer, developed a Stage 4 pressure ulcer (full thickness extends deep into the muscle, tendons, ligaments, or bones) measuring 4.6 centimeter ([cm] unit of measurement) in length, 4.5 cm width, and 0.3 cm deep with moderate fluid, slough (shedding of dead tissue), and black scar (a dry, dark scab of dead skin) in the sacrococcyx (tail bone) and a deep tissue injury ([DTI] a type of pressure ulcer that is non-blanchable [skin redness that does not turn white when pressed] deep red, purple or maroon areas of intact skin, non-intact skin or blood-filled blisters caused by damage to the underlying soft tissues) to the right heel measuring 3 cm in length and 3 cm in width. These deficient practices resulted in a delayed assessment and care causing Resident 1 to develop a Stage 4 pressure ulcer, suffer severe pain, and to stop eating. Resident 1 was transferred to the general acute care hospital (GACH) for treatment. On 6/23/2021 at 4:22 p.m., the Administrator (ADM) and the Director of Nursing (DON), were notified of an Immediate Jeopardy ([IJ], a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) due to the facility's inability to assess, identify, treat and monitor daily the development of Resident 1's pressure ulcer. The facility's ADM and DON were notified of the immediacy and seriousness of the residents' health and safety being threatened. On 6/24/2021, at 3 p.m., the ADM submitted an acceptable Plan of Action (POA) for the correction of the IJ which included: 1. Resident 1 no longer reside in the facility as of 6/14/2021. A licensed nurse performed a skin sweep (skin check) to all in-house residents on 6/23/2021 and 6/24/2021 and identified six residents with new skin injury (Resident 6, 7, 8, 9, 10, 11). The residents identified were assessed, and their physician and responsible party were informed of the changes. 2. Skilled wound care physician assessed and evaluate identified pressure injuries (of Resident 6, 7, 8, 9, 10, 11) on 6/24/21 for treatments and management. 3. The nurse educator initiated an in-service for certified nurse assistants (CNAs) on 6/23/2021, 6/24/2021 and to be completed 100% by 6/28/2021 about utilizing the Daily Body Check Form related to the following: a. Pressure injury identification. b. Pressure injury report d. Pressure injury management 4. The nurse educator initiated an in-service for licensed nurses on 6/23/2021 and 6/24/2021 and to be completed 100% by 6/28/2021 related to the following: a. Skin management policies and procedures. b. Pressure injury identification and reporting utilizing daily body check form. c. Pressure injury skin assessment accuracy related location, appearance, and measurements. d. Person center care planning interventions and implementation. e. Change of condition initiation and notification process. f. Wound documentation and treatments. 5. The Vice President Clinical Operations provided an in-service education to the interdisciplinary team ([IDT] a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident) on 6/24/2021 related to the following: a. IDT review and evaluation process b. Individualized care planning process and evaluation 6. The CNAs will submit a daily body check form by the end of shift to their individual charge nurse and the charge nurse will assess any identified skin issues initiating a change of condition and care plans. 7. The DON will discuss any identified pressure injury during daily stand up meeting Monday through Friday for further review and interventions. 8. A licensed nursing staff and or designee will perform skin inspection twice a month and as needed to all residents to capture new and or declining skin breakdown. Findings will be reported to the DON and or designee for further review and management. Findings will be presented to the quality assurance ([QA] is the coordinated application of one reinforcing aspects of a quality management system) committee for review and further evaluation and recommendation monthly. The QA committee will continue to review the results until it has been proven to be resolved for three consecutive months and or advised by the QA committee, the skin inspections will be performed on an as needed basis. 9. The IDT will conduct team discussion on any reported pressure injuries and or wounds to capture root cause and develop individualized plan of interventions to manage risk outcomes. 10. The DON or designee will discuss patterns and concerns regarding skin management to the QA committee meeting month, for three months, for further recommendation and interventions and will be re-evaluated thereafter for continued compliance. On 6/24/2021 at 4:23 p.m., while onsite, the surveyor verified and confirmed the POA was implemented through observation, interviews, and record reviews, including in-services provided to the licensed nurses by the nurse educator, and the IJ was removed. The ADM and DON were notified. Findings: During a review of Resident 1's Admission Record (Face Sheet), the face sheet indicated Resident 1 was admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's care plan titled, At Risk for Alteration in Comfort Related to Immobility, dated 11/23/2020, the care plan indicated a goal for Resident 1 to achieve an acceptable level of pain control. The staffs' interventions included to assist Resident 1 on reposition, utilizing pillows, appropriate positioning devices and monitor for nonverbal signs of pain such as increased agitation, grimace, and resistant to care. During a review of Resident 1's Braden Scale (assessment tool used for predicting the risk of pressure ulcers) for Predicting Pressure Sore Risk, dated 4/10/2021, the scale indicated Resident 1 had a mild risk to develop a pressure ulcer. During a review of Resident's 1 Order Summary Report, dated 4/29/2021, the report indicated Resident 1 had an order dated 11/23/2020 for a pressure-redistribution cushion (a device used to reduce the redistribution of pressure) to chair and bed. During a review of Resident 1's Change of Condition ([COC] internal communication tool) note, dated 5/11/2021, the COC indicated Resident 1 had an open wound to the sacrococcyx area. During a review of Resident 1's the Skin Integrity Report dated 5/11/2021, the report indicated Resident 1 had a Stage 4 pressure ulcer to the sacrococcygeal measuring 4.6 cm in length, 4.5 cm in width, and 0.3 cm deep with moderate serous sanguineous fluid, slough, and black scar in the sacrococcyx. On 6/920/21 the report indicated Resident 1 had pain, required to be medicated and the pressure ulcer measured 5.2 cm in length, 4.8 cm in width, 0.5 cm in depth, with slough, eschar, moderate fluid. During a review of Resident 1's Progress Notes, dated 5/11/2021 and timed at 1:37 p.m., the note indicated Resident 1 had an open wound on the sacrococcygeal area. On 6/9/2021 and timed at 6:57 p.m., the note indicated Resident 1 had an infection to the sacrococcygeal pressure ulcer with a strong odor and drainage. During a review of Resident 1's Minimum Data Set ([MDS] a standardized care screening and assessment tool), dated 5/18/2021, the MDS indicated Resident 1 was usually able to make herself understood and sometimes was able to understand others. The MDS indicated Resident 1 was totally dependent of a one-person physical assist for locomotion on and off the unit, dressing, and toilet use. The MDS indicated Resident 1 was at risk to develop a pressure ulcer and had an unhealed, Stage 4 pressure ulcer. During a review of Resident 1's Surgical Consult dated 5/19/21, the surgical consult indicated Resident 1 receive management for sacrococcyx wound. The Surgical consult report indicated Resident 1 sacrococcyx wound had an area of slough and necrotic tissue visible along the surface and base of the exposed tissue. The record indicated the sacrococcyx wound measured 4.5 cm in length, 4.3 cm in width and 0.3 cm in depth. The record indicated the sacrococcyx wound was debrided (removal of dead [necrotic] or infected skin tissue During a review of Resident 1's Order Summary Report dated 5/28/2021, the summary indicated Resident 1 had an order dated 5/11/2021 for a low air mattress (mattress used to prevent and treat pressure ulcers) and pressure ulcer treatment. During a review of Resident 1's COC dated 6/9/2021, indicated Resident 1 had an infection in the sacrococcyx pressure ulcer that contained fluid and a strong odor. During a review of Resident 1's progress notes dated on 6/14/2021 and timed at 3:56 p.m., the note indicated Resident 1's physician requested Resident 1 to be transferred to the GACH. During a review of Resident 1's GACH Emergency Treatment Records (ETR), dated 6/15/2021 and timed 12:31 a.m., the ETR indicated Resident 1 was transferred to the hospital due to inability to eat and drink for one month. The ETR indicated Resident 1 was moaning, thin, and appeared cachectic (condition that causes extreme weight loss and muscle wasting). During a review of Resident 1's GACH progress note dated 6/16/2021 and timed at 11:59 a.m., the note indicated Resident 1 had a severe, unstageable (unable to determine the depth) pressure ulcer (in the sacrococcyx), with superficial infection that was highly concerned for neglect (failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress). The note indicated Resident 1 was evaluated for pressure ulcer surgical intervention, but Resident 1 was unlikely to tolerate the procedure due to her poor nutritional status. During a review of Resident 1's GACH Wound Consultation, dated 6/17/2021 and timed at 10:42 a.m., the note indicated Resident 1 had a large, unstageable, pressure ulcer wound in the sacral area. The consult plan indicated Resident 1 was expressing pain and performing a surgical procedure to her pressure ulcer would improve her quality of life During an interview on 6/21/2021, at 1:27 p.m., the DON stated Resident 1 was admitted to the facility without a pressure ulcer. The DON stated Resident 1 was sent to the GACH for failure to thrive (syndrome of weight loss, decreased appetite, poor nutrition, inactivity, dehydration, and depressive symptoms). The DON stated Resident 1's sacrococcyx pressure ulcer was infected. During an interview on 6/21/2021 at 2:11 p.m., Licensed Vocational Nurse 2 (LVN 2) stated Resident 1 was a total care, Spanish speaking, confused, quiet, and was not eating. During a concurrent interview and review of Resident 1's treatments on 6/21/2021, at 2:36 p.m., the Treatment Nurse (Tx Nurse 1) stated Resident 1 was admitted on [DATE] with no pressure ulcers. Tx Nurse1 stated Resident 1 was identified to have an unstageable pressure ulcer that broke into a Stage 4 pressure ulcer on 5/11/2021. The Tx Nurse stated Resident 1 was frail, could not turn in bed by herself, and did not have an air mattress prior to developing the pressure ulcer. The Tx Nurse stated Resident 1 pressure ulcer could have been prevented if the staff paid more attention to her, reported the pressure ulcer earlier, and repositioned Resident 1 earlier on. During an interview on 6/22/2021 at 2:49 p.m., Licensed Vocational Nurse 6 (LVN 6) stated Resident 1 was small, bed bound, slept a lot and was usually in bed. LVN 6 stated she assessed Resident 1 sacrococcygeal when was first reported and the pressure ulcer looked really bad, unstageable with necrotic tissue and slough. LVN 6 stated she thought Resident 1's pressure ulcer developed overnight but she did not understand how the wound could look so bad without anyone reporting. During an interview on 6/23/2021, at 4:04 p.m., Tx Nurse 1 stated the CNAs notified her when the residents have something unusual in the skin. TX Nurse 1 stated she did weakly skin assessment when residents had a pressure ulcer. TX Nurse 1 stated when she initially assessed Resident 1 coccygeal pressure ulcer, Resident 1 had necrotic tissue. Tx Nurse 1 stated if staff had turn and checked on Resident 1, they would have prevented Resident 1 from developing a pressure ulcer. During an interview on 6/24/2021, at 12:01 p.m., Family Member (FM 1) stated she received a call from the GACH notifying her Resident 1 was admitted to the GACH on 6/17/2021 and was informed by the GACH's physician he was concerned of the conditions of how Resident 1 had arrived to the GACH and believed Resident 1 was neglected by the facility. FM 1 stated the GACH physician told her the pressure ulcer was deep into the bone and Resident 1 lost all her protein fighting to heal the pressure ulcer. FM 1 stated when the staff turned Resident 1, she screamed in pain. During a review of the facility's policy and procedures titled Skin Integrity Management dated 5/26/2021, the policy and procedure indicated the facility would provide safe and effective care to prevent the occurrence of pressure ulcers, manage treatment, and promote healing of all wounds. The policy indicated the staff would continuously observe and monitor patients for changes and would implement revisions to the plan of care. The policy indicated the facility would identify the patient's skin integrity status and need for prevention interventions and treatment modalities through review of all appropriate assessment information such as performing skin inspection on admission, readmission, and weekly, nursing staff would observe for any signs of potential or active pressure injury daily while providing nursing care. The policy indicated the facility would develop a comprehensive, interdisciplinary plan of care including prevention and treatments as indicated such as implementing pressure ulcer prevention for identified risk factors, need for support surface for bed and chair, need for offloading devices, turning and repositioning, and revising the care plan as indicated. During a review of the facility's policy and procedures titled, Notification of Change of Condition: revised on 6/1/2021, indicated the facility would immediately consult with the physician a need to alter treatment significantly (that is, a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment).

