Every finding on record at Providence Little Comp of Mary Subacute Care CTR

Based on observation, interview, and record review, the facility failed to ensure dependent residents received timely and appropriate Activities of Daily Living (ADL-activities such as bathing, dressing and toileting a person performs daily) care for three of six sampled residents (Resident 42, Resident 51 and Resident 72). The facility failed to:1.Provide incontinent care to Resident 51 and Resident 72 in a timely manner and not leave the residents with soiled incontinence briefs (absorbent, disposable underwear with fastening tabs on both sides) for an extended time.2. Suction (a procedure that is done to help keep a resident 's airway open and free of mucus) Resident 42 's mouth and right nostril who required suctioning to keep airway (the path that air and oxygen to get in and out of the body) clear from secretions (phlegm and saliva).These failures placed Resident 51 and Resident 72 at risk for discomfort, increased risk for skin breakdown, infection and had the potential to put Resident 42 at risk for shortness of breath and aspiration pneumonia (lung infection caused by breathing food, liquid, vomiting or saliva into the lungs).Findings:1. During an observation on 1/26/2026 at 3:34 p.m. and subsequent observation on 1/26/2026 at 3:52 p.m. in Resident 51's room, Resident 51 was lying in bed , grimaced and turned her back to the right side where a large amount of brown soft stool ( feces- waste material produced during digestion and expelled from the body through the rectum and anus) was seen on resident's buttocks, brown stool and urine were present in the under pad (disposable or reusable highly absorbent sheet) and resident's gown. There was a strong smell of stool present in the room.During a concurrent observation and interview on 1/26/2026 at 4:22 p.m. with Certified Nursing Assistant (CNA)1, CNA1 entered Resident 51's room and stated there was a strong smell of stool present in the room. CNA1 stated the last time she had seen Resident 51 was around 1:00 p.m. and had not seen Resident 51 for the last three hours because her assignments are heavy.During a review of Resident 51's Face Sheet ( front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the resident was admitted on [DATE] with diagnoses including urinary tract infection (UTI- an infection in the bladder / urinary tract), traumatic brain injury (TBI-damage to the brain caused by an external force causing disruption of normal brain function), cervical neck fracture( broken bone in the neck), percutaneous endoscopic gastrostomy(PEG- feeding tube inserted directly into the stomach to provide a way to deliver nutrition, fluids and medications), and functional quadriplegia (complete inability to move due to extreme frailty or severe chronic disability).During a review of Resident 51's Minimum Data Set (MDS- a resident assessment tool) dated 1/12/2026, the MDS indicated the resident had moderately impaired cognitive skills (a person has noticeable ongoing trouble with thinking, memory and learning that goes beyond normal aging) and was dependent (the resident required full assistance from the staff to complete an activity)on staff with oral hygiene, toileting hygiene, bathing, dressing and personal hygiene. The MDS indicated Resident 51 was always incontinent (having no or insufficient voluntary control over urination or defecation [movement of feces through the bowel and out the anus]) of urine and stool and at risk for developing pressure ulcer or injury (localized damage to the skin and/or underlying tissue usually over a bony prominence).During a review of Resident 51's Care Plan titled Altered Urinary Elimination/At risk for Skin Breakdown, dated 8/7/2024 and end date 4/26/2026, the Care Plan indicated Resident 51 was totally incontinent of bladder function related to impaired cognition, communication and mobility. The Care Plan interventions included providing good perineal care (cleansing the genital and anal areas to prevent infection, skin breakdown and odor) every shift especially after episode of incontinence.During an observation on 1/26/2026 at 2:29 p.m. in Resident 72's room, Resident 72 was lying in bed non-verbal with contracted (permanently stiff, bent and shortened due to tight muscles, tendons or skin making them hard to straighten) and crisscrossed legs. There was an observation of brown stool that went up to the posterior (back) of both thighs. The room had a smell of stool.During an observation on 1/26/2026 at 3:35 p.m. in Resident 72's room, Resident 72 remained lying in bed with incontinence brief soiled with stool.During an observation on 1/26/2026 at 4:10 p.m., CNA1 entered resident 72's room and cleaned and changed incontinence brief of Resident 72.During a review of Resident 72's Face Sheet, the Face Sheet indicated Resident 72 was admitted on [DATE] to the facility. Resident 72's had diagnoses including hyperlipidemia (abnormally high level of fats in the blood), gunshot wound of the head ,presence of gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems)contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of the joint.During a review of Resident 72's MDS dated [DATE], the MDS indicated Resident 72 was dependent on the staff with oral hygiene, toileting hygiene, bathing, dressing and personal hygiene. The MDS indicated Resident 72 was always incontinent of urine and stool and at risk of developing pressure injury.During a review of Resident 72's Care Plan titled, Skin Health and Integrity, revised and updated 9/29/2025, the Care Plan indicated Resident 72 remained at risk to develop pressure ulcer or skin breakdown related to incontinence. The Care Plan interventions included providing good skin care every shift, especially after each episode of incontinence.During an interview on 1/26/2026 at 4:35 p.m. with CNA 1, CNA1 stated the nursing staff is expected to make rounds on all residents every two hours. CNA 1 stated repositioning, checking residents' safety and checking if a resident needs to be cleaned or changed if they are soiled with urine and stool. CNA 1 stated on 1/26/2026, the last time she had seen Resident 72 was at 1:30 p.m. and Resident 51 before 1:00 p.m. CNA 1 stated both Resident 51 and Resident 72 would not be able to call for help by using the call lights because of their cognition (thought process). CNA 1 stated the staff need to come and check the residents to ensure their needs are met or taken care of. CNA 1 stated she should have asked for assistance from other staff because she was running behind with her work and had not changed the residents in a timely manner. CNA1 stated Resident 51 and Resident 72 could be at risk of developing pressure injury, skin rashes because of not cleaning them in a timely manner after an incontinent episode.During an interview on 1/26/2026 at 4:16 p.m. with the Licensed Vocational Nurse (LVN) 5, LVN 5 stated CNAs and licensed nurses make rounds every 2 or three hours which involved checking all residents if they are clean or repositioned. LVN 5 stated the last time she saw Resident 72 was at 2:00 pm but did not check if Resident 72 needed to be changed or cleaned. LVN 5 stated the rooms of Resident 72 and Resident 51 had the smell of stool and leaving residents lying in soiled incontinent briefs with stool and urine for an extended time can lead to development of skin breakdown or skin impairment because stool and urine can cause skin irritation.During an interview on 1/28/2026 at 3:20 p.m. with the Registered Nurse (RN) 2, RN 2 stated CNAs, LVNs and RNs should make rounds every 2 hours for repositioning and checking any episodes of bowel or bladder incontinence. RN2 stated the staff should enter the room and physically check all residents from the back and if their incontinence briefs are dry or soiled. RN 2 stated all staff can help clean residents or assist them with their ADLs. RN 2 stated Resident 51 and Resident 72 could be at risk for skin injury or damage due to moisture created by stool and urine in the skin if incontinent care was not provided in a timely manner. RN 2 stated the residents who are not attended in a timely manner could feel miserable and unhappy with their care.During an interview on 1/30/2026 at 11:20 a.m. with the Director of Nursing (DON), the DON stated residents that are not cleaned and changed after an incontinent episode in a timely manner could cause discomfort, and residents could be at risk for pressure injury due to the acidic nature of stool and urine.2.During an observation on 1/26/2026 at 11:47 a.m. in Resident 42's room, Resident 42 was lying upright in bed receiving oxygen 28 % (percent- concentration of oxygen) through a T Bar (T shaped device attached directly to the tracheostomy tube [ a small, curved plastic or metal tube inserted through a surgically created opening in the neck directly into the windpipe] to deliver humidified oxygen). Resident 42 was observed with clear secretions bubbling and dripping down on both sides of the mouth. Resident 42's right nostril was observed with thick greenish yellow mucus discharge.During a review of Resident 42's Face Sheet, the Face Sheet indicated Resident 42 was admitted on [DATE] to the facility with diagnoses including chronic respiratory failure(long term, progressive condition where the lungs become unable to supply enough oxygen or remove enough carbon dioxide from the body), tracheostomy status, anoxic encephalopathy( serious brain injury caused by a total lack of oxygen reaching the brain_, gastrostomy tube (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) dependent, and diabetes mellitus(DM- a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 42's MDS dated [DATE], the MDS indicated Resident 42 was comatose (unconscious and unable to communicate often for a long period of time) and was dependent on staff with oral hygiene, toileting hygiene and bathing.During a review of Resident 42's Care Plan titled, Signs and symptoms of Listed Potential Problems will be Absent or Manageable, dated 12/1/2015 and end date of 4/9/2026, the Care Plan indicated Resident 42 had a tracheostomy tube due to chronic respiratory failure. The Care Plan interventions included providing oral care regularly, suctioning to reduce the risk of infection and monitoring for airway patency (clear, open and unobstructed passage for air to travel from the nose or mouth through the pharynx and into the lungs).During an interview on 1/28/2026 at 11:33 a.m. with LVN 3, LVN 3 stated all nursing staff could provide oral care to residents and performed twice a shift. LVN 3 stated residents are suctioned as needed and the frequency of suctioning depends on the amount of secretions. LVN 3 stated Resident 42 could aspirate his secretions, and his work of breathing can get worse if he is not suctioned in a timely manner.During an interview on 1/28/2025 at 4:43 p.m. with the Respiratory Therapist (RT)1, RT 1 stated Respiratory Therapist make rounds every 4 hours. RT 1 stated Resident 42 did not have a lot of secretions and saw Resident 42 on 1/26/2026 at 7:30 a.m. RT 1 stated licensed nurses could suction Resident 42 orally (via mouth) and nasally (via nose). RT 1 stated suctioning is provided to residents who are dependent on care to ensure their airway is clear. RT 1 stated not providing suctioning in a timely manner who had secretions in the mouth and nose can lead to aspiration pneumonia.During an interview on 1/29/2026 at 10:09 a.m. with the Director of Staff Development (DSD), the DSD stated CNAs and LVNs could change the residents if needed when the CNA is busy because they should work as a team. The DSD stated residents should not be left soiled with stool and urine for more than 5 minutes because it can cause skin injury to the residents. The DSD stated rounding should be performed by CNAs and licensed nurses every 2 hours and should check the residents physically especially the residents who had impaired cognition. The DSD stated Resident 42 should be suctioned and leaving him with secretions on the mouth and right nostril area was unacceptable because that is part of resident's hygiene.During a review of facility's policy and procedure (P&P) titled, Incontinent Resident, Care of, revised 12/2024, the P&P indicated the facility will ensure incontinent residents received appropriate care to prevent incontinence complications and is the responsibility of CNA to ensure care is provided. The P&P indicated incontinent residents should be checked periodically to ensure they are not left wet or soaked for prolonged periods.During a review of facility's P&P titled, Respiratory Care Services: Suctioning-Inline(Tracheal and Endotracheal Suctioning), Nasotracheal and or nasopharyngeal Suctioning, last revised 4/2022, the P&P indicated suctioning will be performed on residents who are unable to clear secretions by themselves and order is not needed to suction patients that are on aerosol therapy ( medical treatment that delivers medication directly to the airways and lungs as a fine mist or aerosol) for tracheostomy management.