Based on observation, interview and record review, the facility failed to ensure adequate supervision was provided to prevent accidents for one of three sampled residents (Resident 1). Resident 1, who had a high risk for falls and was dependent on staff for total care, was left unattended during care while the Certified Nursing Assistant (CNA 1) reached for care supplies and Resident 1 rolled off the bed to the floor and sustained injuries. This deficient practice resulted in Resident 1 sustaining a fracture (broken bone) femur (thigh bone), a skin tear (localized injury to the top layer of the skin when the skin is ripped open and peeled back) to the left elbow, and was transferred to a general acute care hospital (GACH). Resident 1 required a surgical repair of the right femur and intramedullary nail insertion (pieces of a broken bone are put into place using screws, plates, sutures, or rods to hold the broken bone together). Resident 1 required hospitalization from [DATE] to 3/15/21. Findings: During a review of Resident 1's Admission Record, the record indicated the resident was originally admitted to the facility on [DATE] and last readmitted to the facility on [DATE]. Resident 1's diagnoses included: [CONDITION(S)] (low number of red blood cells), age-related physical debility (lacking physical strength), dementia (a group of thinking and social symptoms that interferes with daily functioning), disorders of bone density (a low number of bone minerals), muscle weakness, abnormalities of gait and mobility, and a history of falling. During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 12/1/2020, the MDS indicated Resident 1's cognition (mental capacity to make decisions, ability to remember, learn, and understand) was moderately impaired. The MDS indicated Resident 1 required an extensive assistance with bed mobility, dressing, and total assistance with toileting and bathing. According to the MDS, Resident 1 was always incontinent (inability to control) urine and bowels. During a review of Resident 1's Care Plan, dated 3/5/2021, the care plan indicated Resident 1 was at risk for decreased mobility to perform activities of daily living (ADLs), such as bathing, grooming, personal hygiene, bed mobility, transferring and toileting. The care plan indicated Resident 1 had a decline in cognitive function related to dementia and required assistance for mobility related to weakness. During a review of Resident 1's Physical Therapy ([PT], a trained and licensed medical professional with experience in diagnosing physical abnormalities, restoring physical function and mobility, and maintaining and promoting physical function), evaluation, dated 3/5/2021, the evaluation indicated Resident 1 was a fall risk due to age over 80, walk, and cognition, strength and balance impairment, and had impaired strength in both lower legs. The PT evaluation indicated Resident 1 needed moderate to maximum assist with bed mobility and maximum assistance of a two-persons with transfers. During a review of Resident 1's Admission Nursing Documentation, dated 2/27/2021, the nursing documentation indicated Resident 1 had a history of dementia, was confused and only oriented to person. According to the nursing document, Resident 1's decision making skills were severely impaired, had weakness and impairment in both lower legs, and was totally dependent for bed mobility, dressing/personal hygiene, bathing, and toileting. During a review of Resident 1's Admission Nursing Assessment Outcomes, dated 2/27/2021, the assessment outcomes indicated Resident 1 was a fall risk. During a review of Resident 1's Bed Rail Evaluation, dated 2/27/2021, the bed rail evaluation indicated Resident 1 was at risk for falls, due to impaired mobility and dementia. The Bed Rail evaluation indicated Resident 1 was not able to move upper and lower extremities and no bed rails were recommended. During a review of Resident 1's Change in Condition (CIC) Evaluation, dated 3/10/2021 and timed at 11:15 a.m., the CIC evaluation indicated Resident 1 fell from bed to floor and a malalignment (the bone is not aligned/connected with other bones and is not in proper placement) to the right knee was observed. The CIC evaluation indicated Resident 1 complained of 10/10 pain (0 being no pain and 10 being the worst possible pain) to the right leg and an attempt was made to administer pain medication as ordered, however, Resident 1 could not tolerate elevating the head of bed for the administration of the pain medication. The CIC evaluation indicated the X-ray results showed a midshaft (middle of the bone) femur fracture. Resident 1's physician (Physician 1) ordered Resident 1 to be transferred to the Emergency Department via 911 (emergency services). During a review of Resident 1's Prehospital Care Report Summary, dated 3/10/2021 and timed at 11:55 a.m., the Care Report Summary indicated upon arrival, the EMS personnel found Resident 1 lying in bed with a right femur fracture. The Care Report Summary indicated Resident 1 was injured while staff at the facility attempted to change her bedding. During a review of Resident 1's Nursing Progress Notes (NPN), dated 3/10/2021 and timed at 1:16 p.m., the NPN indicated the charge nurse reported Resident 1 had a fall incident, malalignment to right knee and Resident 1 complained of 10/10 pain. The report indicated Physician 1 was in the facility and was made aware of incident, ordered a STAT (immediate) x-ray and to send Resident 1 to a GACH via 911. The report indicated Paramedics (Emergency Medical Personnel) arrived at facility and administered 50 micrograms (mcg) of [MEDICATION(S)] (a narcotic/controlled substance used to relieve moderate to severe pain) intramuscular ([IM], administered into the muscle) to Resident 1 and transferred Resident 1 to a GACH at 12:15 p.m., on 3/10/2021. During a review of Resident 1's Facility Transfer Form, dated 3/10/2021 and timed at 12:20 p.m., the transfer form indicated Resident 1's transfer to the GACH was unplanned due to a fall. The transfer record indicated Resident 1 was dependent with bathing, dressing, transfers, toileting, and was incontinent of bowel and bladder at the time of the transfer. During a review of Resident 1's Emergency Treatment Record from the GACH, dated 3/10/2021 and timed at 12:28 p.m., the treatment record indicated Resident 1 was transferred from the facility to the Emergency Department (ED), via Emergency Medical Services (EMS) personnel. Resident 1 rolled off the bed onto the floor while the nursing facility staff was changing the resident. During a review of Resident 1's ED provider notes, dated 3/10/2021, the provider notes indicated Resident 1's right leg was internally (facing toward the center of the body) rotated and Resident 1 had diffuse (wide-spread, covering a large area) tenderness to palpation (touching and tapping the skin over an area) over the lateral (side of leg) femur. The ED note also indicated Resident 1 had a skin tear over the top aspect of the elbow with tenderness to palpation. During a review of Resident 1's Inter-Facility Transfer Report from the GACH back to the facility, dated 3/15/2021, the transfer report indicated Resident 1 required surgery while in the GACH, a femoral intramedullary nail insertion on 3/11/2021. During a review of Resident 1's NPN for a Care Plan Meeting, dated 3/11/2021, the care plan meeting notes indicated the interdisciplinary team ([IDT], a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the patient) met to discuss the circumstances in regard to Resident 1's fall on 3/10/2021, which led to Resident 1 being transferred to a GACH. The meeting notes indicated CNA 1 was assigned to Resident 1 and was providing incontinence care. CNA 1 reached for an incontinence diaper and Resident 1 had a sudden movement while laying on her side during care and Resident 1 fell to the floor. During an interview on 3/11/2021 at 2:18 p.m., CNA 1 stated she was providing peri care (cleaning and care of the external genitalia and the anal area, referred to as perineal area) to Resident 1, she (CNA 1) turned to grab a diaper and a sheet from the table and Resident 1 fell to the floor while position on her side on the side of the bed. CNA 1 stated there were no rails on the side of the bed and she was by herself providing care. CNA 1 stated, I don't know if she let go of the mattress and when I turned, Resident 1 was on the floor. During an interview on 3/11/2021 at 4:04 p.m., Resident 2 (Resident 1's roommate) stated that she was in the same room as Resident 1 and CNA 1 was providing care to Resident 1 because Resident 1 needed a diaper change. Resident 2 stated she had her back turned to Resident 1 and was facing the closet but heard Resident 1 yell. Resident 2 stated, It happened so quickly, I just heard her yell for help and then the CNA called for help and the staff came running in the room. During an interview on 3/15/2021 at 11:51 a.m., CNA 2 stated she was working on 3/11/2021 and CNA 1 was working in Resident 1's room and she heard CNA 1 asking for help. CNA 2 stated she went inside Resident 1's room and saw Resident 1 laying on the floor. CNA 2 stated she stayed with Resident 1 while CNA 1 went to call for the charge nurse. CNA 2 stated when the charge nurse, Licensed Vocational Nurse (LVN 1) came into the room, CNA 1 and the LVN 1 put Resident 1 back into bed. During an interview on 3/15/2021 at 12:10 p.m., Registered Nurse (RN 1) was asked what was the process she expects CNAs to use when performing pericare and diaper change. RN 1 stated, You have to make sure the resident was safe. RN 1 stated there should be two nurses to help and one nurse needs to be close to the bedside. RN 1 stated the bed rails can be up if they have consent from family members, but not every resident had bed rails. RN 1 stated, If there are two people available, it's better to use two people. RN 1 stated she was working on 3/11/2021 when Resident 1 fell . RN 1 stated CNA 1 told her the resident was on the floor. RN 1 stated when she arrived to Resident 1's room, the staff had already put Resident 1 back to bed. RN 1 stated LVN 1 was there and said Resident 1 had fallen. RN 1 stated Resident 1 complained of pain and her leg did not look straight. RN 1 stated Physician 1 was in the building, so she told him about Resident 1's fall and Physician 1 instructed her to get a STAT x-ray. RN 1 stated the x-ray technicians were in the building at that time with another resident, so they were able to come to Resident 1's room and do the x-ray. RN 1 stated when Physician 1 saw the x-ray he stated it showed a broken femur. CNA stated she turned the resident and the resident rolled from the bed and she fell on her right side. RN 1 stated Physician 1 instructed her to call 911 and have Resident 1 transferred to the hospital because the bone was broken. RN 1 stated the paramedics came and gave Resident 1 pain medicine and then put Resident 1 in a chair and took her to the hospital. During an interview on 3/15/2021 at 12:18 p.m., Physician 1 stated he was in the building on 3/11/2021 when Resident 1 fell . Physician 1 stated RN 1 came to him and told him Resident 1 had fallen out of bed. Physician 1 stated Resident 1 was having severe pain to her leg and the x-ray showed a right mid-shaft fracture. Physician 1 stated the x-ray technician could only take one view, because Resident 1 was in too much pain to move the leg. Physician 1 stated he observed Resident 1's right leg to be swollen (enlarged beyond normal size) mid shaft and looked broken. Physician 1 stated Resident 1 was alert, pleasant, and would interact, but was demented. Physician 1 stated the resident was 90% bedbound (confined to bed and unable to get out of bed without assistance, due to weakness or illness) and could not sit up in a wheelchair and needed extensive assist. Physician 1 was asked if the facility determined what was the cause of the fall, Physician 1 stated he was told during care, a hand was taken off Resident 1's side. Physician 1 stated, You should always roll a patient towards you, not away from you. Physician 1 stated he thought the fall could have been prevented and Resident 1 was not very large. Physician 1 stated the resident had a regular bed mattress. During an interview on 3/15/2021 at 12:28 p.m., with LVN 2, she was asked if the facility had any policies or procedures that indicated how the CNAs were supposed to position the residents during peri care, diaper changes, and/or bed baths, LVN 2 stated he did not know if there was anything specific to bed safety when the resident was in bed. LVN 2 stated, If not, we can certainly do something like that. LVN 2 stated he would look again at the orientation checklists for CNAs. During a concurrent observation and interview on 3/15/2021 at 12:40 p.m. of a reenactment of what happened, CNA 1 showed Resident 1's former room where the fall had taken place on 3/11/2021. CNA 1 stated Resident 1 been in the B bed and CNA 1 was standing on the left side of Resident 1 and used the sheet to pull Resident 1 towards her, then rolled Resident 1 onto her right side, towards the door. CNA 1 stated staff were taught to roll the resident towards them and then face the resident away from them. When asked if there was anything that could have prevented the Resident from falling, CNA 1 stated, I guess to try and hold the patient and at least use one hand. I had to let go of the resident to reach for the supplies. During an interview on 3/15/2021 at 12:58 p.m., LVN 1 stated she was working on 3/11/2021 when Resident 1 fell . LVN 1 stated she was in the hallway, when CNA 1 came out of Resident 1's room yelling to her for help. LVN 1 stated she went to Resident 1's room with CNA 1 and saw Resident 1 laying in a supine position (faceup position on her back on the floor) between bed A and bed B. LVN 1 stated she asked Resident 1 if she was in pain and she said she was in pain and yelled, I fell . LVN 1 stated she asked what happened and CNA 1 told her that she was providing care and she went to turn the resident and that was when the resident fell from the bed to the floor. LVN 1 stated that she, CNA 1 and CNA 2 got Resident 1 up and put her back to bed. LVN 1 stated they tried to lift the resident up in bed, but Resident 1 yelled, My leg, my leg. LVN 1 stated she asked Physician 1 if she could give Resident 1 something for pain and Physician 1 ordered Tylenol (medication for mild to moderate pain) but stated when she attempted to sit Resident 1 up in order to swallow the medication, Resident 1 screamed. LVN stated Physician 1 and the Director of Nursing (DON) had decided to send the resident out to the hospital. The paramedics came, gave Resident 1 pain medication, and then transferred her to the hospital. When asked if the facility had provided any training on moving residents, LVN 1 stated, That's standard education we went to school for. LVN 1 stated I know we have had inservices. During an interview on 3/15/2021 at 1:24 p.m. the physical therapist (PT 1) stated he had completed an evaluation on Resident 1 at the beginning of 3/2021. PT 1 stated Resident 1 required maximum assist in getting up in bed. During an interview on 3/15/2021 at 2:09 p.m., the Director of Staff Development (DSD), was asked how staff are orientated and trained to move residents during pericare and bed baths, the DSD stated they go over the competency list together and explain they should gather supplies before they close the curtain and make sure the resident was safe in bed. During an interview on 3/15/2021 at 2:12 p.m., with the Administrator (ADM), the ADM stated, the facility determined CNA 1 was changing the resident and during transition, as she reached for a clean diaper, the resident moved and fell to the floor. During a concurrent interview and record review on 3/15/2021 at 2:40 p.m., the DON stated a review of the facility's investigation of Resident 1's fall on 3/11/2021, indicated CNA 1 was working with Resident 1 at the bedside doing a diaper change and she turned to her left to grab a clean diaper and that split second was when the fall happened. The DON stated, Resident 1 was a fall risk. The DON stated the facility make sure the right number of people (staff) helping the resident are on duty, and the residents' mental and functional status are considered. The DON stated that when the staff position a resident, staff should put the resident flat in bed and when staff put the resident on their side, staff need to make sure the resident ends up closer to the middle of the bed rather than the edge of the bed. When asked how the resident should be turned when performing care, the DON stated if the nurse turns the resident towards them the nurse would be quicker to respond. Then the DON stated that some nurses work in [MEDICATION(S)] (in a team of two) and some work alone. When asked if the CNAs should use two persons to turn a resident during pericare or diaper change when there was no side rail, the DON stated that if the staff asks, they can use two people. The DON stated she was not sure if the facility had a policy about working in [MEDICATION(S)]. During a review of the facility's policy and procedure (P/P), titled, Falls Management, revised 2/18/2020, the P/P indicated the guidelines were not intended to replace the judgement and professional discretion of individual clinicians. During a review of the facility's job description for Certified Nursing Assistant (CNA), revised 6/27/17, the CNA job description indicated the CNA would deliver efficient and effective nursing care while achieving positive clinical outcomes and patient satisfaction. The job description indicated the CNA would assist patients [residents] with or perform activities of daily living(ADLs), assist residents with ambulation and transfers, and position residents in correct body alignment in and out of bed. The job description indicated the CNA would promote a culture of safety to ensure a healthy practice and living environment.

Based on interview and record review, the facility failed to ensure all staff who was CPR certified and received hands-on and in-person skills training for cardio-pulmonary resuscitation ([CPR] an emergency lifesaving procedure done when breathing or the heart stops to revive a person) and implemented CPR timely (within 10 seconds) for one of seven sampled residents (Resident 1). Resident 1 was found by a certified nursing assistant (CNA 3) unresponsive, not breathing, and pulseless (no heartbeat) and CPR was not initiated until more than 10 minutes after she contacted a Licensed Vocational Nurse (LVN 3). LVN 3 did not initiate CPR when she arrived in Resident 1's room but left Resident 1 unattended to call for help. LVN 4 responded to LVN 3's call for help, approximately ,d+[DATE] minutes after Resident 1 was initially found unresponsive, and he (LVN 4) assessed Resident 1 and started CPR. This failure of a delay in the initiation of CPR to Resident 1, who had a full code status (full treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The paramedics were called, and upon their arrival, after assessing Resident 1, the paramedics continued CPR unsuccessfully. The paramedics pronounced Resident 1 deceased on [DATE] at 7:27 p.m. During an interview, on [DATE] at 12:30 p.m., the Director of Nursing (DON) was notified of the Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called for the facility's failure to provide the necessary care and emergency services immediately by not performing CPR on Resident 1 (F678). The DON was notified of the immediate action that needs to be taken and the seriousness of the residents' in need of CPR health and safety being threatened. During an interview, on [DATE] at 11:03 a.m., the facility's Administrator submitted an acceptable plan of action (POA) for correction of the IJ, which included the following: 1. In-service education provided to the nursing staff on the CPR process and management, code status (the type of emergent treatment a person would or would not receive if their heart or breathing were to stop) system verification, change of condition sequence of events documentation and cardiac (heart) and respiratory arrest (not breathing) policy and procedures (P/P). 2. Provided CPR training with return demonstration to all nursing staff. 3. Conducted a mock (not authentic or real) code blue (facility staff alert to indicate a medical emergency, such as cardiac or respiratory arrest and the staff should respond) to ensure the staff was completely prepared before they are faced with a real situations) exercises for all nursing staff on all shifts, including the evaluation of facility CPR process and management in any resident emergency situations. 4. Provide residents with DNR (do not resuscitate) status a red colored wrist band including advance directive (a written document that tells what a person wants or does not want if he/she in the future cannot make his/her wishes known about medical treatment) changes. All residents without a red colored wrist band would be considered a full code (full treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 5. Ensure residents' wrist band compliance during daily stand-up meetings Monday-Friday. During an interview on [DATE] at 12:17 p.m., while onsite, the ADM and the DON were notified the IJ was lifted, after verification the Plan of Action (POA) was followed and implemented as per observation, interview, and record review. Findings: During a review of Resident 1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Admission Record (Face Sheet), the face sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's history and physical (H/P), dated [DATE], the H/P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Hemodialysis Communication Record, dated [DATE], the communication record indicated Resident 1 was assessed after returning from [CONDITION(S)]. The record indicated Resident 1 did not have any post-[CONDITION(S)] complications. During a review of Resident 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 1's nurse's note (NN), dated [DATE] and timed at 4 p.m., the NN indicated at 2:15 p.m. on [DATE], Resident 1 returned from [CONDITION(S)] treatment in stable condition, and denied having any pain and/or discomfort. During a review of Resident 1's NN, dated [DATE] and timed at 8:29 p.m., the NN indicated at 6:45 p.m., on [DATE], CNA 3 reported to LVN 3 Resident 1 was found unresponsive and CPR was immediately performed by the staff [sic]. The note indicated on [DATE] at 7 p.m., the paramedics arrived at the facility and continued CPR until Resident 1 was pronounced deceased at 7:27 p.m. The note indicated at 7:28 p.m. on [DATE], Resident 1's family was notified, and at 8:45 p.m., the same day, the local police arrived at the facility to assess Resident 1. During a review of Resident 1's clinical records there was no documented evidence of Resident 1 having a change of condition on [DATE]. During a review of Resident 1's Paramedic Run Sheet (PRS), dated [DATE], the PRS indicated Resident 1's estimated time of cardiac arrest (sudden loss of heart function, breathing and consciousness) was at 6:45 p.m., on [DATE] and the initial time of CPR was at 6:55 p.m. The PRS indicated the paramedics were dispatched at 6:56 p.m. and arrived at the facility on [DATE] at 7:01 p.m. The paramedics documented Resident 1 was observed lying in bed in cardiac arrest. According to the PRS, the nursing staff indicated Resident 1 ate dinner and went to bed 30 minutes prior to being found in cardiac arrest by the nursing staff. During an interview on [DATE] at 12:40 p.m., LVN 1 stated on [DATE] when Resident 1 returned from [CONDITION(S)] treatment, he was alert, oriented, and in no distress with stable vital signs (signs-measurements which includes body temperature, blood pressure, pulse (heart rate), and respiratory rate). LVN 1 was asked what she would do if she was alone and a resident was breathless, pulseless, and unresponsive, LVN 1 stated she would initiate CPR and call a code blue. LVN 1 stated CPR chest compression (an application of pressure to the chest) rate was 15 compressions to two (2) breaths. During an interview on [DATE] at 2:37 p.m., LVN 2 stated the CPR compression rate was 30 chest compressions to 2 breaths. During an interview on [DATE] at 2:50 p.m., CNA 2 stated she could perform CPR in the facility. CNA 2 stated CPR chest compression rate was 10 to 1 breath [sic]. During an interview on [DATE] at 3:20 p.m., CNA 3 stated on [DATE] at approximately 3:15 p.m., she made rounds, observed Resident 1 alert, lying in bed and she provided evening care. CNA 3 stated between the hour of 5 p.m. through 6 p.m., after passing the dinner trays, she went to check on Resident 1 when she observed Resident 1's dinner tray was not touched and thought the resident was asleep. CNA 3 stated she tried to wake Resident 1 by shaking him, but he was not responding and did not wake up. CNA 3 stated when she checked Resident 1's pulse (heart rate), he was pulseless and was not breathing because she did not observe Resident 1's chest moving up and down and the resident's hands were cold. CNA 3 stated she left Resident 1's room to locate LVN 3 who was on the other side of the facility passing medications. CNA 3 stated she asked LVN 3 to check on Resident 1 because he would not wake up. CNA 3 stated she did not inform LVN 3 that Resident 1 was pulseless. CNA 3 stated she did not return to Resident 1's room after informing LVN 3 of the resident's condition because she had to feed a resident. CNA 3 stated she did not perform CPR on Resident 1 once she observed the resident was pulseless, breathless, and unresponsive. CNA 3 stated she must inform the licensed nurses prior to initiating CPR on a resident. CNA 3 stated she could perform CPR in the facility and stated the chest compression rate was 15 compressions to 2 breaths. During an interview on [DATE] at 4:01 p.m., the Director of Staff Development (DSD), stated CPR was not just the licensed nurses' role and CNAs could perform CPR in the facility. The DSD stated when a resident was observed breathless, pulseless, and unresponsive, the staff must initiate CPR and stay with the resident until help arrives. During an interview on [DATE] at 4:07 p.m., the DON stated the CNAs were trained to perform CPR and could perform CPR in the facility. The DON stated CPR chest compression rate was 30 to 2 breaths. During a telephone interview on [DATE] at 11:42 a.m., the DSD stated she had not conducted any in-services with the staff regarding CPR and/or any life saving measures training. During a telephone interview on [DATE] at 11:46 a.m., LVN 3 stated on [DATE] at approximately 5 p.m. to 5:30 p.m., Resident 1 was alert, awake and talkative, when she administered medications to him. LVN 3 stated she continued passing medications and was on the other side of the facility when CNA 3 frantically approached her stating Resident 1 was unresponsive and that she should go to Resident 1's room right away. LVN 3 stated when she entered Resident 1's room she observed food coming out from the resident's mouth. LVN 3 stated upon her assessment of Resident 1, he had a faint pulse, but he was not breathing. LVN 3 stated she observed food in Resident 1's jaw and she thought the resident had choked while eating dinner. LVN 3 stated she turned Resident 1 on his side and tried to orally suction the resident, but nothing came from his mouth. LVN 3 stated she then initiated chest compressions on Resident 1 and instructed CNA 3 to summon the licensed nursing staff for assistance. LVN 3 stated she left Resident 1 unattended to obtain a suction machine which was located on the crash cart (a wheeled container carrying medicine and equipment for use in emergency resuscitations). LVN 3 stated when a resident was found unresponsive, breathless, and pulseless, CPR should be initiated immediately. LVN 3 stated CNAs could perform CPR on the residents in the facility. During a concurrent interview and review of a written declaration by CNA3, dated [DATE] and timed at 6 p.m., CNA 3 stated and documented on [DATE] after she observed Resident 1 pulseless, unresponsive and breathless, it took her three (3) to five (5) minutes to locate and inform LVN 3 about Resident 1's condition. CNA 3 stated LVN 3 attempted to wake up Resident 1 by tapping and shaking the resident and asking him to wake up. CNA 3 stated LVN 3 left Resident 1's room to overhead page a code blue at the nurses' station while no life-saving procedures were being performed on Resident 1. CNA 3 stated when LVN 3 returned to the room, LVN 4 had arrived to assist with Resident 1. CNA 3 stated she and LVN 3 was in Resident 1's room for 5 to 10 minutes before any staff came in to assist. CNA 3 stated she left Resident 1's room before CPR was started by LVN 4. CNA 3 stated she did not perform CPR on Resident 1 when she saw he was pulseless and not breathing, because she had to make sure Resident 1 was not just asleep. CNA 3 stated she knew Resident 1 was not breathing but could not just start performing CPR. CNA 3 stated she did not need permission from the licensed staff to perform CPR but wanted LVN 3 to check Resident 1 first before initiating CPR to ensure Resident 1 was not breathing. During an interview on [DATE] at 7 p.m., LVN 4 stated on the evening of [DATE] he was four rooms away from Resident 1's room when he heard LVN 3 scream for help. LVN 4 stated when he arrived in Resident 1's room and observed Resident 1 not looking good and was pulseless and breathless. LVN 4 stated he began performing chest compressions immediately on Resident 1 while LVN 3 left the resident's room and called 911(emergency services). LVN 4 stated he was unsure if CPR was initiated by LVN 3 prior to his arrival. LVN 4 stated there was no evidence of food in Resident 1's mouth or on his clothes. LVN 4 stated CNAs could perform CPR in the facility without the permission of a licensed nurse. During an interview on [DATE] at 12:07 p.m., LVN 5 was asked if she found a resident who was breathless, pulseless and unresponsive, what should be done, LVN 5 stated the first thing she would do was check the resident's chart for their code status [sic]. LVN 5 stated after determining the resident's code status she would overhead page a code blue, then initiate CPR. LVN 5 stated she would always check the resident code status prior to initiating CPR to ensure the resident was not a do not resuscitate ([DNR] a legal order to withhold CPR). During a review of an article from the American Heart Association (AHA) guidelines 2020, the AHA indicated when a person was found pulseless and not breathing, CPR should be initiated immediately within 10 seconds. The AHA indicated the rescuer for adult CPR is 30 chest compressions to 2 rescue breaths in one cycle. During an interview on [DATE] at 5:52 p.m., the Registered Nurse Supervisor (RNS) stated on [DATE] she was at Nurse's Station 1, near the main entrance of the facility, when she heard the staff call out for help. The RNS stated when she arrived in Resident 1's room, she observed LVN 4 performing chest compressions on Resident 1. The RNS stated LVN 3 informed her that Resident 1 was unresponsive. The RNS stated she observed a suction machine in Resident 1's room, however there was no canister connected to the suction machine. The RNS stated Resident 1 received 30 compressions with 2 rescue breaths. The RNS stated she assessed Resident 1's mouth and it was clear, without of food and/or excessive saliva. During an interview on [DATE] at 6:18 p.m., CNA 4 stated on [DATE], he heard a code blue called to Resident 1's room on the overhead page. CNA 4 stated he ran to Resident 1's room and observed LVN 4 performing chest compressions on Resident 1 and observed LVN 3 on the telephone calling 911. CNA 4 stated he grabbed the crash cart and he took over performing chest compressions on Resident 1, from LVN 4, until the paramedics arrived. During a review of the facility's last revised P/P, dated [DATE] and titled, Cardiac and/or Respiratory Arrest the P/P indicated the facility would perform CPR on all residents, except in certain limited circumstances, unless there was a written physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the P/P, if a resident does not have a DNR order, CPR/Automated External Defibrillator ([AED] a machine that restarts the heart when it stops, the certified staff would initiate CPR/AED and emergency services (EMS) would be activated. According to the P/P, CPR should be provided in the location where the resident is discovered, if the location was safe for the responder and the resident.