Based on observation and interview the facility failed to provide a safe and sanitary environment in the kitchen for all residents by failing to:a. Ensure cooking oil, powdered brown gravy, cream of wheat, pancake mix and corn starch had open dates.b. Ensure disposable food containers were stored in a sanitary manner.c. Ensure the utility carts in the clean area were free from crumbs, dried food particles and grime (dirt).d. Ensure open aluminum cans were not stored at the workstation.These failures had the potential to expose residents to food-borne illnesses (any illness resulting from ingestion of food contaminated with bacteria, viruses, or parasites) and put residents at risk for cross contamination (unintentional transfer of harmful bacteria from one object to another).Findings:During an observation on 1/26/2026 at 8:15 am in the kitchen, multiple open food items cooking oil, powdered brown gravy, cream of wheat, pancake mix and corn starch were observed without open dates. There was an observation of clean disposable food containers that were stored in a plastic bin with trash and food particles, and two food utility carts were observed to have dried food particles and dirt. There was also an observation of multiple open aluminum cans with dried food particles in a workstation.During a concurrent observation and interview on 1/26/2026 at 9:00 a.m. in the kitchen with the dietary aide 1(DA1). DA1 stated that the aluminum cans should not be stored at a workstation, and they should be in the trash. DA1 stated there is a risk for spreading germs and the open cans may attract cockroaches and ants.During an interview on 1/29/26 at 8:45 a.m. with the [NAME] (CK), the Ck stated every time you open a food item you must put an open date on the package to ensure the food is fresh and not contaminated. The cook stated there is a possibility of having stomach issues if food is not fresh.During an interview on 1/29/2026 at 9:00 a.m. in the kitchen with DA 2, DA 2 stated disposable food containers are to be stored in clean well-organized manner and any utility carts that are in the clean area should be clean and well organized to prevent the risk of cross-contamination and food poisoning.During an interview on 1/29/2026 at 9:15 a.m. with the Dietary Supervisor (DS), the DS stated he was aware of the concerns that were found in the kitchen. The DS stated that any time food is opened it must have an open date to ensure the food is fresh. The DS stated that open aluminum cans should be in the trash not on the workstation because of the possibility of attracting flies and ants. The DS stated any utility cart in a clean area must be cleaned after each use to prevent cross-contamination and all disposable food storage containers must be stored in a sanitary manner to prevent food borne illness.During a review of the facility's policy and procedure (P&P) titled (Sanitation of Food Service Equipment and Facilities) dated 6/2024, the P&P indicated to prevent the spread of infection and food borne illness, standard procedures shall be followed to sanitize food service equipment and the facilities. The P&P indicated food service equipment and the facilities shall be cleaned and sanitized routinely and according to established procedures, work tables are cleaned before beginning work, between products or at least every 4 hours and at end of shift, work tables, counters and sinks are cleaned with solitaire soap, rinsed, sanitized and allowed to air dry.During a review of the facility's policy and procedure (P&P) titled Food Supplies and Storage dated 10/2025, the P&P indicated all food and non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. The P&P indicated to cover, label and date unused portions and open packages and after removing single -serve items such as disposable plates or containers from the original case or carton, they must be stored inverted on clean surfaces to prevent contamination.During a review of the facilities policy and procedure (P&P) Infection Prevention Program and Risk assessment dated 3/2025, the P&P indicated the purpose of the infection prevention program is to identify infections and mitigate the risks of disease transmission through the development and implementation of preventive measures. The P&P indicated Food Safety in nutritional Care services should have maintenance of a sanitary environment for food safety and preparations, safe cooling of all potentially hazardous foods, appropriate hand hygiene, and safe discarding of potentially hazardous foods for pest or vector control.

Based on observation and interview, the facility failed to ensure the trash receptable was covered, not overflowing with trash and disposed of properly outside the kitchen.This failure had the potential to attract pest/rodents, pose health risk and cause infection control violations.Findings:During an observation on 1/26/26 at 9:12 am outside of the kitchen, there was trash stored in two trash cans that were not covered and one was overflowing with trash.During an interview on 1/29/26 at 9:15 am with the Dietary Supervisor (DS), the DS stated there were two trash cans that were not covered and one was overflowing with trash. The DS stated trash cans should not be overflowing with trash and that they should be covered to prevent the possibility of attracting pests like flies, ants and rodents.During an interview on 1/30/2026 at 7:26 am with the Director of Nurses (DON), the DON stated trash cans should not be overflowing with trash and need to be covered. The DON stated there could be issues with pest control when trash is not disposed of properly.During a review of the State Operations Manual (SOM-federal guidelines long term care) dated 11/28/17. The SOM indicated the facility must:-Dispose of garbage and refuse properly. Ensure waste is properly contained in dumpsters or compactors with lids or otherwise covered.-Ensure storage areas are maintained in a sanitary condition to prevent the harborage and feeding of pests.-Ensure garbage receptacles are covered when being removed from the kitchen area to the dumpster.During a review of the facilities policy and procedure (P&P) Infection Prevention Program and Risk assessment dated 3/2025. The P&P indicated the purpose of the infection prevention program is to identify infections and mitigate the risks of disease transmission through the development and implementation of preventive measures. The P&P indicated to have maintenance of a sanitary environment for food safety and safe discarding of potentially hazardous foods. The P&P indicated the storage and disposal of regulated and non-regulated waste is needed for pest or vector control.

Based on observation, interview and record review the facility failed to ensure one of 20 sampled residents (Resident 105) was provided with an adaptive call light (specialized device for patients with limited mobility) upon admission.This failure put Resident 105's at risk for falls, delay of care, and emotional neglect.Findings:During a concurrent observation and interview on 1/26/26 at 2:14 pm at Resident 105's bedside, Resident 105 was able to mouthed the words that he did not have a call light and could not move his body.During a review of Resident 105's admission Record (Face sheet), dated 1/28/26, the admission record indicated Resident 105 was admitted on [DATE]. Resident 105's diagnosis included hemorrhagic stroke (bleeding in the brain), quadriplegic (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), respiratory failure (lung disease) and GERD (indigestion).During a review of Resident 105's Physical Therapy (PT) Initial Evaluation, dated 1/26/26, the PT evaluation indicated Resident 105 was unable to mobilize his neck, bilateral upper extremities (both arms) and bilateral lower extremities (both legs) so a trial of sip and puff call light (breath operated call light) was recommended.During an interview on 1/26/26 at 2:18 pm with Resident 105's family member (FM1), FM1 stated Resident 105 was admitted on [DATE] and has not had a call light to call staff for assistance.During a concurrent observation and interview on 1/26/26 at 2:28 pm at Resident 105's bedside with the Social Worker1(SW1), SW1 stated Resident 105 did not have a call light that was accessible and he should have had one upon admission. SW1 stated that Resident 105 was at risk of his needs not being met because he didn't have an accessible call light.During an interview on 1/28/26 at 3:54 pm with Nursing Manager 1 (NM 1), NM 1 stated all residents upon admission should have a call light that is accessible, so they can communicate their needs to the staff.During an interview on 1/30/26 at 12:12 pm with the Director of Nursing (DON), the DON stated all residents upon admission should have a call light. The DON stated he was made aware that Resident105 did not have a call light that was appropriate for Resident 105's medical condition. The DON stated there was a potential for Resident 105's needs not to be met when not having the proper call light.During a review of the facility's policy & procedure (P&P) Call light Responsibilities (undated), the P&P indicated the purpose was to ensure the safety of all residents and timely response to call lights. The P&P indicated it is the responsibility of the Licensed Nurse/Certified Nurse Assistant (CNA), when admitting the resident, to explain the use of the call light, the emergency light in the bathroom, and the intercom at the nurse station.

Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 10) had a Level 2 Preadmission Screening and Resident Review (PASARR-a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) assessment done when diagnosed with a mental illness prior to admission.This failure had the potential to result in Resident 10 not receiving the necessary services and appropriate psychiatric level of treatment and evaluation in the facility.Findings:During a review of Resident 10's Face Sheet, the Face Sheet indicated Resident 10 was re-admitted to the facility on [DATE]. Resident 10 had diagnoses including cerebral palsy (the most common motor disability in childhood, affecting movement, balance, and posture), intellectual disability (a neurodevelopmental condition characterized by significant limitations in both intellectual functioning (such as learning, reasoning, and problem-solving) and adaptive behavior (practical, social, and everyday life skills), pneumonia (a common lung infection that causes the tiny air sacs in one or both lungs to become inflamed and fill with fluid or pus) and chronic respiratory failure (a long term condition where the lungs cannot properly oxygenate blood or remove carbon dioxide).During a review of Resident 10's Minimum Data Set (MDS- a resident assessment tool), dated 11/5/2025, the MDS indicated Resident 1 rarely had the ability to make self-understood and to understand others. The MDS indicated Resident 10 was severely impaired (refers to a significant, long-term (12 plus months) physical or mental limitation that severely restricts an individual's ability to perform basic work activities or age-appropriate daily functions) regarding task of daily life. The MDS indicated Resident 10 was dependent (a person or a thing that relies on another for support, existence, or determination) on nursing staff for eating, oral hygiene, toileting, and showering. The MDS indicated Resident 10 was dependent on nursing staff with dressing, putting on and taking off footwear, personal hygiene and rolling from left to right.During a review of Resident 10's Notice of PASARR Level 1 Screening Results, dated 11/4/2025, the Notice of PASARR Level 1 Screening Results indicated Resident 10 was positive for intellectual disability, developmental disability (a group of diverse, lifelong conditions caused by impairments in physical, learning, language, or behavior), or related conditions. The Notice of PASARR Level 1 Screening Results indicated Resident 10 required a PASARR Level 2 Mental Health Evaluation Referral for intellectual disability, developmental disability, or related conditions. During an interview on 1/30/2026 at 9:12 a.m. with Registered Nurse (5), RN 5 stated she reviewed Resident 10's diagnoses, medication and mental status for appropriate admission to the facility. RNS 5 stated if a resident has a diagnosis of any mental illness, or psychiatric issues these residents would need a Level 2 PASARR evaluation. RN 5 stated Resident 10 needed a Level 2 PASARR Mental Health Evaluation. RN 5 stated Resident 10 needed a level 2 evaluation referral to address and to receive appropriate care and services. RN 5 stated Resident 10's Notice of PASARR Level 1 Screening Results were not reviewed accurately. During a concurrent interview and record review on 1/30/2026 at 12:08 p.m. with the Director of Nursing (DON), Resident 10's Notice of PASARR Level 1 Screening Results, dated 11/4/2025, was reviewed. The Notice of PASARR Level 1 Screening Results indicated a Level 2 Mental health Evaluation Referral for intellectual disability, developmental disability, or related conditions was needed. The DON stated this was missing. The DON stated the negative outcome of not receiving an evaluation referral resulted in Resident 10 not receiving the appropriate level of care.During a review of the Facility's Policy and Procedure (P&P), titled South Division Care Management Standard Work, revised date 9/2024, the P&P indicated the Person completing the screening must submit in the system as soon as possible. Level 1 Screening, the results of this screening will be known immediately after submission.During a review of the P&P, titled California Standard admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities, dated 8/2023, the P&P indicated, It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to, the following a right to treatment and habilitation services and supports in the least restrictive environment. The P&P indicated Treatment and habilitation services, and support should foster the developmental potential of the person and be directed toward the achievement of the most independent, productive, and normal lives possible. The P&P indicated such services shall protect the personal liberty of the individual and shall provide with the least restrictive conditions necessary to achieve the purpose of the treatment, services, or supports.