Based on observation, interview and record review, the facility failed to provide the necessary care and services such as treatments, assessment, daily monitoring of pressure ulcers (prolonged pressure on the skin that results in injury to the skin and underlying tissue), to prevent the development and worsening of pressure ulcers for three of four sampled residents (Residents 1, 3 and 4). (Cross referenced to F655). Resident 1 developed a three (3) centimeter ((cm) units of measurement) sacrum (tailbone) wound on 4/29/2020, which worsen and became infected (contaminated with a harmful organism) requiring Resident 1 to be transfer to the general acute care hospital (GACH) for treatment. Resident 1's wound was reported to the physician on 4/29/2020 and order for treatment was not carried-out until 5/2/2020 (3 days later). Resident 3's Stage III sacrum pressure ulcer (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because of obscured by slough (shedding of dead tissue) or eschar (a dry, dark scab of dead skin)) that worsen to a Stage IV (full-thickness skin loss with extensive destruction; tissue necrosis, damage to muscle, bone, or supporting structure) according to the dermatologist assessment on 6/12/2020. Resident 3 did not receive wound care treatment for [REDACTED]. Resident 4 developed a sacrum Stage II (skin opened, wears away, or forms an ulcer, which is usually tender and painful; looks like a scrape (abrasion), blister, or a shallow crater in the skin) wound and treatment initiated on 5/12/2020. These deficient practices resulted in a delay in care and treatment for [REDACTED]. On 6/11/2020 at 5:41 p.m., the Center Nurse Executive (CNE) and the Minimum Data Set Nurse (MDSN), were notified of an Immediate Jeopardy ((IJ), a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called for the facility's inability to provide the necessary care and services such as treatments, assessment, daily monitoring of pressure ulcers to prevent the development and worsening of pressure ulcer, development/evaluation of care plans and notification of the physician to manage a resident's pain and wound's condition, development and worsening condition of existing pressure ulcer. The facility's CNE and MDSN were notified of the immediacy and seriousness of the residents' health and safety being threatened. On 6/13/2020 at 1:15 p.m., the CNE and MDSN submitted an acceptable Plan of Action (POA) for the correction of the IJ which included: 1. Should Resident 1 return to the facility a skin assessment would be perform upon readmission, wound treatment orders and care plan will be added for any wounds. A wound care consult and notification to the physician will be made. 2. Resident 3's physician assessed the resident on 6/12/2020 and prescribed medication to assist with the itchiness and order a dermatologist (branch of medicine that treats skin conditions) consult. 3. On 6/11/2020, a designated charge nurse started a skin sweep to identify worsening of wounds and if any noted, the physician would be notified for new orders. 4. On 6/12/2020, a second skin sweep would be conducted by the wound physician and nurse to identify any new or worsening wounds. 5. The CNE and MDSN will create and revise any wound care plans of the residents identified. Medical Records staff will ensure residents have a base line care plan for new admissions. 5. Weekly skin wound reports to be provided to the CNE by the care nurse. 6. The Nurse Educator began in-servicing licensed nurses on 6/11/2020 and 6/12/2020 on care plans, neglect/abuse, wound assessment, change of condition (COC), assessment, vital signs, reporting, physician's orders [REDACTED]. 7. A wound Care Surgical Group was hired that will come to the facility on Fridays to assist with resident's wound treatments. 8. The facility has two designated wound treatment nurses for the week and weekend for the COVID area and two wound treatment nurses that will designated to cover the non-COVID area. 9. Resident 2's [DEVICE] was changed on 6/12/2020. 7. The Quality Assurance and Assessment ((QAA) team members working together concerns in a facility) will be communicated in a monthly basis for the next three months until the manner is considered resolve. 8. The Interdisciplinary Team ((IDT) group of healthcare providers residents from different fields who work together toward the same goal to provide the best care or outcome for a patient) will identify any items that need to be added to a resident's baseline care plan. 9. The CNE will track any trends or concerns regarding personalized baseline care plans. On 6/14/2020 at 1:27 p.m., during an interview with the CNE and the MDSN were notified the IJ was lifted, after the team verified the POA was followed and implemented observations, interviews and record reviews. Findings: a. A review of Resident 1's Face Sheet (Admission Record) indicated the facility first admitted the resident on 1/14/11 and was last readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. [MEDICAL CONDITION] (paralysis on one side of the body) affecting right dominant (most important) side of the body. A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 3/8/2020 indicated the resident was sometimes understood and sometimes understand others. The MDS indicated the resident was totally dependent requiring a two or more-person physical assist for bed mobility (how the resident moves to and from lying position, turning side to side, and positioning of body) and a one-person physical assist for personal hygiene. The MDS indicated Resident 1 was always incontinent of bowel and bladder (lack of voluntary control) and had limited range of motion on one side of upper extremities and impairment of bilateral (both) lower extremities. The MDS indicated Resident 1 did not have pressure ulcers upon admission but was at risk to develop them. A review of Resident 1's Braden Scale (scale for predicting pressure sores), dated 12/10/19 indicated Resident 1's score for pressure ulcers development was moderate risk with a total score of 13. The lower the number, the higher the risk for developing an acquired ulcer/injury, as follow: 19-23 = no risk; 15-18 = mild risk; 13-14 = moderate risk. A review of Resident 1's care plan titled, Skin Breakdown, with revised date of 3/15/15 indicated Resident 1 was at risk for skin break due to impaired sensation, limited mobility and history of pressure ulcer. The care plan goal Resident 1 not to show signs of skin breakdown. The staffs' interventions included to evaluate and monitor for any localized skin problems, such as dryness, redness, pustules (small blister or pimple on the skin containing pus) and inflammation. The staff to observe skin condition and report abnormalities to primary physician. A review of Resident 1's Change of Condition ((COC) decline or improvement in a resident's mental or physical functioning) dated 4/29/2020 and timed at 11:12 a.m. indicated the resident was assessed with [REDACTED]. The nurse's note indicated the physician was notified and no new orders given. A review of Resident 1's nurse's notes from 4/29/2020 through 5/1/2020 did not indicate a wound treatment what initiated to prevent further worsening of the world. A review of Resident 1's Skin Integrity Report, indicated the measurements for the resident's sacral wound as follow: On 5/2/2020 the measurements were 4 cm in length (L) by(x) 3.5 cm width (W) x 0.1 cm depth (D) with bloody drainage and no odor. On 5/8/2020 the measurements were 4.5 cm x 3.7 cm x 0.5 cm with heavy bloody drainage and no odor. On 5/15/2020 the measurements were 5.1 cm x 3.8 cm x 0.5 cm with heavy bloody serosanguineous drainage with odor. On 5/22/2020 the measurements were 5.2 cm x 4 cm x 0.7 cm with heavy bloody drainage with odor. On 5/29/2020 the measurements were 5.3 cm x 4 cm x 0.6 cm with heavy bloody drainage with odor. A review of Resident 1's ADL Correction Form indicated on 5/13/2020, 5/17/2020, 5/20/2020, and 5/23/2020 the CNAs noted the sacral wound bad odor and worsen condition. The CNAs note indicated the facility's charge nurses were notified. A review of Licensed Progress notes, dated from 5/1/2020 through 5/29/2020 did not indicate Resident 1's primary physician was notified of sacral ulcer worsening with a bad odor and/or a wound physician consulted. A review of Resident 1's Laboratory results collected on 5/30/2020 and timed at 3 p.m. with a result report, dated 6/3/2020 and timed at 3:34 p.m. indicated Resident 1 had moderate growth of bacteria on the sacral area. A review of Resident 1's Nurse's notes dated 6/4/2020 and timed at 2:03 p.m. indicated Resident 1's primary physician ordered to transfer Resident 1 to the GACH for evaluation of the sacral wound infection. The note indicated Resident 1 was transported to the GACH on 6/4/2020 at 11:45 a.m. A review of Resident 1's Discharge Form, dated 6/4/2020 indicated to discharge resident to the general acute care hospital (GACH) for infected sacral wound. A review of Resident 1's GACHs ED note dated 6/4/2020 indicate Resident 1 was admitted for evaluation sacral ulcer and alter mental status. A review of the GACHs Consultation Note, dated 6/5/2020 and timed at 12:53 p.m., indicated Resident 1 had an infection related to an infected sacral ulcer. A review of Resident 1's GACH operative report dated 6/9/2020 and timed at 7:30 p.m., indicated a post-operative [DIAGNOSES REDACTED]. The report indicated a sharp excisional debridement (removal of damage tissue) with a Bovie (instrument used for electrosurgical dissection) was use to cut of skin, subcutaneous tissue, muscle, fascia (thin casing of connective tissue that surrounds and holds every organ), ligaments (flexible fibrous connective tissue which connects two bones or cartilages or holds together a joint) and bone. The report indicated much of the sacral bone had eroded (destroyed). A review of Resident 1's pathology (branch of medicine that deals with the laboratory examination of samples of body tissue) report, collected on 6/10/2020 with results received on 6/11/2020 indicated the resident had a [DIAGNOSES REDACTED]. On 6/8/2020 at 5:30 p.m., during a telephone interview, Licensed Vocational Nurse 1 (LVN 1) stated the facility did not have a treatment nurse for the month of May 2020 because the treatment nurse was sent to the COVID area. LVN 1 stated not being able to complete the daily wound treatments for the residents because not having enough time. LVN 1 stated notifying LVN 3 to assist with the treatments, but LVN 3 would sign as completed without doing the wound treatments. LVN 1 stated Resident 1's physician was not notified of the resident wounds. LVN 1 stated the CNE did not do anything when she was notified of the resident's wounds. On 6/10/2020 at 8:56 a.m., during a telephone interview, LVN 2 stated she did not have time to get to all the wound treatments. LVN 2 stated the facility did not have an assigned treatment nurse and the LVN's had to conduct their own medication pass and wound treatments for all residents. On 6/10/2020 at 9:23 a.m., during a telephone interview, Certified Nurse Assistant (CNA 1) stated the facility did not have assign treatment nurses. CNA 1 stated being forced to perform wound treatment for [REDACTED]. On 6/11/2020 at 10:45 a.m., during a concurrent interview and record review of the Licensed Progress notes, LVN 3 stated Resident 1 was sent out to the GACH a week ago for evaluation of sacral wound infection. LVN 3 stated Resident 1's physician was notified on 20 of the worsening of the wound and the bad odor coming from the wound. LVN 3 stated no documentation was done of the physician notification or wound assessments. On 6/11/2020 at 11:58 a.m., during an interview and review of Resident 1's clinical chart, Registered Nurse 1 (RN 1) stated first informing Resident 1's primary physician on 4/30/2020. RN 1 stated no orders for wound treatment were carried out until 5/2/2020, three (3) days after the wound was identified. RN 1 stated the wound consult ordered on [DATE] was not carried out. RN 1 stated it was the responsibility of the treatment nurse to assess and document the status of the wound. The RN 1 stated no documentation of Resident 1's wound assessment was done. On 6/11/2020 at 1:20 p.m., during an interview and review of Resident 1's record with the CNE and the MDSN, the MDSN stated Resident 1's Stage II sacral ulcer was identified on 4/29/2020 and physician orders [REDACTED]. The MDSN stated no wound treatments were done on 4/29/2020 through 5/1/2020. The MDSN stated no there was no wound assessments and or IDT done or found in Resident 1's clinical chart. The MDSN stated the RN 1 fail to enter the physician's orders [REDACTED]. On 6/12/2020 at 4:19 p.m., during a telephone interview, Resident 1's family member (FM 1) stated Resident 1 was admitted to the facility without wounds to her sacral area. FM 1 stated being informed by the GACHs upon Resident 1's admission of the severity of the sacral wound. FM 1 stated the facility did not made attempts to notify the family regarding the development of Resident 1's sacral ulcer. On 6/12/2020 at 7:10 p.m., during an interview, CNA 7 stated several charge nurses were made aware of Resident 1's wounds but nothing was done. CNA 7 stated all the Licensed Nurses in the