Based on interview and record review the facility failed to develop and implement an individualized and person-centered care plan for two of six residents (Resident 8 and Resident 15) by failing to:a. Develop a new care plan when Resident 8 rash reoccurred.b. Implement the care plan for monitoring Resident 15's inappropriate sexual behavior and providing a psychiatric (relating to mental illness and its treatment) consult to assess Resident 15's behavior.These failures had the potential to put Resident 8 and Resident 15 at risk not to receive the necessary care and services to meet their needs which could compromise Resident 8 and Resident 15 physical and psychosocial well-being.Findings: a. During a review of Resident 8's Face Sheet (front page of the chart that contains a summary of basic information about the resident) dated 1/28/2026. The Face Sheet indicated that Resident 8 was admitted on [DATE] to the facility. During a review of Resident 8's History and Physical (H&P), dated 4/14/25, the H&P indicated Resident 8 was in a persistent vegetative state. The H&P indicated Resident 8 had the diagnosis including quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), chronic respiratory failure (lung disease), ventilator dependent (machine that moves air in and out of the lungs) and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 8's Minimum Data Set (MDS – a federally mandated resident assessment tool) dated 9/12/2025. The MDS indicated Resident 8 was cognitively impaired. The MDS indicated Resident 8 was totally dependent (staff member does all the work) with activities of daily living (ADLs such as toileting, dressing and personal hygiene). During a review of Resident 8's Order Summary Report dated 1/19/2026. The order summary report indicated Resident 8 was prescribed, vitamin A & D (topical ointment) apply to left and right upper arm, left and right upper leg, left and right groin (lower stomach meets the inner thigh) areas BID start date 1/19/2026 end date 1/26/2026. During a concurrent interview and record review on 1/27/2026 with RN 4, Resident 8's weekly wound assessment dated [DATE] and vitamin A&D order dated 1/19/2026 was reviewed. RN 4 stated Resident 8's rash resolved to left lateral back, left upper back, left lateral leg, left upper quadrant, right lateral back and right medial leg on 12/23/25 and that on 1/18/2026 Resident 8's rashes came back to left and right upper arm left, left and right groin areas. RN 4 stated she should have started a new care plan when the rashes started on 1/18/2026. RN 4 stated a care plan is a guideline on how the staff are going to take care of the residents, if there is no care plan there is no goal there is a risk of residents not being healed because staff won't know the plan of care. During an interview on 1/30/26 at 7:50 a.m. with the Director of Nursing (DON). The DON stated the moment the rashes come back the care plan should have been started, that is where we reflect the treatment and the plan to care for the residents. The care plan is the general rule to guide the staff when providing care to the residents. During a review of facility's policy and procedure(P&P) titled, Comprehensive Care Plan, dated 1/2026, the P&P indicated the facility will provide care and services that will attain and maintain resident's highest practical, physical, mental, and psychosocial well-being. The P&P indicated the facility will implement appropriate treatment to assist in attaining or maintaining quality of life and according to residents' goals and preferences. b. During a review of Resident 15's Face Sheet, the Face Sheet indicated the resident was admitted on [DATE] to the facility. Resident 15's diagnosis included Pneumonia (PNA-an infection/inflammation in the lungs), muscular dystrophy (group of diseases that muscles weaker and tighter over time making harder to move), chronic respiratory failure (long-term condition where the body cannot maintain healthy levels of oxygen and carbon dioxide on its own) requiring use of nocturnal mechanical ventilation (use of breathing machine at night) through a tracheostomy(procedure to help air and oxygen reach the lungs by creating an opening into the windpipe from outside the neck). During a review of Resident 15's Minimum Data Set, dated [DATE], the MDS indicated Resident 15 had an intact cognition (thought process) and used a manual or electric wheelchair as a mobility device (any device or equipment that helps a person with limited mobility, injuries or limited strength to move around more easily, safely and independently). The MDS indicated Resident 15 required partial/moderate assistance (helper or caregiver provides less than half the effort to complete the activity with bathing, upper body dressing (ability to dress and undress above the waist) and toileting hygiene. During a review of Resident 15's Care Plan titled, Identify Related Risk Factors and Signs and Symptoms, dated 9/25/2025 and end date of 4/8/2026, the Care Plan indicated the patient was verbally inappropriate towards staffs, calling staff names and making sexual remarks. The Care Plan indicated Resident 15 asked female staff to clean his private area despite the resident was able to do it. The Care Plan interventions included monitoring Resident 15's behavior every shift and providing psychiatric consult as needed. During a concurrent interview and record review on 1/28/2026 at 3:46 p.m. with the Social Worker (SW)1, Resident 15's Progress Notes of Social Worker dated 9/18/2025 and 10/23/2025 were reviewed. SW 1 stated Resident 15 showed inappropriate sexual behavior towards female Certified Nursing Assistants (CNAs) especially young women. SW 1 stated Resident 15 was assigned male CNAs because he wanted female CNAS to touch him on his private area. SW 1 stated the Resident 15 could clean his private area by himself but asked female CNAs to do it. SW 1 stated he was not aware if the physician was notified about his inappropriate sexual behavior towards female CNAs. SW 1 stated no psychiatric consult was provided to address the behavior. During an interview on 1/28/2026 at 10:25 a.m. with Nurse Manager (NM) 1, NM 1 stated Resident 15's inappropriate sexual behavior towards the female CNAs started on 5/1/2025. NM 1 stated three female CNAs had come to him and were concerned of Resident 15's inappropriate sexual behavior. NM 1 stated Resident 15 liked young female CNAs and disliked old CNAs. NM 1 stated the facility had to take immediate action because of sexual harassment and immediately pulled all three CNAs from taking care of Resident 15. NM 1 stated Resident 15 was now assigned to male CNAs, but sometimes female CNAs were assigned due to inadequate number of male CNAs. During a concurrent interview and record review on 1/29/2026 at 12:06 p.m. with NM1, Resident 15 Plan of Care Note dated 5/1/2025, Progress Notes, Plan of Care Notes and Care Plan titled Identify Related Risk Factors and Signs and Symptoms were reviewed. NM 1 stated the facility documented the inappropriate sexual behavior of Resident on 9/23/2025. NM 1 stated interventions of the Care Plan included monitoring of Resident 15's behavior every shift. NM 1 stated there was no documentation addressing specific inappropriate sexual behavior that was monitored by the staff. NM 1 stated the facility should have placed monitoring of specific behavior addressing the inappropriate sexual behavior of Resident 15. NM 1 stated there was no documentation the physician was notified about Resident 15's inappropriate sexual behavior towards female CNA's for a psychiatric consult was ordered by a physician to address Resident 15's behavior. NM 1 stated the importance of care plan is to individualize the care of a resident and interventions like monitoring of inappropriate sexual behavior should be monitored according to Resident 15's Care Plan. NM 1 stated other residents had the potential to be at risk for abuse or mental distress if Care Plan was not followed. During a review of facility's policy and procedure(P&P) titled, Comprehensive Care Plan, dated 1/2026, the P&P indicated the facility will provide care and services that will attain and maintain resident's highest practical, physical, mental, and psychosocial well-being. The P&P indicated the facility will implement appropriate treatment to assist in attaining or maintaining quality of life and according to residents' goals and preferences.