facility were aware about Resident 1's sacral ulcer, but did not care. CNA 7 stated Resident 1's wound was black in color, with green drainage and bad odor. CNA 7 stated not being able to turn all residents every two (2) hours because of the workload. On 6/14/2020 at 12:30 p.m., during an interview, CNA 2 stated Resident 1's wound smelled as if it was rotten and had brown/red drainage. On 6/15/2020 at 3:15 p.m., during a telephone interview, Resident 1's FM 2 stated the facility neglected the resident and did not prevent the wound in her sacral area. FM 2 stated of not being made aware of Resident 1's wound by the facility. FM 2 stated Resident 1 would complain of back pain, but the facility would ignore her pain. FM 2 stated feeling bad the facility did not care for Resident 1. b. A review of Resident 3's Face Sheet (Admission Record) indicated the facility admitted the resident on 6/5/2020. Resident 3's [DIAGNOSES REDACTED]. A review of Resident 3's Braden Scale, dated 6/5/2020 indicated Resident 3's score for pressure sores development was moderate risk with a total score of 18. A review of Resident 3's care plan titled, Resident has Actual Skin Breakdown on Sacral Area, dated 6/6/2020. The goal was for the resident's sacral ulcer to decrease in size and heal. The staffs' interventions included to evaluate and monitor for any localized skin problems such as dryness, redness, pustules and inflammation, observe skin condition, care and report abnormalities to primary physician. During a review of Resident 3's Weekly Bath and Skin Report, dated 6/8/2020 indicated Resident 3 was noted with open areas on the bilateral forearms, right knee, right foot and sacral area. The report indicated the charge nurse was notified of the open body areas. A review of Resident 3's Licensed Progress notes, dated 6/5/2020 through 6/11/2020 did not indicate the physician was notified of Resident 3's opened skin areas and sacral wound. A review of Resident 3's Licensed Progress note, dated 6/5/2020 and timed at 7:10 p.m. indicated Resident 3 was admitted to the facility with a Stage III sacral wound. A review of Resident 3's Treatment Assessment Record (TAR) for the month of June 2020 did not indicate a sacral wound care treatment was initiated upon admission on 6/5/2020. A review of Resident 3's skin integrity report, dated 6/12/2020 indicated a sacral pressure wound Stage IV identified measuring 2.4 centimeters (cm (unit of measurement)) in length by 2.4 cm in width by 0.5 cm in depth. The skin integrity report indicated underlining in all directions of the wound measuring 1 cm and moderate serosanguineous (collection of body fluid and blood) drainage. On 6/11/2020 at 10 a.m., during an observation of Resident 3's wounds with LVN 2, LVN 2 stated Resident 3's sacral wound had not been treated because she was passing medications. LVN 2 stated wound care treatments are completed from 6 am to 8 am. On 6/11/2020 at 4:20 p.m., during an interview and review or Resident 3's care plans and TARs, the RN 1 indicated being aware Resident 3 was admitted with s sacral wound but fail to initiate a care plan for interventions to prevent the wound from worsening. RN 1 also stated she did not enter the wound treatment orders because, I was too busy and did not have time. RN 1 stated she forgot to do treatment orders for Resident 3. c. A review of Resident 4's Face Sheet (Admission Record) indicated the facility first admitted the resident on 2/20/2020 and was last readmitted on [DATE]. Resident 4's [DIAGNOSES REDACTED]. A review of Resident 4's MDS dated [DATE] indicated the resident sometimes understood and understand others. The MDS indicated Resident 4 required extensive assist of a one-person physical assist for bed mobility. The MDS indicated Resident 4 was always incontinent of bowel and had impairment of bilateral lower extremities. The MDS indicated Resident 4 had two (2) pressure ulcers. A review of Resident 4's Braden Scale, dated 4/7/2020 indicated Resident 4's score for pressure sores development was moderate risk with a total score of 16. A review of Resident 4's skin assessment, dated 4/7/2020 indicated the resident did not have sacrum wounds. A review of Resident 4's care plans did not indicate a plan of care for the sacral ulcer was created on 5/11/2020 when the wound was identified. A review of the Licensed Progress note dated 5/11/2020 and timed at 1:07 p.m. indicated a skin wound was identified. At 10:36 p.m. on 5/11/2020 a note indicated a COC was initiated for Resident 4's left buttock Stage II and lower back skin wound. A review of Resident 4's physician's telephone order, dated 5/12/2020 indicated to turn and reposition Resident 4 every two (2) hours and perform wound care evaluation. A review of Resident 4's Licensed Progress note, dated 5/19/2020 and timed at 5:29 p.m. indicated Resident 4 was noted with a sacral ulcer measuring 10 cm in L x 8 cm in W and no depth. On 6/13/2020 at 10:40 a.m., during a telephone interview, FM 3 stated Resident 4 was transfer to a GACH for evaluation of wounds. FM 3 stated the facility fail to notify them of Resident 4's sacral wound. FM 3 stated Resident 4 did not have any wounds on the sacral area upon admission to the facility. On 6/13/2020 at 3:30 p.m., during an interview, LVN 8 stated there was no treatment done for Resident 4's sacral ulcer. LVN 8 stated Resident 4's sacrum wound developed in the facility. On 6/14/2020 at 1 p.m., during an interview and review of Residents 1, 3 and 4 clinical records (care plans, TARs, nurses notes, COC, physician orders, ADL sheets) indicated the CNE stated and confirmed the facility's staff did not follow the policy for wounds and the staff was responsible to assess, document, and carried out orders for residents. The CNE stated Residents 1 and 4 developed sacral wounds that worsen in the facility and Resident 3's sacral wound worsens in the facility. The CNE stated the staff fail to notify the resident's physician, create and update care plan, prevent development/worsening of sacral wounds and provide treatment as order by the primary physician. The CNE stated she was not made aware of the wounds because she was focus on the COVID (virus) residents. A review of the facility's policy and procedures (P/P) titled, Skin Integrity Management, revised 1/31/2020 indicated the purpose of the facility was to provide safe and effective care to prevent the occurrence of pressure ulcers, manage treatment, and promotes healing of all wounds. The P/P indicated the standard of practice was for staff to review pre-admission information to plan patient's needs prior to admission, identify patient's skin integrity status and need for prevention interventions or treatments modalities through review, perform skin inspection on admission/re-admission and weekly. Perform wound observation and measurements upon initial identification, weekly and upon decline. The P/P indicated to notify the physician to obtain orders and notify resident's representative/family and document daily monitoring.

Based on observation, interview and record review, the facility failed to follow its policy and procedure (P/P), titled Abuse Prohibition, to ensure one of three sampled residents (Resident 3) was free of neglect and received necessary care and services to treat his skin wounds. Resident 3 had a skin condition that caused severe pain and itching that the facility failed to address and notified the physician, which resulted in Resident 3 picking and scratching his skin all over his body (crossed referenced to F580). This deficient practice of the facility neglecting Resident 3's [DIAGNOSES REDACTED] (rare skin condition causing large fluid-filled blisters) all over the body condition with severe pain and itching for over 6 days without any care and treatment resulting in self-inflicting wounds and sores all over the body. The resident suffered undue pain, itching and mental anguish and the inability to sleep at night and resulted in opened wounds with bleeding that had the potential to become infected (occurs when germs, such as bacteria, grow within the damaged skin of a wound). Findings: A review of Resident 3's Face Sheet (Admission Record) indicated the facility admitted the resident on 6/5/2020. Resident 3's [DIAGNOSES REDACTED]. A review of Resident 3's Licensed Progress note, dated 6/5/2020 and timed at 7:10 p.m. indicated Resident 3 was admitted to the facility with a Stage III sacral wound (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because of obscured by slough (shedding of dead tissue) or eschar (a dry, dark scab of dead skin)) and discoloration to upper and lower bilateral (both) extremities. A review of Resident 3's Licensed Progress notes, dated 6/5/2020 through 6/11/2020 did not indicate the resident's physician was notified of Resident 3's opened skin areas from severe itching and pain. A review of Resident 3's care plans, did not indicate a care plan was initiated upon admission on 6/5/2020 or/on 6/8/2020 when the multiple wounds were identified by the staff and/or any physician notification of Resident 3's opened wounds. A review of Resident 3's Weekly Bath and Skin Report, dated 6/8/2020 indicated Resident 3 was noted with open wounds on bilateral forearms, right knee, right foot and sacral area. The report indicated the charge nurse was notified of Resident 3's opened wounds. The note did not indicate Resident 3's physician was notified. A review of Resident 3's Treatment Assessment Record (TAR) for the month of June 2020 did not indicate wound care treatment was being provided to the resident for the pain and itching of the skin. A review of an online Mayo Clinic article titled, [DIAGNOSES REDACTED] dated 12/4/18 indicated Pemphigoid was common in elder adults and was life-threatening when in poor health. According to the article, Pemphigoid was categorized by large reddish dark blisters that are painful and sensitive when rupture or touched. On 6/11/2020 at 10 a.m., during an observation of Resident 3's wounds and a concurrent interview, Licensed Vocational Nurse 2 (LVN 2) stated Resident 3's sacral wound had not been treated because she was passing medications. Resident 3 was observed moaning unable to answer any questions when asked about his pain level. Resident 3 had generalized body discoloration of purple/black in color, dry blood on arms, fingernails, face, bed linens, the wall and bed rails. LVN 2 stated of not being aware how Resident 3 sustained the skin injuries but was aware the resident had a behavior of picking his skin. LVN 2 stated Registered Nurse 1 (RN 1) was aware of Resident 3's skin injuries. A review of Resident 3's dermatologist (branch of medicine dealing with the care of the skin) report, dated 6/12/2020 indicated Resident 3 had been complaining of blisters (small bubble on the skin filled with fluid) all over the body that had been flaring up for weeks with pain. The dermatologist report indicated Resident 3 was diagnosed with [REDACTED]. The dermatologist report indicated to treat Resident 3 with [MEDICATION NAME] (an antibiotic) 100 micrograms (mcg (unit of measurement)) capsules by mouth three times a day and [MEDICATION NAME] (used to treat inflammation (the body's response to injury) and allergic conditions) 60 milligrams (mg) by mouth once a day for five days then decrease the dosage by 10 mg every five days for a total of 30 days. On 6/11/2020 at 10:10 a.m., during an observation and interview regarding Resident 3's generalized skin injuries with RN 1, RN 1 stated Resident 3 was admitted to the facility with behavior of picking/scratching his skin causing skin tears. RN 1 stated Resident 3 had no care treatment ordered for the resident's skin injuries. On 6/11/2020 at 4:20 p.m., during an interview and review of Resident 3's physician orders, Treatment Assessment Record (TAR) and care plans, RN 1 stated there was no care plan to address Resident 3's self-inflicting injuries or an assessment conducted. RN 1 stated being aware of Resident 3's itching since 6/5/2020 upon admission but failed to notify the physician because, I was too busy and did not have time. RN 1 stated she forgot to do treatment orders for Resident 3. On 6/12/2020 at 12:40 p.m., during an observation and interview, Resident 3 was seen scratching himself. Resident 3 stated his skin was itchy and painful. Resident 3 stated he informed the nurses of the skin pain with itching, but no medication was offered. Resident 3 stated the pain and itching was horrible and it would prevent him from sleeping at night. On 6/14/2020 at 1 p.m., during an interview and review of Residents 3's clinical record (care plans, TARs, nurses' notes, Change of Condition (COC), physician orders, Activities of Daily Living (ADL) sheets) the Center Nurse Executive (CNE (another name for director of nurses)) stated and confirm the facility's staff did not follow the policy for wounds and the staff was responsible to assess, document, and carried out orders for residents. A review of the facility's policy and procedure, revised on 7/1/19 and titled, Abuse Prohibition, indicated neglect was defined as the failure of the center, its employees, or service providers to provide goods and services to a patient that are necessary to avoid physical harm, mental anguish, or emotional distress.

Based on observation, interview and record review, the facility failed to notify a physician when one of three sampled residents (Resident 3) had a change of condition ((COC) sudden, clinical deviation from a resident's baseline) on 6/5/2020. Resident 3 had a skin condition that caused severe pain, itching and inability to sleep, which resulted in Resident 3 picking and scratching his skin all over his body. This deficient practice resulted in a 6-day delay in [DIAGNOSES REDACTED]. Resident 3 suffered undue pain, itching and mental anguish and inability to sleep at night and resulted in opened wounds with bleeding that had the potential to become infected (occurs when germs, such as bacteria, grow within the damaged skin of a wound). Findings: A review of Resident 3's Face Sheet (Admission Record) indicated the facility admitted the resident on 6/5/2020. Resident 3's [DIAGNOSES REDACTED]. A review of Resident 3's Licensed Progress note, dated 6/5/2020 and timed at 7:10 p.m. indicated Resident 3 was admitted to the facility with a Stage III sacral wound (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because of obscured by slough (shedding of dead tissue) or eschar (a dry, dark scab of dead skin)) and discoloration to upper and lower bilateral (both) extremities. A review of Resident 3's Weekly Bath and Skin Report, dated 6/8/2020 indicated Resident 3 was noted with open wounds on bilateral forearms, right knee, right foot and sacral area. The report indicated the charge nurse was notified of Resident 3's opened wounds. The note did not indicate Resident 3's physician was notified. A review of Resident 3's care plans, did not indicate a care plan was initiated on 6/8/2020 when the multiple wounds were identified by the staff and/or any physician notification of Resident 3's opened wounds. On 6/11/2020 at 10 a.m., during an observation of Resident 3's wounds and a concurrent interview, Licensed Vocational Nurse 2 (LVN 2) stated Resident 3's sacral wound had not been treated because she was passing medications. Resident 3 was observed moaning unable to answer any questions with generalized body discoloration purple/black in color, dry blood on arms, fingernails, face, bed linens, the wall and bed rails. LVN 2 stated of not being aware how Resident 3 sustained the skin injuries but was aware the resident had a behavior of picking his skin. LVN 2 stated Registered Nurse 1 (RN 1) was aware of Resident 3's skin injuries. On 6/11/2020 at 10:10 a.m., during an observation and interview of Resident 3 with RN 1 stated Resident 3 was admitted to the facility with the behavior of picking/scratching his skin causing skin tears. RN 1 stated Resident 3 had no care treatment ordered for the resident's skin injuries. A review of Resident 3's Licensed Progress notes, dated 6/5/2020 through 6/11/2020 did not indicate the resident's physician was notified of Resident 3's opened skin areas from severe itching and pain. A review of Resident 3's Treatment Assessment Record (TAR) and Medication Administration Record [REDACTED]. On 6/11/2020 at 4:20 p.m., during an interview and review of Resident 3's physician orders, Treatment Assessment Record (TAR) and care plans, RN 1 stated there was no care plan to address Resident 3's self-inflicting injuries or an assessment conducted. RN 1 stated being aware of Resident 3's itching since 6/5/2020 upon admission but failed to notify the physician because, I was too busy and did not have time. RN 1 stated she forgot to do treatment orders for Resident 3. On 6/12/2020 at 12:40 p.m., during an observation and interview, Resident 3 was seen scratching himself. Resident 3 stated his skin was itchy and painful. Resident 3 stated he informed the nurses of the skin pain with itching, but no medication was offered. Resident 3 stated the pain and itching was horrible and it would prevent him from sleeping at night. A review of Resident 3's dermatologist (branch of medicine dealing with the care of the skin) report, dated 6/12/2020 indicated Resident 3 had been complaining of blisters (small bubble on the skin filled with fluid) all over the body that had been flaring up for weeks. The dermatologist report indicated Resident 3 was diagnosed with [REDACTED]. The dermatologist report indicated to treat Resident 3 with [MEDICATION NAME] (an antibiotic) 100 micrograms (mcg (unit of measurement)) capsules by mouth three times a day and [MEDICATION NAME] (used to treat inflammation (the body's response to injury) and allergic conditions) 60 milligrams (mg) by mouth once a day for five days then decrease the dosage by 10 mg every five days for a total of 30 days. A review of an online Mayo Clinic article titled, [DIAGNOSES REDACTED] dated 12/4/18 indicated Pemphigoid was common in elder adults and could be life-threatening when in poor health. According to the article, Pemphigoid was categorized by large reddish dark blisters that are painful and sensitive when rupture or touched. On 6/14/2020 at 1 p.m., during an interview and review of Residents 3's clinical record (care plans, TARs, nurses notes, COC, physician orders, Activities of Daily Living (ADL) sheets) the Center Nurse Executive ((CNE) another name for director of nurse) stated and confirm the facility's staff did not follow the policy for wounds and the staff was responsible to assess, document, and carried out orders for residents. A review of the facility's P/P revised on 11/1/19 and titled, Assessment: Nursing, indicated an initial assessment was conducted to determine resident's condition and clinical needs. Upon the resident's admission, the licensed nurse would conduct a change in condition assessment as needed and notify physician of assessment findings.

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) was safely secured in the facility's transport van during transportation from an appointment. Resident 1's wheelchair tipped over inside the facility's transport van while being transported back to the facility from an appointment. The facility's driver stopped the facility's van, found Resident 1 on the floor of the van, and assisted the resident back to her wheelchair. This deficient practice resulted in Resident 1 falling and sustaining a compression fracture (occurs when the bones in the spine collapses, making them shorter in height) to the lower back spine and she required a transfer to a general acute care hospital (GACH) for evaluation and treatment with pain medication. Findings: A review of Resident 1's Face Sheet (admission record) indicated the facility admitted the resident on 12/22/18, and last readmitted her on 5/15/19. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), an assessment and care-screening tool, dated 10/25/19 indicated Resident 1 had moderately impaired cognition (thought process) and required limited assistance with transfer and walking, and an extensive assistance (staff provide weight bearing support) with dressing and toilet use. A review of Resident 1's care plan titled, Fall Risk Prevention and Management, dated 4/18/19, indicated to encourage Resident 1 to use assistive devices, such as a wheelchair (W/C) or a front wheel walker (FWW) for transfer and ambulation (walking). A review of Resident 1's Nurses Progress Note, dated 11/14/19 and timed at 18:42 (6:42 p.m.) indicated Resident 1 fell from her wheelchair during transport back to the facility from [MEDICAL TREATMENT] (treatment to filter waste and water from the blood of a person whose kidneys are not working normally). The note indicated Resident 1 vomited and complained of mild pain in the lower back. According to the note, Resident 1's physician ordered a transfer to a general acute care hospital (GACH) for further evaluation. A review of Resident 1's computed tomography scan ((CT) an x-ray that allows doctors to see inside the body) of the lumbar spine (lower back), dated 11/14/19 and timed at 9:41 p.m., indicated an acute (sudden) compression [MEDICAL CONDITION] endplate (referring to the spine) of the L1 vertebral body (lower back). A review of Resident 1's GACH progress note, dated 11/14/19, indicated Resident 1 had an acute compression [MEDICAL CONDITION] endplate of the L1 vertebrae (lower back) as a result of a fall incident (on 11/14/19). The note indicated Resident 1 continued to complain of pain, especially on the left side of the lumbar area (lower part of the back). A review of Resident 1's GACH After Visit Summary, dated 11/14/19, indicated Resident 1 was treated with [MEDICATION NAME] ((Tylenol) pain reliever) for pain. A review of Resident 1's nursing progress note, dated 11/15/19 and timed at 1:48 a.m., indicated the facility readmitted Resident 1. On 11/19/19 at 1:35 p.m., during an interview, Licensed Vocational Nurse (LVN) 1 stated, If safety precautions are not properly implemented and secured during the transportation, it can potentially hurt the resident. LVN 1 stated the maintenance personnel should maintain the equipment with regards to latches, straps, seats, W/C or anything involved with the safety of residents riding in the facility's van to prevent accidents. LVN 1 stated the maintenance supervisor should maintain the equipment in good working condition. LVN 1 stated in-service trainings should have been provided when it comes to safety precautions when handling all residents. On 11/19/19 at 1:58 p.m., during an interview, the Maintenance Supervisor (MS) stated his primary responsibility was to maintain the facility's equipment and building in good working condition. The MS stated that the facility's transportation van should be properly checked on a regular basis and as needed before and after use to help prevent accidents. On 11/19/19 at 2:13 p.m., during an interview, Certified Nursing Assistant (CNA) 1 stated Resident 1 was alert, responsive, able to make her needs known, and could recall events. CNA 1 stated Resident 1 could walk with a one-person assist, but she could not keep her balance without assistance, which could lead to falls/accidents if safety measures were not properly implemented. On 11/19/19 at 2:24 p.m., during an interview, the Social Services Director (SSD) stated during the time of Resident 1's fall incident (on 11/14/19), the facility's van was used because the regular transportation was not available to transport Resident 1 from the facility to the [MEDICAL TREATMENT] (treatment that replaces kidney function by removing waste products and excess fluid from the body) treatment center and back. The SSD stated if safety precautions were not in place, accidents could happen that could lead to injuries. On 11/19/19 at 2:35 p.m., during an observation, the MS demonstrated how to properly secure a resident in a W/C inside the facility's van. The demonstration showed that when the W/C was properly strapped and secured, it did not shift nor move. On 11/19/19 at 2:50 p.m., during an interview, Registered Nurse (RN) Supervisor 1 stated, If resident's W/C was not strapped or secured properly during the transportation using the facility's van, the W/C can potentially shift from its original position, either front or back, and that can lead to accident and injury. On 11/19/19 at 3:10 p.m., during an interview, the Director of Nursing (DON) stated, If a resident's W/C is not properly strapped and secured during transportation it is considered a safety issues that can lead to accidents, injuries and even death. On 11/19/19 at 3:45 p.m., during an interview, LVN 2 stated, Safety precautions needs to be implemented before transporting any resident to prevent accidents and injuries. During the huddles (quick meeting to share and discuss information), safety issues are always being discussed to make sure charge nurses talk among licensed nurses, CNAs, and the rehabilitation department. On 11/20/29 at 9:35 a.m., during an interview, Resident 1 stated the W/C tipped over backwards and she had to scream loud for the facility's driver (Driver 1) to stop. Resident 1 stated Driver 1 pulled over and helped her back in the W/C and continued to transport her back to the facility. Resident 1 stated her W/C was not properly strapped/secured and that was why it tipped over. Resident 1 stated she continued to have pain because of the accident, especially on the left lower back area. On 11/20/19 am at 10:16 a.m., during a telephone interview, Resident 1's family member (FM 1) stated she was not happy regarding Resident 1's incident. FM 1 stated the facility should train them (the facility's staff or driver) on how to properly transport residents safely. On 11/21/19 at 9:24 a.m., Driver 1 stated it was already dark outside and she kept asking Resident 1 if she was okay during the bumpy ride. Driver 1 stated Resident 1 did not answer back so she pulled over to check Resident 1 and saw Resident 1 on the floor of the van and the W/C was halfway to the floor. Driver 1 stated she helped Resident 1 back in her W/C and continued to transport the resident back to the facility. Driver 1 stated she did not see exactly what really happened for Resident 1 to fall, but she strapped the resident well to secure the ride based on her recollection. A review of the facility's policy titled, revised on 7/1/19 and Transportation and Escort: Patient, indicated staff may escort patients if needed but will not use their own vehicles to transport patients. The purpose of the policy is to assure patients safety.