Based on observation, interview and record review, the facility failed to ensure one of 20 sampled residents (Resident 8) was seen by a Dermatologist (doctor who specializes in skin disorders) for an unresolved whole-body rash that started on 7/18/2025.This failure caused Resident 8 to suffer with discomfort and itching and had the potential for infection, sleep disruption and emotional distress.Findings:During an observation on 1/26/26 at 2:04 p.m. at Resident 8's bedside, Resident 8 had scattered rashes with red patches all over his body.During a review of Resident 8's admission Record (Face sheet), dated 1/28/26, the admission record indicated Resident 8 was admitted on [DATE]. Resident 8 had diagnosis including quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), chronic respiratory failure (lung disease), ventilator dependent (machine that moves air in and out of the lungs), gastrostomy tube ([GT] a soft tube surgically inserted directly into the stomach to administer medication, fluids and nutrition) and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 8's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 9/12/2025. The MDS indicated Resident 8 was cognitively impaired. The MDS also indicated Resident 8 was totally dependent (staff members do all the work) with activities of daily living (ADLs such as toileting, dressing and personal hygiene).During a review of Resident 8's order summary reports dated 7/2025-1/2026. The order summary report indicated Resident 8 was prescribed:1. Diphenhydramine (medication used for itching) 2% topical (on the skin) cream three times a day (tid) as needed (PRN) for itching to apply to the upper chest, shoulder and neck for a skin rash, starting 6/28/2025 -7/12/2025.2. Triamcinolone (medication used to treat inflammatory conditions) 0.1% topical ointment once a day for rashes on the abdomen (stomach) starting 7/25/25-8/22/2025.3. Triamcinolone 0.1% topical ointment once a day for a rash on the back, arm, starting 9/01/2025- 9/22/2025.4. Clotrimazole- betamethasone (anti-fungal medication) 0.5% cream apply topically for rashes to the left posterior arm, left flank, left side of abdomen and right anterior (front) arm two times a day (BID) starting 9/28/2025-10/19/2025.5. Hydrocortisone (medication used for itching) 1% ointment apply to left upper arm rash four times a day (QID) starting 10/29/2025-11/18/2025.6. Fluocinonide (steroid) 0.5% cream apply topically BID to left upper back, right upper back, left upper arm and right upper arm rashes, starting 11/18/2025-2/2/2025.7. triamcinolone 0.1% topical ointment BID for rashes on the left lateral back, left quadrant, left lateral leg, right medial leg and the right lateral back start date 12/07/25 end date 12/21/25.8. Vitamin A&D ointment (skin moisturizer) apply topically to left and right upper arm left and right upper leg, left and right groin (lower stomach meets the inner thigh) areas BID starting 1/19/2026 -1/26/2026.9. Diphenhydramine (medication used for itching) 25 milligrams (mg-unit of measure) via g-tube every six hours as needed for itching starting 1/18/2026 and treatment is ongoing.During a review of Resident 8's Interdisciplinary team ([IDT] team members from different departments working together with a common purpose to set goals and make decisions that ensure residents receive the best care) care conference dated 8/22/2025, the IDT care conference indicated, the family was concerned about rashes spreading all over the left side of Resident 8's body.During a review of Resident 8's IDT care conference dated 9/26/2025, the IDT care conference indicated Resident 8 had rashes that started on 8/12/2025 to the left abdomen, left lateral flank (side of body between the rib and the hip) and left upper arm.During a review of Resident 8's IDT care conference dated 10/25/2025, the IDT care conference indicated Resident 8 had rashes on the left upper arm, left abdomen and left lateral flank.During a review of Resident 8's consultation to case management dated 11/16/2025, the consultation to case management indicated to: Obtain an authorization for a dermatology (specializing in diagnosing and treating skin conditions) consult for dry skin and scattered skin rashes to the entire body.During a review of Resident 8's IDT care conference dated 12/11/2025, the IDT care conference indicated Resident 8 still had rashes and there was minimal response to the previously ordered hydrocortisone cream and a dermatology referral was pending.During a review of Resident 8's IDT care conference dated 1/16/2026, the IDT care conference indicated Resident 8 still had a rash, there was minimal response to the previously used hydrocortisone cream, dermatology referral pending.During a review of Resident 8's medical doctor (MD) progress dated 1/19/2026, the progress note indicated Resident 8 still had a rash and there was minimal response to the previously used hydrocortisone cream.During a review of Resident 8's case manager progress note dated 1/23/2026, the progress note indicated Resident 8 did not need an authorization and will call hospital staffing and look for possible dermatologic provider.During a telephone interview on 1/26/26 at 2:08 p.m. with FM2, FM2 stated Resident 8 had a rash all over his body for over six months. FM 2 stated the facility just kept putting cream on the rashes. FM 2 stated they wanted Resident 8 to be seen by a Dermatologist.During a concurrent observation and interview on 1/27/26 at 11:15 a.m. with Treatment Nurse (TXN) 1, Resident 8's skin treatments were observed. TXN 1 stated Resident 8 has had these rashes for months all over his body. TXN 1 stated many different steroid creams have been used on Resident 8 rashes, but they come back. TXN 1 stated Resident 8 is waiting to be seen by a Dermatologist. TXN 1 stated Resident 8 was neglected and should have been seen by a dermatologist sooner.During a concurrent interview and record review on 1/27/2026 at 3:21 p.m. with Registered Nurse (RN) 4, Resident 8's progress note was reviewed. RN 4 stated Resident 8 had a rash all over his body since 7/25/2025 and that the rash comes and goes. RN 4 stated we have been waiting for authorization from Resident 8's insurance company to see a Dermatologist. RN 4 stated Resident 8 was not comfortable and that she (RN 4) should have escalated the dermatology consultation. RN 4 stated there was a delay in care for Resident 8.During an interview on 1/28/2026 at 11:49 a.m. with the Case Manager (CM). The CM stated Resident 8 does not need an authorization to see a Dermatologist. The CM stated after she talked to RN 4 on 1/26/26 that is when CM started looking for a Dermatologist for Resident 8. The CM stated regardless of Resident 8's insurance, he needed to be seen by a dermatologist. The CM stated Resident 8 was a human being and should not have to suffer.During an interview on 1/30/26 at 7:50 a.m. with the Director of Nurses (DON), the DON stated he was aware of what was going on with Resident 8's Dermatologist consultation. The DON stated there was a gap in the system and that the Dermatologist consult should have been escalated. The DON stated the rashes on Resident 8 would continue to spread if the cause was not found. The DON stated if it were his family member, he would be worried.During a review of the facilities Case Management job description dated 1/2026, the case management job description indicated, Case Management process facilitates communication and care coordination. The goals of Case Management include the achievement of optimal health, access to services, advocacy, appropriate utilization of resources and collaboration with post-acute care providers to ensure patient's needs are met in the community. The Care Manager utilizes the following processes to meet the patient's individual healthcare needs: assessment, planning/intervention, implementation, care coordination, monitoring, evaluation of the plan of care and communication.During a review of the facility's Policy and Procedure (P&P), titled Abuse prevention dated 5/2025, the P&P indicated neglect was failure to exercise that degree of care that a reasonable person would exercise including but not limited to failure to assist in personal hygiene or provision of food, clothing or shelter; failure to provide medical care; failure to protect from health and safety hazards.During a review of the facility's Policy and Procedure (P&P), titled Residents Rights dated 1/2025, the P&P indicated all residents have rights guaranteed to them under Federal and State law. The P&P indicated resident rights shall include but are not limited to choosing a physician and treatment and participating in decisions and care planning activities.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 15) with behavioral problems was adequately monitored and received the necessary care and services by failing to:Monitor Resident 15's inappropriate sexual behavior towards female and implement plan of care.Provide psychiatric (relating to mental illness and its treatment) care to evaluate and assess Resident 15's inappropriate sexual behavior.This failure placed Resident 15 at risk with a delay in psychosocial (having to do with the mental, emotional, and spiritual aspects of a person's life) needs/care which had the potential for worsening behavior that could pose a danger to other residents.Findings:During a review of Resident 15's Face Sheet (front page of the chart that contains a summary of basic information about the resident) the Face Sheet indicated the resident was admitted on [DATE] to the facility. Resident 15 had diagnoses including Pneumonia (PNA-an infection/inflammation in the lungs) muscular dystrophy(group of diseases that muscles weaker and tighter over time making harder to move) and chronic respiratory failure (long-term condition where the body cannot maintain healthy levels of oxygen and carbon dioxide on its own) requiring use of nocturnal mechanical ventilation (use of breathing machine at night)through tracheostomy(procedure to help air and oxygen reach the lungs by creating an opening into the windpipe from outside the neck).During a review of Resident 15's Minimum Data Set (MDS- resident assessment tool) dated 12/30/2025, the MDS indicated Resident 15 had an intact cognition (thought process) and used a manual or electric wheelchair as a mobility device( any device or equipment that helps a person with limited mobility, injuries or limited strength to move around more easily, safely and independently). The MDS indicated Resident 15 required partial/moderate assistance (helper or caregiver provides less than half the effort to complete the activity with bathing, upper body dressing (ability to dress and undress above the waist) and toileting hygiene.During a review of Resident 15's Care Plan titled, Identify Related Risk Factors and Signs and Symptoms, with start date of 9/25/2025 and end date of 4/8/2026, the Care Plan indicated Resident 15 was verbally inappropriate towards staffs, calling staff names and making sexual remarks. The Care Plan Indicated Resident 15 asked female staff to clean his private area despite the resident was able to do it. The Care Plan interventions included monitoring Resident 15's behavior every shift and providing psychiatric consult as needed.During an interview on 1/28/2026 at 8:02 a.m. with Resident 15, Resident 15 stated Certified Nursing Assistant (CNA) 3 came to the room (unknown date) around 2:00 am or 3:00 a.m. and saw him with a penile erection (caused by sexual stimulation) then reported him to the Nurse Supervisor.During a telephone interview on 1/28/2026 at 9:29 a.m. with CNA3, CNA 3 stated she entered Resident 15's room around early morning to check his roommate, Resident 15 called and told her to look at him. CAN 3 stated Resident 15 had exposed himself, was holding his penis and this incident was reported to the Nurse Manager (NM) 1. CNA 3 stated this incident happened before but did not report the incident to the supervisor.During a concurrent interview and record review on 1/28/2026 at 3:46 p.m. with the Social Worker (SW)1, Resident 15's Progress Notes of Social Worker dated 9/18/2025 and 10/23/2025 were reviewed. SW 1 stated Resident 15 showed inappropriate sexual behavior towards female certified nursing assistants (CNAs) especially young women. SW 1 stated Resident 15 was assigned male CNAs because he wanted female CNAS to touch him on his private area. SW 1 stated the resident can clean his private area by himself but asked female CNAs to do it. SW 1 stated he was not aware if the physician was notified about his inappropriate sexual behavior towards female CNAs. SW 1 stated no psychiatric consult was provided to address the behavior.During an interview on 1/28/2026 at 10:25 a.m. with the Nurse Manager (NM) 1, NM 1 stated Resident 15's inappropriate sexual behavior towards the female CNAs started on 5/1/2025. NM1 stated three female CNAs had come to him and were concerned of Resident 15's inappropriate sexual behavior. NM1 stated Resident 15 liked young female CNAs and disliked old CNAs. NM 1 stated the facility had to take immediate action because of sexual harassment and immediately pulled all three CNAs from taking care of Resident 15. NM 1 stated Resident 15 was now assigned to male CNAs, but sometimes female CNAs were assigned due to inadequate number of male CNAs.During a concurrent interview and record review on 1/29/2026 at 12:06 p.m. with the NM1, Resident 15 Plan of Care Note dated 5/1/2025, Progress Notes, Plan of Care Notes and Care Plan titled Identify Related Risk Factors and Signs and Symptoms were reviewed. NM 1 stated the facility documented the inappropriate sexual behavior of Resident on 9/23/2025. NM 1 stated interventions of the Care Plan included monitoring of Resident 15's behavior every shift. NM 1 stated there was no documentation addressing specific inappropriate sexual behavior that was monitored by the staff. NM 1 stated the facility should have placed monitoring of specific behavior addressing the inappropriate sexual behavior of Resident 15. NM1 stated there was no documentation the physician was notified about resident's inappropriate sexual behavior towards female CNA's or psychiatric consult was ordered by a physician to address Resident 15's behavior. NM1 stated the importance of care plan is to individualize the care of a resident and interventions like monitoring of inappropriate sexual behavior should be monitored according to Resident 15's Care Plan. NM 1 stated other residents had the potential to be at risk for abuse or mental distress if Care plan was not followed.During an interview on 1/30/2026 at 11:20 a.m. with the Director of Nursing (DON), the DON stated Resident 15 is mobile (able to move or be moved easily) but he used his electric wheelchair to move around the facility and can get into other residents' rooms. The DON stated there are no specific behavioral monitoring addressing Resident 15's inappropriate sexual behavior and the physician was not notified about resident 15's display of inappropriate sexual behavior towards female CNAs on several occasions. The DON stated there were gaps in the care because Resident 15 was not assessed or evaluated by a mental health provider to address his behavior. The DON stated there was no documentation in the Nursing Notes about Resident 15's inappropriate sexual behavior and they failed to notify the physician about resident's behavioral problem. The DON stated other residents could be at risk for Resident 15's display of inappropriate sexual behavior if not addressed.During a review of facility's policy and procedure (P&P) titled, SACC Psychosocial Assessment, revised 12/2024, the P&P indicated each resident will be reassessed as indicated or upon significant change in status such as change in psychosocial/emotional behavior patterns and all assessment documentation will be entered in resident medical record.During a review of facility's P&P titled, SACC Psychiatric Consultation and Evaluation, revised 12/2024, the P&P indicated the facility will identify and address each resident with psychiatric problem and provide care as needed.

Based on observation, interview and review, the facility failed to observe infection control practices for one of six sampled residents (Resident 34) by failing to:1. Ensure the linen hamper lid was closed and not overflowing with dirty gowns in Resident 34's bathroom.This failure had the potential to cause cross contamination (the transfer of bacteria, viruses, microorganisms, or other harmful substances from one surface to another through improper or unsanitary equipment, procedures, or products) and spread of infection among the residents, staff and visitors in the facility.Findings:During an observation on 1/26/2026 at 9:31 a.m. in Resident 34's bathroom, a linen hamper had an open lid filled with soiled non-disposable isolation gowns that were hanging outside the hamper. There was an observation of signage for Enhanced Barrier Precaution (EBP-infection control intervention designed to reduce transmission of multi drug resistant organism [MDRO, superbug bacteria or germs that have changed to resist many common antibiotics]) in nursing homes which involved gown and glove use during high-contact resident care activities) posted on the wall before the entrance of the room.During a subsequent observation on 1/26/2026 at 2:02 p.m. in Resident 34's bathroom, there was a linen hamper open and some of the soiled yellow non-disposable gowns were not completely inside the hamper.During a review of Resident 34's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 34 was admitted on [DATE] to the facility. Resident 34's diagnosis included chronic respiratory failure (long-term condition where the body cannot maintain healthy levels of oxygen and carbon dioxide on its own), anemia (a condition where the body does not have enough healthy red blood cells), atrial fibrillation(irregular heartbeat) and deep vein thrombosis of right leg(DVT- blood clot forms in a vein located deep inside the body).During a review of Resident 34's Minimum Data Set (MDS- a resident assessment tool) dated 11/3/2025, the MDS indicated Resident 34 had an intact cognition (thought process) and was dependent on staff with toileting hygiene, bathing, and dressing.During an interview on 1/28/2026 at 7:49 a.m. with the Housekeeping (HSK) 1, HSK 1 stated all staff in the facility are responsible in ensuring linen hampers are closed after using to prevent cross contamination and spread of infection. HSK 1 stated it is not sanitary if the hamper is open and overflowing with dirty linens and isolation gowns inside the bathroom of a resident. HSK 1 stated if the hamper is overflowing with soiled linens and isolation gowns, the hamper should be emptied and lid should be closed.During concurrent observation and interview on 1/29/2026 with the Certified Nursing Assistant (CNA) 5, CNA 5 stated the linen hamper in Resident 34's bathroom had an open lid, full and non-disposable isolation gowns were not completely inside the hamper. CNA 5 stated the hamper should be checked if the lid was closed and the hamper should have been emptied because it was almost full. CNA 5 stated residents can be at risk of infection if dirty linens, non-disposable yellow gowns were not disposed in the hamper properly by ensuring the lid is closed and all soiled linens and gowns are completely inside the hamper.During an interview on 1/29/2026 at 10:26 a.m. with the Director of Staff Development (DSD), the DSD stated linen hamper's lid should be closed and no dirty linens or soiled isolation gowns should be tucked inside and nothing is hanging. The DSD stated if the hamper bag should be emptied if the bag is full or three quarters (3/4) full. The DSD stated open lid and soiled linens and gowns not disposed completely inside the hamper bag could transmit infection to the caregivers, the environment and visitors using Resident 34's bathroom.During a review of facility's policy and procedure(P&P) titled, Linen and Laundry Policy, dated 9/2024, the P&P indicated soiled linen shall be handled by observing universal precautions, be placed in an impervious blue plastic liner and handled with minimal agitation and covered hampers for soiled linen should be used in all areas.