Based on observation, interview, and record review, the facility failed to ensure assisted devices were used for a resident who did not have the ability to sit upright in a wheelchair due to [MEDICAL CONDITION] (paralysis (inability to move) on one side of the body) and [MEDICAL CONDITION] (weakness on one side of the body) while being pushed in a wheelchair for one of three sampled residents (Resident 1). Resident 1, who was confused and agitated at times, had the tendency of leaning forward in the wheelchair without staff utilizing the footrest and a seatbelt for safety. While being pushed in the wheelchair, Resident 1 fell out of the wheelchair onto the floor and sustained facial injuries. This deficient practice resulted in Resident 1 falling sustaining a laceration (an injury to the skin and the soft tissue underneath it; a cut) over the left eyebrow, an opened wound on the bridge of her nose, swelling to the left upper lip and a slit (a long, narrow cut or opening) in the center of the bottom lip. Resident 1 was transferred to a general acute care hospital (GACH) for evaluation, care and treatment. Findings: A review of Resident 1's Admission Face sheet indicated Resident 1 was admitted to the facility on [DATE], with a most recent readmission on 6/30/19. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Assessment Outcomes, dated 3/3/18 and timed at 1:47 p.m., indicated Resident 1 was at risk for falls. It also indicated Resident 1 was confused, unable to make significant changes in position independently and required extensive assistance with care. According to this report, Resident 1 used a wheelchair for mobility and had the potential to slide down in a chair. A review of Resident 1's Morse Fall Risk Screen (an assessment and screening tool indicating if a resident was at risk for falls), dated 12/13/18 ,indicated Resident 1 had a score or 65 (a score of 45 and above indicated high fall risk). A review of Resident 1's Minimum Data Set (MDS), an assessment and care screening tool, dated 7/7/19, indicated Resident 1's cognition (thought process) was intact. The MDS indicated Resident 1 required a one-person physical assist with bed mobility, dressing, eating, toilet use and personal hygiene. According to the MDS, Resident 1 had a fall in the last two-six months prior to admission and was taking antipsychotic (medication to treat mental disorders) medication. A review of a facility's report titled, Event Summary Report, dated 7/21/19 and timed at 7 p.m., indicated on 7/21/19 at 6:57 p.m., Certified Nursing Assistant 1 (CNA 1) was wheeling Resident 1 in a wheel chair when Resident 1 placed her foot under the wheelchair's wheel and leaned forward and fell out the wheelchair on her face. According to this report, Resident 1 sustained a laceration over the left eyebrow, an opened wound on the bridge of her nose, swelling to the left upper lip and a slit in the center of the bottom lip. A review of a Situation Background Assessment and Recommendation (SBAR) Internal Communication Form, dated 7/21/19, indicated Resident 1 had one or more falls. A review of Resident 1's Nursing Home to Hospital Transfer Form, dated 7/21/19 and timed at 10:45 p.m., indicated Resident 1 was transferred to a GACH after a fall incident. On 7/23/19 at 7:05 a.m., during a concurrent observation and interview with Registered Nurse 2 (RN 2), Resident 1 was in bed with no floor mats next to the bed and the bed side table was not within the resident's reach. Resident 1's left eye was observed swollen and bruised. There were five (5) sterile strips (adhesive skin closures) on Resident 1's left eye lid and one sterile strip on the bridge of the nose. Resident 1's left upper lip and left chin were bruised. RN 2 stated that Resident 1 did not have a floor mat because the resident did not get out of bed. RN 2 stated that Resident 1's bed side table should have been closer to the resident to prevent the resident from stretching and falling. On 7/23/19 at 9:59 a.m., during an interview, CNA 1 stated that on 7/21/19 while wheeling Resident 1 in the hallway, the resident's feet were on the floor, not on the foot rest, and Resident 1 was trying to walk (move her feet as though walking) while the wheelchair was in motion. CNA 1 stated that Resident 1 was confused and agitated (feeling or appearing troubled). CNA 1 stated that she continued to push the wheelchair and did not ask Resident 1 to stop. According to CNA 1, as the wheel chair was moving, Resident 1 suddenly leaned forward and fell on her face onto the floor, slit her lower lip and sustained a laceration to the eye and was bleeding from the injuries. CNA 1 stated she was not sure if placing the resident's feet on the foot rest could have stopped the resident from falling and getting injured. On 7/23/19 at 11:15 a.m., during an interview, the facility's Director of Rehabilitation (DOR) stated that Resident 1 was unable to walk, was cognitively impaired and had poor safety awareness. The DOR stated that Resident 1's feet should have been placed on the foot rests when someone was pushing the wheelchair because Resident 1 was erratic (unpredictable) and had a tendency of sliding out of the wheelchair. According to the DOR, placing Resident 1's feet on the foot rest would have prevented the fall with injuries. On 7/23/19 at 11:48 a.m., during a telephone interview, Licensed Vocational Nurse 1 (LVN 1) stated that Resident 1 was agitated, confused and had a tendency of standing up abruptly while in the wheelchair. LVN 1 stated that while CNA 1 was wheeling Resident 1 she leaned forward, fell on her face and sustained injuries. On 7/23/19 at 12:20 p.m., during an interview, Registered Nurse 1 (RN 1) stated that on 7/21/19 after dinner, CNA 1 was wheeling Resident 1 from the dining room. Resident 1, who was very confused, put her foot by the wheel of the wheelchair while being pushed and fell face down. RN 1 stated that the resident was bleeding from the eye brow and nose and her dentures and food fell out of her mouth to the floor. RN 1 stated that using a wheel chair with a seat belt around Resident 1's waist could have prevented the fall. RN 1 stated since Resident 1 was agitated and confused, CNA 1 should have pushed the wheelchair with one hand and supported the resident's shoulder with another hand to prevent the fall. A review of the facility's policy with a revision date of 5/27/15 and titled, Accidents and Incidents, indicated the purpose of the policy was to provide a safe and healthy environment to residents, visitors and employees. A review of a facility's policy titled, Falls Management, with a revision date of 3/15/16, indicated the purpose of the policy was to reduce risk for falls and minimize the actual occurrence of falls. The policy also indicated that injury and providing care for a fall would be addressed such as identifying residents fall risk status to caregivers, develop an individualized care plan, review, and revise care plans regularly if a fall incident occurred.

Based on observation, interview, and record review, the facility failed to follow its policy, physician orders, and plan of care for three of four sampled residents (Residents 1, 3, and 4) who were assessed as an elopement (act of leaving without permission) risk. Resident 1's wanderguard (tracking device worn on the wrist or ankle that alarms when one leaves a designated area) was not checked for functionality and placement, per physician order. Resident 3, who was identified as an elopement risk, was not provided a wanderguard per plan of care. Resident 4, who was at risk for elopement, had no care plan to address the identified problem. These deficient practices resulted in Resident 1 eloping, falling, and sustaining a fracture (broken bone) to the left thumb, and had the potential for Resident 3 and 4 to elope from the facility which could result in harm and/or injury. Findings: a. A review of Resident 1's Admission Face sheet indicated the resident was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's care plan, dated 3/16/18, indicated the resident was at risk for falls. The staff's interventions indicated to provide frequent checks every shift and provide verbal cues for safety as needed. A review of resident 1's History and Physical (H/P) report, dated 3/19/18, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS), a comprehensive assessment and care-screening tool, dated 4/12/18, indicated Resident 1 had difficulty focusing attention and difficulty keeping track of what was said. The MDS indicated Resident 1 required an extensive physical assist from staff for bed mobility, moving from one location to another, dressing, eating, toileting and personal hygiene, and was incontinent (inability to control) of bowel and bladder function. A review of Resident 1's Progress Note, dated 5/14/18, and timed at 1:46 p.m., indicated Housekeeper 1 (HSK 1) and Resident 2 notified Registered Nurse 1 (RN 1) that Resident 1 eloped from the facility at 6:05 a.m. on the same day. The note indicated HSK 1 followed Resident 1 but was not able to locate the resident, after Resident 1 passed through an open gate in an apartment complex. At 6:30 a.m., a licensed nurse located Resident 1, who was found to be confused and combative, and had bloody drainage to the left hand and thumb. At 8:30 a.m., Resident 1 was transferred to a general acute care hospital (GACH). A review of Resident 1's GACH radiology (X-Ray) report, dated 5/14/18, indicated the resident had a fracture (broken bone) to the left thumb. A review of the facility's Witness Interview Record, dated 5/15/18, indicated Resident 1 walked out of the facility, pushed himself through a gate of an apartment complex located next to the facility, and locked the gate behind him. The record indicated the staff jumped the gate and found the resident on the ground. The resident sustained [REDACTED]. Resident 2 and HSK 1 notified RN 1 that Resident 1 eloped into a locked gate apartment, the staff made several attempts to get the resident, and found the resident talking with a neighbor who stated the resident might have fallen while climbing onto a balcony. According to the record, Resident 1 was disheveled, confused, combative, difficult to talk to, and had no shoes on. Resident 1 complained of mucho dolor (Spanish phrase translated to a lot of pain). RN 1 indicated in the record the extent of Resident 1's left hand injuries could not be determined and the resident requested to be taken to a GACH. On 5/17/18 at 7 a.m., during a concurrent observation and interview, RN 1 stated the exit door through which Resident 1 eloped, was unlocked, and unalarmed and that it opened into a street with passing cars. RN 1 stated the housekeeping staff turned the alarm off in the morning because they were in and out through that door. RN 1 stated Resident 1 was found across the street in the huge apartment complex, which had several levels, stairs, shrubs and an open pool. RN 1 stated that the staff followed the blood marks on the ground and door knobs in the apartment complex to trace Resident 1, who was found bleeding profusely from the left hand, and complained of a lot of pain. RN 1 stated the staff was not able to assess the depth of the resident's injury due to the bleeding, and was unsure if the resident hit his head after falling. According to RN 1, a neuro check (test to check for [MEDICAL CONDITION]) was not performed on Resident 1 because the resident was transferred to a GACH at 8:30 a.m. (over two hours after the resident had an unwitnessed fall). RN 1 stated neuro checks should be performed when a resident has an unwitnessed fall. On 5/17/18 at 7:30 a.m., during an interview, HSK 1 stated Resident 2 informed him on 5/14/18 at 6 a.m., which Resident 1 walked out of the corner door. HSK 1 stated he went out and observed Resident 1 entering an apartment complex. HSK 1 also stated that he did not see the resident leave and the door alarm did not activate, but should have. On 5/17/18 at 7:33 a.m., during an interview, the Housekeeping Supervisor (HSKS) stated the doors with alarms were supposed to stay on at all times. On 5/17/18 at 7:39 a.m., during an interview, the Maintenance Supervisor (MS) stated the facility's administrator (ADM) informed him that Resident 1 eloped but did not mention that it was through the emergency exit. The MS stated the ADM did not tell him that the alarm to the door was off when Resident 1 eloped. The MS stated he had to inspect the doors to make sure the alarms were on. On 5/17/18 at 7:59 a.m., during an interview, Licensed Vocational Nurse 2 (LVN 2) stated Resident 1 had a wanderguard and that nurses were supposed to check for its placement and functionality at the beginning of their shift. LVN 2 stated she did not check Resident 1's wanderguard but that she should have checked it at the start of the shift to prevent the resident from leaving the facility without notice. On 5/17/18 at 8:05 a.m., during an interview, LVN 1 stated on 5/1/14/18, at 6:05 a.m., she accompanied RN 1 into the huge apartment complex to look for Resident 1. LVN 1 stated the door knobs and walk ways in the apartment complex had fresh blood. Resident 1's left hand was covered with blood, and she was unable to see the cut. LVN 1 added that there were three flight of stairs, a walk way and more stairs, and an unlocked pool. According to LVN 1, Resident 1 might have hit his head or even drowned in the open swimming pool. LVN 1 added that the door alarm did not go off when Resident 1 eloped from the facility. On 5/17/18 at 8:12 a.m., during an observation of the facility's exit doors in the presence of the MS, the Emergency (ER) Exit (Door 1) did not activate when opened. The MS stated all ER exit doors were supposed to stay on and alarm when opened. The MS also stated ER exit doors were inspected for functionality daily, and the nurses were responsible for checking the placement and functioning of the residents wanderguards while the MS ensured the doors were working well. On 5/17/18 at 8:17 a.m., during an interview, the Director of Staff Development (DSD) stated that nurses were supposed to check the placement and functioning of the resident's wanderguards at the start of their shift to ensure they were on and working. The DSD stated checking the wanderguards would ensure the safety of the residents and prevent the residents from elopement. On 5/17/18 at 9:16 a.m., during an interview, Certified Nursing Assistant 1 (CNA 1) stated that she did not see Resident 1 leaving the building and did not hear the door alarm. CNA 1 also stated a few minutes before Resident 1 eloped, the resident was restless and eager to get out of bed. CNA 1 stated that RN 1 who was located on the other side of the facility and made aware. CNA 1 also stated Resident 1 pulled his gastrostomy tube ((GT) surgically created opening in the stomach for food, hydration, and medication administration). On 5/17/18 at 9 a.m., during an interview, Resident 2 stated that he observed Resident 1 leaving the facility through the facility's corner door and the alarms did not activate. Resident 2 stated that there was no nurse present on that side of the facility at the time Resident 1 eloped. b. A review of Resident 3's Admission Face sheet indicated the resident was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. A review of Resident 3's care plan, dated 3/6/18, indicated the resident was at risk for elopement related to one or more attempts of trying to leave the facility. The staff's interventions indicated to re-apply a wanderguard, check the placement and functioning of the wanderguard, and monitor what contributed to the resident's elopement behavior. A review of Resident 3's MDS, dated [DATE], indicated the resident could not understand and be understood