Based on interview and record review the facility failed to ensure one of two residents (Resident 22) and resident representatives were provided education regarding the risks and benefits of refusing influenza (flu - a contagious respiratory illness caused by influenza viruses that infect the nose, throat, and sometimes the lungs) vaccination.This failure had the potential to result in the resident or resident representative making uninformed decisions regarding refusal of influenza vaccine, increasing the risk for vaccine-preventable illness, complications, hospitalization, and transmission of infection within the facility.Findings:During a review of Resident 22's Face Sheet (admission Record), the Face Sheet indicated the facility re-admitted Resident 22 on 1/7/2026 with diagnoses including chronic respiratory failure with hypoxia (a long-term condition where the lungs cannot adequately transfer oxygen into the blood, resulting in low blood oxygen levels)During a review of Resident 22's history and physical (H&P) dated 11/21/2025, the H&P indicated Resident 22 was nonverbal and was unable to give any information.During a review of Resident 22's Minimum Data Set (MDS - a resident assessment tool) dated 11/21/2025, the MDS indicated Resident 22 was comatose (in a state of deep unconsciousness for a long period or could not be woken up) and was unable to think or make decisions. The MDS indicated Resident 22 did not receive influenza vaccination for the 2025-2026 flu season.During a review of Resident 22's Care Plan titled Absence of Infection Signs and Symptoms dated 11/21/2025, the Care Plan indicated family refused flu vaccine to be administered to patient for 2025-2026 flu season. The care plan did not indicate Resident 22's family were educated regarding declination of the flu vaccine.During a concurrent interview and record review on 1/27/2026 at 3:06 p.m. with the Infection Preventionist (IP), Resident 22's immunization screening was reviewed. The IP stated Resident 22's family declined flu vaccine on 11/22/2025 and 12/22/2025 but was not given the Vaccine Information Statement (VIS - paper hand out). The IP stated resident or family education regarding declination of vaccines should be documented on the care plan. The IP stated the importance of providing education and the VIS to resident was to explain the risks of not receiving the vaccine and benefits of receiving the vaccine. The IP stated if the resident or family was not educated regarding the flu vaccine and the resident or family declined the vaccine, there would be an increased risk of exposure to the flu virus and development other flu virus related complications.During a review of the facility's policy and procedure (P&P) titled SACC: Guidelines for Pneumococcal, Influenza and COVID-19 Vaccination of Adult Residents in Subacute & Long-Term Care revised 7/2025, indicated .Before offering immunization, the resident or their legal representative will be given the appropriate Vaccine Information Statement (VIS) for education regarding benefits and potential side effects of the immunization(s). This education and the edition date of the VIS given will be documented on the medication administration record (MAR).

Based on observation, interview, and record review the facility failed to maintain infection control practices when: 1.Certified Nursing Assistant 1 (CNA 1) provided care to Patient 2 then proceeded to Patient 1s bedside without changing CNA 1s personal protective equipment (PPE) gown prior to initiating care for Patient 1. 2.CNA 2 placed clean linen intended for Patient 1 on top of a used soiled linen cart and proceeded to Patient 1s bedside to initiate care. These deficient practices had the potential to cause cross-contamination (the unintentional physical movement or transfer of harmful bacteria from one person, object, or place to another) of infectious pathogens (bacteria and microorganisms) from patient to patient and/or within the facility. Findings: During an observation on 1/15/25 at 10:30 AM, an Enhanced Barrier Precautions ([EBP] measures that use gowns and gloves to reduce the spread of infection) sign is posted outside Patient 1s door which indicated when entering the room, providers and staff must apply a gown and gloves. This is a double occupancy room with the patients distinguished by bed A and bed B. During an interview with the Infection Control Preventionist (IP) on 1/22/25 at 3:33 PM, IP indicated Patient 1 is on EBP which requires glove and gown use during high-contact patient care activities with patients who have wounds and/or indwelling (inside your body) medical devices or are infected or colonized (presence of with an infection where contact precautions (set of practices used to prevent the spread of infectious diseases) do not apply. EBPs are to be observed in addition to standard precautions. Regarding gown/PPE changes between patients, caregivers are educated/trained to not use the same PPE for care of more than one patient. Donning and doffing (putting on and removal) of PPE, as well as hand hygiene practices are part of core infection prevention principles that caregivers are required to get training on upon hire and on a yearly basis. Other educational opportunities on infection prevention practices are also offered all throughout the year in addition to education when a missed opportunity is observed. During an interview with CNA 1 on 1/27/25 at 20:15 PM, CNA 1 reports helping bed A (Patient 2) change Patient 2s urinary pad. CNA 1 then took the PPE gloves off, performed hand hygiene and put on new gloves. CNA 1 indicated the PPE gown was not changed. CNA 1 stated the gown was not changed due to not thinking clearly. CNA 1 stated this was due to bed B (Patient 1) requesting assistance. CNA 1 reports wanting to act quickly for bed B and forgot to change the gown. During an interview with CNA 2 on 1/23/25 at 21:03 PM, CNA 2 reports remembering the incident. CNA 2 stated that the clean linen was grabbed for Patient 1. The linen was held in one hand and the dirty linen hamper with the other hand to bring the items closer to the bed. This is to assist throwing the linen in the hamper as it is removed. CNA 2 stated when walking into the room, bed A (Patient 2) began to cough. CNA 2 reports placing the linen on top of the soiled linen hamper and immediately went to help bed A (Patient 2) with repositioning in order to help maintain Patient 2s airway. After CNA 2 provided care, CNA 2 grabbed the linen and soiled linen hamper and started towards bed B ' s (Patient 1s) side of the room. CNA 2 reported there was no intention of using the items, but the family observed CNA 2 walking toward bed B (Patient 1) and became upset. CNA 2 reports apologizing and listening to the family member ' s concern. CNA 2 stated new linen was gathered and care continued for Patient 1. During review of the facilities policy and procedure (P&P) titled, SACC: Enhanced Barrier Precaution, dated 05/2024, the P&P indicated the purpose is to protect patients, caregivers, providers, and others by placing patients in EBP as indicated. EBP is based on the principle that Multidrug-resistant Organisms ([MDRO] germs that are resistant to more than one antibiotic) may be indirectly transferred (spread by multiple steps and not directly from one source to another) from patient-to-patient during high contact care activities. All caregivers including clinical and non-clinical personnel are expected to follow appropriate precautions during high contact patient care activities. PPE must be used consistently whenever performing any high contact patient care activities. The P&P defines high contact resident care activities as care activities that involves close physical or direct contact with the patient, patient environment, or devices such as during: Dressing Bathing or showering Transferring Providing hygiene Changing linens and/or collecting dirty laundry Changing briefs, or assisting with toileting Device care use such as central line, catheter, feeding tube, tracheostomy or ventilator care Wound care Rehabilitation or therapy services

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and preparation practices when: 1.Several food items were not dated for thaw date in the walk-in refrigerator. One box of pepperoni was stored uncovered in the walk-in freezer. One medium container of black beans with expire date of [DATE], one large container of blueberry sauce for toppings and one large container of cooked apple with an expire date of [DATE] exceeding storage period for the food were stored in the reach in refrigerator. Two boxes of (baked pastry) and one package of sliced ready to eat turkey deli meat were stored on the shelf next to raw shelled eggs. One box of raw chicken thighs thawing on the shelf next to raw ground beef. This had the potential to cross contaminate food and result in food borne illness in 14 residents who received food from the kitchen. 2. Ice machine was not maintained in a sanitary manner and the inside compartment of the ice machine was stained and dirty. This deficient practice had the potential to cross contaminate food and put 14 residents, staff, and visitors at risk for food borne illness. 3.One large bucket filled with used grease, fat and oil from cooking was stored on the shelf under the kitchen counter. The bucket was not maintained in a clean manner to prevent the potential harborage of pests and growth of microorganisms. The bucket was not clean and covered with grease and residue and it was sticky to touch. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness in 14 out of 99 residents who received food from the kitchen. Findings: 1.During an observation in the kitchen on [DATE] at 10:36AM There was on medium container of cooked black beans with dates [DATE]-[DATE] stored in the walk-in refrigerator. There were 4 large pieces of turkey and one pan with smaller pieces of turkey thawing with no thaw or pull out of the freezer date. During a concurrent observation and interview, Food Service Director (FSD) stated the beans are expired and should have been discarded. FSD removed the beans to discard. FSD stated turkey is thawed for 3 days and hold up to 5 days then cooked. FSD stated there is no date and he doesn't know when it was pulled out of the freezer. During the same observation raw Ground beef with no date was thawing next to raw chicken thighs with no date. FSD stated the ground beef and chicken thighs were delivered [DATE] but does not know when it was removed from freezer to refrigerator to thaw because there is no date for thawing. FSD stated its important to mark the thaw date so staff will ensure the product is prepared on time or discarded. FSD stated ground beef should not be stored next to chicken for potential cross contamination. FSD stated the chicken should be on the shelf below the ground beef. There were also two boxes of croissant and sliced turkey deli meat stored on the same shelf next to raw shelled eggs. FSD stated he will inform staff and review safe storage guidelines. During an interview with [NAME] (Cook1) on [DATE] at 10:45AM Cook1 stated he removed the turkey from the freezer this morning and forgot to put a thaw date. He also said the croissant and the sliced turkey deli meat should not be next to raw shelled eggs for potential for contamination. During a concurrent observation and interview in the facility walk in freezer on [DATE] at 10:50AM there was on large box of pepperoni stored in the freezer. The box was open, and the peperoni were exposed to freezer environment. During an interview with FSD, FSD said food should be covered tight to prevent cross contamination. During an observation in the reach in refrigerator on [DATE] at 11:00AM there was on large pan with cooked blueberry sauce topping and another large pan of cooked apples with dates [DATE]-[DATE]. During a concurrent observation and interview with FSD, FSD stated the cooked fruit has exceeded use by date and should be discarded. A review of facility policy titled, FNS: Food handling Guidelines (HACCP) (revised ,d+[DATE]) indicated, Thaw frozen meat/poultry/seafood count the day the raw meat is removed from the freezer as Day1; it must by cooked by the end of +4 days. Label with the date it was removed from the freezer and the date by which it must be used. A review of facility policy titled FNS: Food Preparation and Distribution (,d+[DATE]) indicated, All stored foods are to be covered. All leftovers are covered, labeled and dated. Leftovers which have not been utilized within 48 hours are discarded. All prepared perishable foods and custard shall be covered, labeled and dated with a three-day expiration date to be discarded on the day of expiration. A review of facility policy and Procedures titled, FNS-Food Handling Guidelines (HACCP) (Revised ,d+[DATE]) indicated, Contamination Precautions: Food shall be protected against cross-contamination by: appropriately separating types of raw animal products such as beef, fish, lamb, pork and poultry during storage and processing with the use of separate equipment or areas .and appropriately separating raw (potentially hazardous) foods from ready to eat food products during storage, preparation, and or service. 2.During an observation of the facility ice machine on [DATE] at 10:10AM located in the kitchen, there was brown color residue located inside the ice machine bin (where ice is stored inside the machine). The residue was towards the back wall of the ice bin. During a concurrent observation and interview with FSD, FSD stated facility staff Food Service Attendant (FSA1) is responsible for cleaning the ice machine. FSD verified there are brown color residue on the back wall of the ice bin. FSD stated the ice machine is not clean, FSD stated it is important for ice machine to be clean, and any residue can contaminate the ice. FSD stated will discard the ice and clean the ice machine. During an interview with FSA1 on [DATE] at 10:20AM, FSA1 stated she cleaned the ice machine last week. FSA1 stated the bin is not clean and the ice can touch the dirty areas. FSA1 stated she did not clean the back wall of the bin because it was hard to reach. she will remove and discard the ice and clean and sanitize the ice machine. A review of the 2022 U.S. Food and Drug Administration Food Code titled Equipment Food-Contact Surfaces and Utensils Code# ,d+[DATE].11, indicated, Surfaces of utensils and equipment contacting food that is not time/temperature control for safety food such as iced tea dispensers, carbonated beverage dispenser nozzles, beverage dispensing circuits or lines, water vending equipment, coffee bean grinders, ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. 3. During an observation in the kitchen food preparation area on [DATE] at 11:20AM one large bucket filled with used cooking grease, fat and oil was stored on the shelf under the food prep counter. The bucket and cover were dirty and covered with grease and brown color residue and was sticky to touch. During a concurrent interview with FSD, he stated the oil and fat is collected from the grills and pots then filled into the bucket and transferred to the grease storage tank outside of the kitchen. FSD stated the bucket is reused and it has not been cleaned. FSD stated the outside of the bucket is covered with the oil and fat and can attract pests in the facility kitchen. A review of facility policy titled FNS: Food Preparation and Distribution (,d+[DATE]) indicated, the purpose is to ensure the safe, sanitary and timely provision of food service to patients .All equipment, utensils and work surfaces are sanitized before and after each use away from the food preparation areas. A review of the kitchen task schedule indicated take dirty oil out to the Hazmat Gate, Slowly and carefully pour the dirty oil into receptacle. If any spills, clean it up. A review of the 2022 U.S. Food and Drug Administration Food Code titled Equipment Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils Code# ,d+[DATE].11, indicated, (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Non-FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. A review of the 2022 U.S. Food and Drug Administration Food Code titled Equipment Food-Contact Surfaces and Utensils Code# ,d+[DATE].11, indicated, E) surfaces of UTENSILS and EQUIPMENT contacting FOOD that is not TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cleaned: (4) In EQUIPMENT such as ice bins and BEVERAGE dispensing nozzles and enclosed components of EQUIPMENT such as ice makers, cooking oil storage tanks and distribution lines, BEVERAGE and syrup dispensing lines or tubes, coffee bean grinders, and water vending EQUIPMENT: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold.

Based on observation, interview, and record review, the facility failed to ensure the trash stored in the dumpster areas located in the loading and food delivery area behind the kitchen were maintained in a sanitary manner. One of six garbage dumpsters had the lid open, the dumpster was uncovered and overfilled with cardboard, and trash. There were disposable gloves, plastic, paper, and food on the ground surrounding the trash dumpsters. The trash was in the loading and food delivery area next to the kitchen back door. This deficient practice had the potential for harborage and feeding of pests, which may be attracted into the facility kitchen. Findings: During a concurrent observation and interview with the Food Service Director (FSD) on 12/3/2024 at 11:15AM, there were a total of six large trash bins. One trash bin was full of cardboard boxes and bags of trash, the dumpster was overfilled and not covered. There was trash on the floor including disposable gloves, paper, plastic wraps, and food. During a concurrent interview with the FSD, the FSD stated housekeeping is responsible for cleaning the trash area. The FSD agreed that the areas was dirty and it was close to the kitchen food delivery area. The FSD stated the area should be clean and the trash bin should always stay covered to prevent attracting flies and other pests to the kitchen. A review of Food and Drug Administration (FDA) Food Code 2022 dated 1/18/2023, code number 5-501.113 titled Covering receptacles, indicated: receptacles and waste handling units for refuse, recyclables, and returnable shall be kept covered with tight-fitting lids or doors if kept outside the establishment. The Food Code also indicated under code number 5-501.110 titled Storing Refuse, Recyclables, and Returnable indicated refuse, recyclables, and returnable shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents.

Based on observation, interview and record review, the facility failed to report an injury of unknown origin (the cause of injury was not observed by any person or could not be explained by the resident) to the California Department of Public Health (CDPH) for one of two sampled residents (Resident 41) when Resident 41 developed a blood (a fluid-filled sac in the outer layer of skin) blister on the right big toe of the right foot. This failure had the potential to result into a delayed investigation to rule out abuse. Findings: During a review of Resident 41's Admission Record, the Admission Record indicated the resident was admitted on [DATE] to the facility with diagnoses that included respiratory failure (condition when the lungs are not able to effectively take in oxygen and remove carbon dioxide from the blood), cerebral vascular accident (CVA-stroke, loss of blood flow to a part of the brain), tracheostomy (an opening surgically created through the neck into the windpipe to allow air to fill the lungs) in place, gastrostomy tube (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 41's Minimum Data Set (MDS- a resident assessment tool) dated 10/23/2024, the MDS indicated the resident had severely impaired cognitive skills (significant decline in a person's ability to think, learn, remember, reason, and make decisions affecting their daily life) and was dependent on staff with bed mobility, oral hygiene, bathing, dressing, personal hygiene and transfer to and from a bed to chair or wheelchair. The MDS indicated Resident 41's skin was intact with no infection on the foot and no presence of pressure injury (localized damage to the skin and/or underlying tissue usually over a bony prominence). During a review of Resident 41's Flow sheets for skin assessment dated [DATE], at 2:51 p.m., 11/30/2024 at 10:22 p.m., 12/1/2024 at 1:33 p.m., and 12/1/2024 at 11:54 p.m., the flowsheets indicated skin color was consistent with ethnicity, blanchable (skin appeared white or not as reddened after being pressed on and skin returns to its normal color) warm, dry skin, and skin was elastic (ability of skin to stretch and return to its original shape). During a review of Resident 41's Progress Notes dated 12/2/2024 timed at 7:22 a.m., the Progress Notes indicated resident's right great toe blood blister was observed by an unnamed Certified Nursing Assistant (CNA) while resident was being cleaned on 12/1/2024 at 6:27 a.m. During a review of Resident 41's Progress Notes dated 12/2/2024 at 12:09 p.m., the Progress Notes indicated Registered Nurse (RN3 ) received report from the morning that the resident had a bruise to the right great toe . The Progress Notes indicated Resident 41's right great toe had a large blood blister, of purple, dark red brown color measuring 1.5-centimeter (cm- unit of measurement) x 2 cm, with slight swelling and tenderness on the right big toe on assessment. The Progress Notes indicated the family, and the physician were notified, and right toe x-ray (imaging that shows organs and bones of the body) was ordered. During a review of Resident 41's x ray of the right big toe performed on 12/2/2024 at 12:49 p.m. and resulted on 12/2/2024 at 1:48 p.m., the x-ray indicated a possible nondisplaced tuft of the big toe fracture (tip of the toe bone has cracked or fractured but the broken pieces of bone are still aligned and have not moved out of position) and soft tissue swelling overlying the big toe. During a review of Resident 41's Custodial Progress Note dated 12/3/2024 timed at 10:56 a.m., the Custodial Progress Notes indicated the possible nondisplaced area is less than 2 millimeter (mm- unit of measurement) and minor enough to buddy tape (a method of treating an injured toe by taping it to an uninjured digit or toe next to it to provide support and protection for an injured digit) as if there is a minor fracture. The Progress Notes indicated the resident would be receiving an antibiotic (medicine used to treat an infection) for five days for the redness and swelling like cellulitis (skin infection that causes swelling and redness). During an observation on 12/3/2024, at 10:37 a.m., Resident 41 was sitting in a wheelchair watching a program on an electronic device. Observed an unnamed physician came and examined resident's right foot. Observed Resident 41's right foot resting on a pillow while in a wheelchair was slightly swollen and red. During an interview on 12/3/2024, at 12:18 p.m., Resident 41's family member (FM1), FM1 stated she could not understand why Resident 41's great big toe was broken or how the injury occurred. During an interview on 12/5/2024, at 3:32 p.m. with Certified Nursing Assistant (CNA1), CNA1 stated on Resident 41 last 12/1/2024 she gave Resident 41 a shower and confirmed she did not observe any skin breakdown or injury on his feet. CNA1 stated she asked CNA2 to assist her with the shower of the resident and used a mechanical lift (device used to assist with transfers from one surface to another for residents that cannot move without assistance) get him out of bed. During an interview on 12/5/2024, at 4:14 p.m., with CNA2, CNA 2 stated she helped CNA1 remove resident's clothes including socks and got him ready for his shower. CNA2 stated Resident 41 required 2 person assist and she did not see any redness, open skin or discoloration during the shower or when they were dressing him up. During an interview on 12/5/2024, at 4:24 p.m., with Licensed Vocational Nurse (LVN5), LVN 5 on the morning of 12/2/2024 when she was making rounds, she observed darkish discoloration on the right big toe of Resident 41 and the resident stayed in the bed that day. During a concurrent interview and record review of Resident 41's electronic chart on 12/6/2024, at 10:11 a.m. with LVN 6, LVN 6 confirmed she documented on the chart dated 12/1/2024 that Resident 41's skin was normal. LVN 6 stated the LVNs do a head-to-toe skin assessment and if there was any change in resident's skin, the RN would be notified. LVN 6 stated on 12/1/2024 at 11:54 p.m., confirmed Resident 41 was within normal limits and there were no skin changes. LVN 6 stated on 12/1/2024 she did not observe any skin breakdown, redness or blood blister especially on the feet. During a concurrent interview and record review of Resident 41's electronic chart on 12/5/2024, at 4:53 p.m. with RN 3, RN 3 stated the night RN discovered the blood blister on Resident 41's right big toe and the physician was notified. RN 3 stated the x-ray of the right big toe indicated a possible nondisplaced fracture on the tuft of the right big toe. RN 3 stated the treatment was splinting by buddy taping the first and second toes together. RN 3 stated blood bisters can be caused by pressure or trauma, and nobody knew how the resident got the blood blister or what caused it. RN 3 stated the facility made an incident report because was an injury of unknown origin and should be investigated as to why it happened. RN3 stated she did not know why it was not reported to CDPH and she did not report the incident because she did not think it was abuse. RN 3 stated she notified the House Supervisor (HS) but was not told to report to CDPH. During a concurrent interview and record review of Resident 41's electronic chart on 12/6/2024, at 9:32 a.m., with House Supervisor (HS1) , HS 1 stated the facility did not know how Resident 41 got a blood blister on his right great big toe and it was an injury of unknown origin. HS 1 confirmed LVNs skin assessment for the day shift and the night shift on 12/1/2024 indicated Resident 41's skin assessment was within normal limits. During a concurrent interview and record review of facility's policy and procedure titled Abuse Prevention on 12/6/2024, at 6:35 p.m., and subsequent interview on 12/6/2024, at 7:05 p.m., with the Director of Nursing (DON), the DON stated an injury of unknown origin is reported to CDPH within 24 hours. The DON stated it was important to report any suspicion of abuse or injury of unknown origin to CDPH within 24 hours to rule out abuse or neglect. During a review of facility's policy and procedure(P&P) titled Abuse Prevention dated 6/2021, the P&P indicated investigation of injuries of unknown origin, or suspicious injuries must be immediately investigated to rule out abuse. The P&P indicated if the injury is unexplainable, a report must be made to the facility designated State agency within 24 hours of the initial findings and employee must always report any abuse or suspicion of abuse immediately.