by others, and had a Brief Interview for Mental Status (BIMS) score of 5 (0-7= severely impaired). The MDS indicated Resident 3 required a one to two-person physical assist with bed mobility, moving from one location to another, dressing, toilet use and personal hygiene. A review of Resident 3's Elopement Evaluation Record, dated 5/16/18, indicated the resident had a history of [REDACTED]. A review of Resident 3's physician's orders [REDACTED]. On 5/17/18 at 8:05 a.m., during a concurrent interview and record review, LVN 1 stated that Resident 3 was on the list for residents at risk for elopement. LVN 1 stated the residents who were at risk for elopement wore wanderguards. LVN 1 stated at the beginning of every shift, the nurses were to make sure those residents at risk for elopement wore their wanderguards and were to check to ensure they were working. On 5/17/18 at 8:10 a.m., during a concurrent observation and interview, LVN 4 stated Resident 3 did not have a wanderguard because the resident only wandered in the facility and never tried to leave. LVN 4 stated Resident 3 was always going around looking for her white dog. On 5/17/18 at 8:20 a.m., during a concurrent interview and record review, the Director of Nursing (DON) stated Resident 3 was not at risk for elopement. The DON stated Resident 3 had a care plan for elopement because the resident was only at risk when she had a urinary tract infection ([MEDICAL CONDITION] bladder infection), and was taken off the list of residents at risk of elopement. The DON stated the staff were not aware Resident 3 was no longer at risk for elopement. On 5/17/18 at 12:05 p.m., during an interview, the DON stated Resident 3 was re-assessed and placed as an elopement risk, because the DON felt that Resident 3 should remain an elopement risk. The DON stated that when Resident 3 was initially at risk for elopement, the DON failed to get an order for [REDACTED]. On 5/17/18 at 12:39 p.m., LVN 4 stated Resident 3 was at risk for elopement but never had a wanderguard. c. A review of Resident 4's Admission Face sheet indicated the resident was admitted to the facility on [DATE], and last readmitted on [DATE]. Resident 4's [DIAGNOSES REDACTED]. A review of Resident 4's undated History and Physical (H/P) indicated the resident did not have the capacity to understand and make decisions. A review of Resident 4's Elopement Evaluation Records, dated 2/22/18 and 3/22/18, indicated the resident had a history of [REDACTED]. A review of Resident 4's MDS, dated [DATE], indicated the resident could not understand and be understood by others, and had a BIMS score of 5 (severely impaired cognition). The MDS also indicated Resident 4 required a one to two-person physical assist with bed mobility, transfers, walking, dressing, toilet use and personal hygiene. A review of Resident 4's clinical record indicated there was not a care plan developed to address the problem with the resident's risk for elopement. On 5/17/18 at 7:42 a.m., during a concurrent observation, interview, and record review, the DSD verified Resident 4 did not have a wanderguard on, and that the resident was listed as an elopement risk, but did not have a care plan. The DSD stated Resident 4 did not have a wanderguard because the resident was weak and not able to propel his wheelchair. On 6/22/18 at 10:40 a.m., during an interview, the administrator (ADM) stated the facility was not a locked (enclosed area equipped with locks or other security devices that permit access only to authorized persons) facility and there was no need for alarms. The ADM stated alarms were used to alert the staff if a resident tried to leave the building and that the alarms were supposed to be on at all times. A review of the facility's policy and procedure titled, Elopement of Patient, with a revision date of 5/15/14, indicated residents at risk for elopement would have an elopement prevention care plan and an elopement risk form for all at risk residents placed in a binder that is easily accessible to the staff. The policy indicated that security system checks would be conducted and documented to ensure the function of wander systems, triggered bracelets, door alarms and security cameras. A review of the facility's policy and procedure titled, Accidents/Incidents, revised on 11/28/16, indicated an accident is any unexpected or unintentional incident which may result in injury or illness to a resident. The purpose of this policy included to define causative/contributing factors and institute preventive measures to avoid further occurrences. A review of the facility's policy and procedure titled, Person-Centered Care Plan, revised on 3/1/18, indicated the purpose of the policy was to attain or maintain the resident's highest practicable, metal and psychological well-being. The policy indicated the facility must develop a care plan that included instructions needed to provide effective and person-centered care that met professional standards of quality care. The policy indicated care plans must be communicated with appropriate staff.

Based on observation, interview, and record review, the facility failed to ensure one of three residents (Resident 1) received adequate supervision as per the facility's policy and the resident's plan of care to prevent or reduce the risk for falls. Resident 1, who had a high risk for falls, had an unsupervised fall sustaining a fracture (broken bone) of the right leg. This deficient practice resulted in Resident 1 sustaining a fall after being left unsupervised in the patio without a chair alarm and fell from the wheelchair to the ground, sustaining a right femur (thighbone) fracture. Findings: A review of Resident 1's Admission Record, indicated the resident was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a comprehensive assessment and care-screening tool, dated 10/6/17, indicated Resident 1 was unable to understand and be understood by others. The resident's Brief Interview of Mental Status (BIMS) score was 7 (0-7= severe cognitive impairment (thought process)). The MDS indicated Resident 1 required an extensive assistance in moving to or from: bed, chair, wheel chair and/or to a standing position. Resident 1 was assessed to be totally dependent on staff in moving from one unit to another. The MDS indicated the resident was not steady in standing and was only able to stabilize with staff assistance in walking and transferring between bed, chair and/or wheelchair. According to the MDS, Resident 1 used a wheelchair and walker for mobility. A review of Resident 1's Initial Nursing Assessment, dated 9/29/17, indicated the resident had a history of [REDACTED]. A review of Resident 1's care plan titled, At Risk for Falls, dated 9/29/17, indicated the staff's interventions were to monitor Resident 1 and assist with toileting needs, utilize low bed with floor mat, implement safety precautions per facility protocol, provide a bed alarm, and chair alarm. A review of Resident 1's Restrictive Device Consent form, dated 10/3/17, indicated for the use of a chair alarm and floor mats for safety/fall risk precaution. The form indicated the above interventions were ordered by Resident 1's physician as part of the resident's overall plan of care. A review of Resident 1's physician's orders [REDACTED]. A review of a Progress Note, dated 10/17/17, indicated Resident 1 had a fall at 8 p.m. that day, as reported to the charge nurse by a certified nursing assistant (CNA). According to the note, the Registered Nurse (RN) supervisor completed a head to toe assessment on Resident 1 and there were no fractures, bleeding or pain noted. A review of a Progress Note, dated 10/18/17, and timed at 2:51 a.m., indicated Resident 1 had a change of condition and was assessed to have swelling on the left foot/toes with redness. According to the note, Resident 1's physician was notified. A review of Resident 1's Radiology Report for x-rays of the right leg, dated 10/18/17, indicated the resident had a right femur fracture. On 11/1/17 at 8:30 a.m., during an interview, the Director of Nursing (DON) stated that Resident 1 was found by a Licensed Vocational Nurse (LVN 3) on the ground in the patio on 10/17/17. The DON stated Resident 1's fall was not witnessed and that the resident was confused, and per the facility's protocol, confused residents were to be monitored every two hours. The DON further stated that since Resident 1 was assessed to be at risk for falls, the resident should have had a chair alarm. On 11/1/17 at 8:50 a.m., during an interview, LVN 1 stated that residents who were at high risk for falls should be monitored frequently, every one to two hours, and should have a bed alarm per the physician's orders [REDACTED]. On 11/1/17 at 10 a.m., during an interview, LVN 2 stated that LVN 3 found Resident 1 on the ground in the patio with his face down and the wheelchair behind him. LVN 2 stated Resident 1 did not have a wheelchair alarm at the time of the fall incident, as indicated in the resident's care plan. On 11/1/17 at 10:12 a.m., during an interview, a Certified Nursing Assistant 2 (CNA 2) stated that Resident 1 was being monitored every one to two hours , because the resident had a tendency of getting out of bed unassisted. CNA 2 stated that Resident 1 was taken to the nurses' station or activity room for close monitoring when a nurse was unavailable. During an observation, on 11/1/17 at 10:41 a.m., Resident 1 was observed being wheeled to physical therapy. There was no chair alarm on Resident 1's wheelchair. On 11/1/17 at 12:20 p.m., during a concurrent observation and interview, CNAs 1 and 3 stated that Resident 1 did not have a chair alarm on his wheel chair and that the resident should have had one. On 11/1/17 at 12:30 p.m., during an interview, the DON stated that bed or chair alarms were used as a nursing protocol and did not require a physician's orders [REDACTED].>On 12/8/17 at 7:58 a.m., during an interview, LVN 3 stated that he did not witness Resident 1's fall, but saw the resident on the ground after the incident. LVN 3 stated Resident 1's wheelchair was located behind him and there was no alarm on the resident's wheelchair at the time of the fall. A review of the facility's policy titled, Falls: Care Delivery Process, dated 7/25/16, indicated the most successful fall program was a collaboration of all disciplines to identify and manage risk factors and causes. The policy indicated the nursing staff was to identify appropriate interventions to reduce fall risk and minimize injury. A review of the facility's policy titled, Fall Management, with a revision date of 3/15/16, indicated residents at risk for falls would receive appropriate interventions to reduce risk and minimize injury.

Based on interview and record review, the facility failed to ensure a resident who required limited to extensive assistance from staff for his activities of daily living (ADL), and was assessed as a high risk for falls, received the assistance he required to prevent falls, for one of three sampled residents (Resident 2). On January 7, 2013, at approximately 1:45 p.m., Resident 2 fell in his bathroom while attempting to transfer himself from the toilet back into his wheelchair unassisted, resulting in a left sub-capital femur fracture (a broken hip) that required surgery. Findings: A review of Resident 2's admission records indicated he was originally admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. A Care Plan was initiated April 29, 2009, and was reviewed every three months for risk for fall as evidenced by history of falls, impaired balance, poor coordination, visual deficit and generalized weakness. The interventions included to encourage the resident to communicate needs, to ask for assistance, to place call light within easy reach of the resident, and to reinforce the need to call for assistance. A review of the Resident Fall Evaluation form dated February 12, 2012, February 18, 2012, March 26, 2012, June 14, 2012, September 14, 2012, and December 28, 2012, indicated the resident was a high risk for falls. The evaluation indicated that Resident 2 required assistance with bed mobility, transfers and ambulation, had problems with behavior, and had impaired vision. A Care Plan was initiated July 13, 2012, for self-care deficit related to change in mobility, cognitive impairment, decreased balance, depression, impaired coordination and vision impairment. The interventions included to adjust level of care according to individual needs, to report persistent changes to the physician and family, to allow sufficient time for dressing/undressing since the task may be tiring, painful and difficult, and keep the call light within reach and answer promptly. The care plan did not address how the resident would be assisted for toileting. The Minimum Data Set (MDS), an assessment and care screening tool, dated December 29, 2012, indicated the resident's cognitive status for daily decision making was intact, and he was alert and able to make his needs known. The resident was assessed with [REDACTED]. The resident was also assessed as always continent of bowel and bladder. The balance section indicated the resident was not steady, and only able to stabilize self with staff assistance with moving from a seated to standing position, walking, turning around while walking, moving on and off the toilet, and surface to surface transfers between the bed and chair or wheelchair. The mobility devices indicated were a walker and wheelchair. The Interdisciplinary Progress Notes dated January 8, 2013, 7 a.m., to 3 p.m. at 9:30 a.m., late entry for January 7, 2013, indicated Resident 2 fell in his bathroom while getting off the toilet and back to his wheelchair. The note indicated Resident 2 stated his wheelchair moved. The resident was found sitting on his bottom on the floor with his legs straight in front of him. The resident stated he hit the back of his head on the wall. The physician was notified and an x-ray of the skull and left hip were ordered. The note further indicated the skull x-ray result was received and it was negative for fracture. The left hip x-ray result was a subcapital fracture with slight displacement. The physician was notified and the resident was transferred to a general acute care hospital (GACH). The Operative Report obtained from the GACH dated January 10, 2012, indicated the preoperative [DIAGNOSES REDACTED]. The resident was admitted to the GACH and returned to the facility on [DATE]. On January 29, 2013, at 12:15 p.m., during an interview with Resident 2 regarding his fall incident, he stated he put the call light on to ask for assistance, waited 20 to 30 minutes and no one came, so he got up (unassisted) from the bed to the wheelchair, and then transferred to the toilet. He stated he knew he was supposed to call for assistance, however, he always has to wait a long time, and that's why he got up by himself. He stated that when he attempted to transfer from the toilet back to his wheelchair, the wheel chair slid back, and he fell on his left side. He further stated he calls for assistance all the time before going to the bathroom by himself, wait for 20 to 30 minutes, but when no one comes to help him he goes to the bathroom by himself. On March 21, 2013, at 1 p.m. during an interview, the director of nursing (DON) stated the call lights should be answered in a timely manner within three to four minutes. The DON stated that Resident 2 was not on a bowel and bladder program, and he knew that Resident 2 went to the bathroom by himself. The DON further stated that there was no care plan to address the type of assistance the resident required for toileting, even though the MDS assessment indicated he required limited assistance with one person assist for toilet use and transfer.