49889 Based on interview and record review, the facility failed to ensure two of four sampled residents (Resident 84 and Resident 96) were free of unnecessary psychotropic (any drug that affects the brain activities associated with mental processes and behavior) medications by failing to: 1.Ensure Resident 84 and Resident 96 were provided with non-pharmacological interventions (intervention that does not primarily use medicine before administering a prn (as needed) psychotropic medication. 2. Ensure prn psychotropic medication use had not exceeded 14 days. These failures placed Resident 84 and Resident 96 at risk for adverse consequences (unintended, harmful events attributed to the use of medication) due to unnecessary prolonged use of psychotropic medication. Findings: During a review of Resident 96's Admission Record, the Admission Record indicated the resident was admitted on [DATE] to the facility with diagnoses including respiratory failure ( serious condition when the lungs cannot get enough oxygen into the blood or remove carbon dioxide from the body). During a review of Resident 96's History and Physical (H&P) dated 10/19/2024, the H&P indicated the resident had a medical history of hypertension (HTN-high blood pressure), intracranial hemorrhage (life-threatening condition that occurs when blood pools inside the skull or between the brain and skull), tracheostomy (an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs) and gastrostomy(a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 96's Minimum Data Set (MDS- resident assessment tool) dated 10/25/2024, the MDS indicated the resident had severe cognitive (a person has trouble with memory, learning, concentration, decision making and understanding) impairment and was dependent on staff with bed mobility, bathing, toileting hygiene, dressing, oral hygiene, and personal hygiene. During a review of Resident 96's Physician Order dated 10/18/2024 with an end date of 12/27/2024, the Physician Order indicated an order of Ativan (Ativan- medicine to treat anxiety disorder) 0.5 milligram (mg.- unit of measurement) per gastrostomy tube every 8 hours prn for anxiety manifested by agitation/ restlessness. During a review of Resident 96's Care Plan titled Reduce Risk of Medication Side Effects started on 10/18/2024 (resident is on Ativan) related to diagnoses of anxiety manifested by anxiousness, unable to relax, pulling at essential tubings, and disconnecting from the ventilator (breathing machine) started 10/18/2024 The Care Plan goal indicated the resident will be free from adverse effects focusing on assessment and monitoring for appropriate effectiveness of the medicine and the proper dosage adjustments and reductions. The Care Plan interventions include to monitor mood every shift. Implement diversional activities, observe, and minimize noise level and monitor signs and symptoms of medication's side effects. During a concurrent interview and record review of Resident 96's electronic chart on 12/5/2024, at 11:21 a.m., and subsequent interview on 12/5/2024, at 2:37 p.m. with Licensed Vocational Nurse (LVN 4), LVN 4 confirmed she administered Ativan .5 mg. on 12/4/2024 at 3:04 p.m., because the resident was fighting the ventilator and was moving a lot. LVN 4 stated she documented the non- pharmacological interventions implemented at the end of the shift at 7:18 p.m., LVN 4 stated they always document the behavioral monitoring and provision of non-pharmacological interventions after administration of a prn psychotropic medicine like Ativan. During a concurrent interview and record review on 12/5/2024, at 2:56 p.m., with Registered Nurse (RN2), RN 2 confirmed Ativan .5 mg. every 8 hours prn for agitation and restlessness was ordered on 10/18/2024 with an end date of 12/27/2024 and the physician's order had exceeded the 14 days for prn. RN 2 stated the initial order for prn psychotropic medicine should only be for 14 days and after the 14 days, the need for Ativan use should be assessed and evaluated by the facility. RN 2 confirmed Resident 96 received Ativan on 12/4/2024 at 3:04 p.m. but non-pharmacological interventions were documented at 7:18 p.m. RN 2 stated LVN 4 should have provided the non-pharmacological interventions first before administering Ativan at 3:04 p.m. RN2 stated administering Ativan first before provision of non-pharmacological interventions could put Resident 96 at risk for side effects and could be considered unnecessary medicine for the resident. During a concurrent interview and record review of Resident 96's electronic chart on 12/6/2024, at 1:06 p.m., with RN 1, RN stated prn psychotropic medicine like Ativan is used for 14 days only and the resident should be reevaluated by the physician for renewal of the order, RN 1 stated the facility should provide non-pharmacological interventions first before administering prn psychotropic medicine to ensure the resident did not receive unnecessary medicine that could cause sedation and side effects. During a concurrent interview and record review on 12/6/2024, at 4:15 p.m. with Registered Pharmacist (RPH 1), RPH1 stated all prn psychotropic medicine should only have a duration of 14 days and after 14 days, the order will be renewed based on the documented evaluation of the physician for continued use. RPH1 stated non- pharmacological interventions should be performed first before administering the prn Ativan. During a review of Resident 84's Admission Record, the Admission Record indicated Resident 84 was admitted to the facility 9/23/2024. During a review of Resident 84's H&P, dated 9/24/2024 the H&P indicated Resident 84 had the capacity to understand and make decisions and also indicated that Resident 84 was admitted with diagnoses of Amyotrophic Lateral sclerosis (progressive degeneration of nerve cells in the spinal cord(ALS), chronic respiratory failure, hyperparathyroidism (high levels of calcium in the blood), panic disorder, functional quadriplegia (completely unable to move due to medical condition). During a review of Resident 84's MDS dated [DATE] the MDS indicated Resident 84's cognition was intact. The MDS indicated Resident 84 was dependent (someone who relies on another person for support) with activities of daily living (ADL's- activities such as bathing, dressing, and toileting a person performs daily). During a review of Resident 84's All Active Orders list dated 12/06/2024, the All Active Orders list indicated resident 84 had orders for Ativan1mg every 3 hours PRN for anxiety manifested by tachycardia (fast heart beat), hyperventilation (rapid, shallow breathing), verbalization of anxiety and restlessness, Ativan order stated on 10/2/2024 and ends on 12/12/24. During a concurrent interview and record review on 12/6/2024 at 2:50 p.m., with RN1, Resident 84's, Active Medication Orders list for dates 11/5/24 at 2:50 am, 11/23/24 at 3:18 am, and 12/3/24 at 4:34 am was reviewed, the Active medication Orders list indicated Resident 84 was not provided with nonpharmacological interventions prior to being given Ativan 1mg and that the Ativan order started on 10/2/2024 and ended on 12/12/2024, RN1 stated that prior to giving any PRN psychotropic medications you must provide the resident with nonpharmacological interventions to ensure the residents are not given any unnecessary psychotropic medications because they are considered a chemical restraints (is the use of a drug to restrict a patient's movement or freedom, or to sedate them). RN 1 stated that all PRN Ativan orders can only be prescribed for 14 days at a time and that the resident needs to be reassessed by the physician prior to a new order being written. During a concurrent interview and record review on 12/6/2024 at 5:05 p.m. with Pharmacist1, Resident 84's Psychotropic Medication Monitoring dated October 2024, the Psychotropic Medication Monitoring indicated that the pharmacist recommended psychiatry (branch of medicine concerned with the study, diagnosis, and treatment of mental illness) consult due to multiple anxiolytics used for the same indication, concern for polypharmacy (use of multiple drugs to treat a single condition) and also indicated that Ativan PRN needed a stop date in October and that on 11/27/2024 the physician added a stop date of 12/12/2024 for the Ativan and psychiatry consult was done on the same day. Pharmacist1 stated she reviews the medications monthly and makes the recommendations and either her or the nursing staff reach out to the doctors to follow up with the recommendations. Pharmacist1stated that all Ativan orders given PRN can only be given for 14 days at a time and then the resident must be reevaluated by the physician, before the medication can be reordered. Pharamcist1 stated residents on multiple psychotropic medication for the same indications should have a psychiatric consult to prevent possible polypharmacy. During an interview on 12/6/2024 at 8:03 a.m., with the DON, the DON stated that the pharmacy and nursing work together to ensure residents are not prescribed any unnecessary medication. Ativan PRN orders can only be written for 14 days to ensure the resident really needs the medications. The DON stated that prior to resident receiving the Ativan, the Resident should have been provided with nonpharmacological interventions. [NAME] stated if the resident gets more medications, then they need it can affect their quality of life. During a review of the facility's policy and procedure (P&P) titled, Psychotropic Drug Management for Long Term Care Facilities dated 4/2021, indicated, psychoactive medications (anti-psychotics, anti-depressants, anti-anxiety, hypnotics) must only be prescribed: By a person authorized to prescribe medications. Non-pharmacological interventions, unless clinically contraindicated, and gradual dose reductions are implemented for patients receiving psychotropic medications. PRN orders for psychotropic drugs are limited to 14 days. PRN Psychotropics other than Anti-psychotics: may be extended beyond 14 days if the physician/provider believes it is appropriate to extend the order and documents the rationale for the extended time period in the medical record. Specific duration must be indicated. Non-pharmacological interventions, unless clinically contraindicated, have been implemented prior to initiating or instead of continuing psychotropic medication. Safe use of psychoactive drugs shall be monitored for adverse consequences or complications, continuation of drug usage, dose/frequency, changed or discontinued, in the monthly drug reduction assessment tool (see attached Monthly Psychoactive Drug Reduction Assessment Tool).

Based on observation interview and record review the facility failed to ensure one of 22 sampled residents (Resident 46's food and cultural preferences were honored. This failure resulted in weight loss due to inadequate consumed calories for residents who did not receive the food items of their choices and preference. Findings: During a review of Resident 46's Admission Record, the Admission Record indicated Resident 46 was admitted to the facility on [DATE] with a diagnoses including respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen into the blood or remove enough carbon dioxide). During a review of Resident 46's History and Physical (H&P), dated 6/11/2029, the H&P indicated Resident 46 had diagnoses of but not limited to craniotomy (a surgical procedure that involves removing a piece of the skull to access the brain), cerebrovascular accident (stroke, loss of blood flow to a part of the brain) with hemiplegia (paralysis of one half of the body) and Moyamoya disease (a rare progressive disease that occurs when the carotid arteries in the brain narrow and become blocked). The H&P indicated Resident 46 only speaks Korean. The H&P indicated Resident 46 does not always eat and requires gastrostomy tube (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) supplementation. During a review of Resident 46's Minimum Data Set (MDS - a resident assessment tool), dated 9/19/2024, the MDS indicated Resident 46 sometimes understood others and sometimes made self understood. The MDS indicated Resident 46 was dependent on staff for toileting, showering, dressing, and putting on and taking off shoes. The MDS indicated Resident 46 needed maximal assistance with sitting, lying, standing and personal hygiene. The MDS indicated Resident 46 lost 5 percent or more of weight in the last month or lost 10 percent or more in the last six months. During a review of Resident 46's Care Plan, titled Aspiration (Enteral Nutrition), dated 11/07/2024, the Care Plan indicated Resident 46 had inadequate oral intake related to frequently refusing meal trays. During a review of Resident 46's Physician Orders, dated 11/29/2024, the Physician Orders indicated Resident 46 had an order for tube feeding (nutrition solution provided through a plastic tube surgically inserted into the stomach) carbohydrate (units digested as sugar) controlled at 55 milliliters for 16 hours a day. The Physician Orders indicated Resident 46 had an order for a general dysphagia (difficulty swallowing) diet with thin liquids (a liquid that flows easily) and soft bite sized textured food. During a concurrent interview and record review on 12/5/2024 at 3:18 pm, with, Restorative Nurse Assistant (RNA) 1, Resident 46's Adult Nutrition Summary was reviewed. The Adult Nutrition Summary indicated the following monthly weights: June 11, 2024 - 147 pounds July 11, 2024 - Resident 46 refused to be weighed. August 21, 2024 - 135 pounds September 17, 2024 - 136 pounds October 13, 2024 - 139 pounds November 11, 2024 - 139 pounds During an interview on 12/06/2024 at 10:43 am, with, Licensed Vocational Nurse (LVN) 7, LVN 7 stated Resident 46 likes Korean food but she is not given her cultural food preferences. LVN 7 stated it is important to know Resident 46's preferences, likes and dislikes so she can eat and maintain her weight. LVN 7 stated if Resident 46 does not like the food weight loss can occur and the resident will be unhappy. LVN 7 stated any staff member can document residents' food preferences, food likes and food dislikes. During an interview on 12/6/2024 at 4:30 pm, with Registered Nurse (RN) 4, RN 4 stated Resident 46 refuses meals and is getting continuous tube feedings. RN 4 stated Resident 46 had an eight-pound weight loss. RN 4 stated when Resident 46 refuses her meals she gets offered sandwiches, yogurt, and Jello. RN 4 stated Resident 46's cultural preferences were not honored. RN 4 stated when the residents food preferences are not honored the resident can have weight loss. RN 4 stated Resident 46 refused breakfast and ate 20 percent of the lunch tray. During an interview on 12/6/2024 at 7:17 pm with the Registered Dietician (RD), the RD stated there was no documentation of Resident 46's food preferences. The RD stated Resident 46's is given rice, tea and stir fry. RD stated she has not met Resident 46 or Resident 46's family to find out what her food preferences are. During a review of the facility's policy and procedure (P&P), titled Clinical Dietetics: Religious and Culture Food Preferences, dated 10/2023, the P&P indicated, The RD will ensure that religious and cultural food preferences and request are granted in accordance with their diet. The patient will be visited as soon as possible to obtain menu and food preferences.

Based on observation, interview, and record review, the facility failed to observe infection control measures for three of 10 residents (Resident 29, 62, and 86) by failing to: 1. Ensure Resident 29's water bag was labeled and dated. 2. Ensure Resident 62's tube feeding bottle was labeled and dated. 3. Ensure Resident 86's tube feeding bottle was dated. These failures had the potential to result in the transmission of infectious microorganisms and increase the risk of infection for Residents 29, 62, and 86. Findings: 1.During a review of Resident 29's Admission Record, the Admission Record indicated Resident 29 was readmitted to the facility 11/1/2024. During a review of Resident 29's History and Physical (H&P), the H&P indicated Resident 29 was admitted with diagnoses of ruptured cerebral aneurysm (a weak spot in a blood vessel in the brain, like a tiny balloon, has burst open, causing bleeding in the surrounding brain tissue) and gastroparesis (stomach muscles are weakened or impaired, causing food to remain in the stomach longer than normal). During a review of Resident 29's Minimum Data Set ({MDS}- a resident assessment tool) 8/12/2024 the MDS indicated Resident 29 was comatose (someone is completely unconscious and unresponsive to their surroundings). The MDS indicated Resident 29 was dependent (someone who relies on another person for support) with activities of daily living ({ADL's}- activities such as bathing, dressing, and toileting a person performs daily). During a review of Resident 29's care plan initiated 12/5/2023 with a focus on Resident 29 having altered nutrition related to dysphagia (swallowing difficulties) as evidenced by chronic tube feed, dependence on 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). During a review of Resident 29's care plan initiated 1/6/2018 with a focus on Resident 29 having a risk to develop infection (invasion and growth of germs in the body) related to the presence of a GT Interventions included monitoring Resident 29 for signs and symptoms (s/s) of infection. 2.During a review of Resident 62's Admission Record, the Admission record indicated Resident 62 was readmitted to the facility 11/3/2024. During a review of Resident 62's H&P, the H&P indicated Resident 62 was admitted with diagnoses of subdural hematoma (a buildup of blood on the surface of the brain) and chronic respiratory failure (when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). During a review of Resident 62's MDS dated [DATE], the MDS indicated Resident 62 was comatose. The MDS indicated Resident 62 was dependent with ADL's. During a review of Resident 62's care plan initiated 4/27/2022 had a focus on Resident 62 was at risk for infections related to tube feeding dependent due to dysphagia. Interventions included monitoring Resident 62 for s/s of infection. During a concurrent observation and interview on 12/3/2024 at 11:11 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 62's tube feeding bottle was not labeled or dated. LVN 1 stated she is responsible to ensure the tube feeding bottles are labeled and dated when she does her rounding, but stated she missed this one. LVN 1 stated it's important the tube feeding bottles are changed every 24 hours to prevent infection for the resident. During a concurrent observation and interview on 12/3/2024 at 11:27 a.m., with LVN 2, LVN 2 verbally confirmed Resident 29's water bag was not labeled or dated. 3.During a review of Resident 86's Admission Record, the Admission Record indicated Resident 86 was admitted to the facility 11/27/2024. During a review of Resident 86's H&P, the H&P indicated Resident 86 was admitted with diagnoses of encephalopathy (swelling of the brain), hx of hemicraniectomy (Section of skull removed to relieve extreme pressure on the brain), respiratory failure (lungs failing) dysphagia (unable to swallow correctly), g-tube. During a review of Resident 86's MDS dated [DATE], the MDS indicated Resident 86 was comatose The MDS indicated Resident 86 was dependent (someone who relies on another person for support) with ADL's During a review of Resident 86's All Active Orders dated 12/06/24 indicated resident 86 has orders for continuous tube feeding (liquid food being delivered through tube in the stomach) carbohydrate controlled, diabeticsource ac 1.2 (1320kcal/1100ml 50cc hr x 22hours a day. During a concurrent observation and interview on 12/3/2024 at 10:34 a.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated Resident 86's tube feeding bottle was not dated. LVN 3 stated she is responsible to ensure the tube feeding bottles are dated LVN 3 stated it's important to have a date on the tube feeding bottles to ensure the tube feeding is changed every 24 hours to prevent spoilage. LVN 3 stated residents are at risk for stomach issues if tube feeding is not changed every 24 hours. During an interview on12/5/2024 at 10:44 a.m., with the Infection Prevention Nurse (IPN) 1, IPN 1 stated it's important to change and label the tube feeding bottles and water bags at least daily because they are breeding ground for organisms which could result in an infection for the resident. During an interview on 12/6/2024 at 8:03 a.m., with the Director of Nursing (DON), the DON stated for their GT's, they use a closed system for infection control and follow the manufacturers guidelines which indicated to change the tubing every 24 hours and label with the resident's name, date, rate, and type of feeding. The DON stated it's important the tube feeding bottles and water bags are labeled and dated so the staff is aware when it was changed because the feeding can spoil which could potentially cause diarrhea and gastrointestinal (stomach and intestines) issues for the resident. During a review of the facility's policy and procedure (P&P) titled, SACC: Tube Feeding Through Nasogastric Tube, Gastrostomy, or Jejunostomy Intermittent and continuous, revised 11/18/2024, indicated, Make sure that the enteral formula container is labeled with the patient's identifiers; formula name; date and time of formula preparation; date and time that the formula was hung. Label the enteral administration set with the date and time that it was first hung. Change the enteral administration set according to the manufacturer's instructions to prevent bacterial growth. 49889

Based on interview and record review, the facility failed to address and monitor the use of antibiotic on two of five sampled residents (Resident 41 and Resident 98) when residents' conditions or symptoms did not meet McGeer criteria(a set of criteria used in long term care facilities to determine if signs and symptoms constitute a true infection). This failure had the potential to result in Resident 41 and Resident 98 developing resistance (antibiotic will not be effective to treat infection) from unnecessary or inappropriate use of antibiotic. Findings: a. During a review of Resident 98's Admission Record, the Admission Record indicated the resident was admitted on [DATE] facility with diagnoses that included respiratory failure (condition when the lungs are not able to effectively take in oxygen and remove carbon dioxide from the blood). During a review of Resident 98's History and Physical (H&P), dated 10/26/2024, the H&P indicated Resident 98 had diagnoses of but not limited to traumatic brain injury (TBI-a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head), and encephalopathy (damage or diseases affecting the brain). During a review of Resident 41's Minimum Data Set (MDS- a resident assessment tool) dated 11/4/2024, the MDS indicated Resident 98 was dependent on nursing staff for oral hygiene, toileting, showering, dressing, putting on and taking off footwear, personal hygiene, and transferring. The MDS indicated Resident 98 used an external catheter (a noninvasive device that collects urine from outside the body). The MDS indicated Resident 98 did not have a urinary tract infection in the last 30 days. During an interview on 12/06/2024 at 12:05 pm with Registered Nurse (RN) 5, RN 5 stated Resident 98 was prescribed ampicillin (medication used to treat bacterial infections) per oral (PO)o on 10/30/2024 and ended on 11/5/2024. RN 5 stated Resident 98 was prescribed ampicillin for a urinary tract infection (UTI- an infection in the bladder/urinary tract). During an interview on 12/06/2024 at 2:59 pm with Infection Preventionist (IP), the IP stated on 10/27/2024 urine was collected from Resident 98. IP stated on 10/29/2024 the results of the urine collection indicated Resident 98 did not meet the MC Greer's criteria and did not meet NHSN (National Healthcare safety Network) criteria because the Resident 98 did not have any symptoms of a urinary tract infection. IP stated Antibiotic Stewardship is used to determine surveillance and to determine if the resident meets the criteria for antibiotic use. IP stated the Mc Geer criteria is used so resident are not getting overuse and resistance to antibiotics. During an interview on 12/6/2024 at 4:13 pm with Registered Pharmacist (RPH) 3, RPH 3 stated the Mc Geer criteria is used to diagnose a true infection versus colonization. RPH 3 stated unnecessary administration of antibiotics can adversely affect the resident by causing resistance to pathogens. During a review of resident 98's Physician Orders, the Physician Orders indicated on 10/29/2024 Resident 98 had an order for ampicillin 500 milligrams four times a day. During a review of Resident 98's IP Notes, the IP Notes indicated on 10/27/2024 a urine specimen was collected. The IP Notes indicated the urine specimen resulted on 10/29/2024 and Resident 98 did not meet Long term care NHSN (National Healthcare safety Network) criteria (the infection criteria is used by the National Healthcare safety Network (NHSN) to monitor healthcare-associated infections). b. During a review of Resident 41's Admission Record, the Admission Record indicated the resident was admitted on [DATE] to the facility with diagnoses that included respiratory failure( condition when the lungs are not able to effectively take in oxygen and remove carbon dioxide from the blood), cerebral vascular accident (CVA-stroke, loss of blood flow to a part of the brain), tracheostomy(an opening surgically created through the neck into the windpipe to allow air to fill the lungs) in place, gastrostomy tube (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 41's MDS dated [DATE], the MDS indicated the resident had severely impaired cognitive skills( significant decline in a person's ability to think, learn, remember, reason, and make decisions affecting their daily life) and was dependent on staff with bed mobility, oral hygiene, bathing, dressing, personal hygiene and transfer to and from a bed to chair or wheelchair. During a review of Resident 41's Order Report dated 12/3/2024, the Order Report indicated an order of cephalexin (Keflex- medicine used to treat infection) capsule 500 milligrams(mgs- unit of measurement) 4 times daily. During a review of Resident 41's Subacute Custodial Progress Note dated 12/3/2024, the Subacute Custodial Progress Note indicated the resident will be given Keflex for 5 days for the right big toe because the area is red, swollen and like cellulitis(a skin infection that causes swelling and redness). During a concurrent interview and record review of Resident 41's chart on 12/6/2024, at 5:45 p.m. and subsequent interview on 12/6/2024, at 5:22 p.m. with Infection Preventionist (IP), IP confirmed the resident was on Keflex 500 mgs. per gastrostomy tube (GT- a flexible tube surgically inserted through the abdominal wall and into the stomach for delivery of nutrition, fluids, and medications) started on 12/3/2024 to 12/8/2024 for the rt. big toe of the right foot. IP stated the Mcgeer Criteria for cellulitis is diagnosed when there are a pus present in the wound, or a new or increasing presence of at least four signs including: heat at the affected site, swelling, tenderness, and at least one of the symptom of fever, leukocytosis(increased white blood count),acute decline in mental status( sudden and significant change in person's cognitive abilities which can manifest as confusion, disorientation and lack of energy) and functional decline( inability to perform activities of daily living). IP confirmed Resident 41 only met the criteria for tenderness , swelling and redness on the site of the right big toe and there was no drainage or pus was present. IP stated the Mcgeer criteria did not need to be followed because it depends on the physician's order and antimicrobial stewardship collaboration with the pharmacists. IP stated the pharmacists took the lead in the Antibiotic Stewardship Program and performed the surveillance. IP stated residents receiving antibiotic that is not appropriate could build resistance from the antibiotics and could be at risk for the development of multi-drug resistance organism ( MDRO- a germ that is resistant to many antibiotics and can be difficult to treat). During a record review of Resident 41's Podiatry Consult Note dated 12/4/2024, the Podiatry Consult Note indicated the resident had a complaint of long and painful toenails of both feet of long duration. The Podiatry Consult Note indicated the resident's skin is warm to touch on bilateral (both) feet, no pedal edema (no swelling in the feet and ankles) and toenail plates( visible ,hard, and flat part of a toenail that protects the toe) on the bilateral feet were adequate length and appeared recently trimmed. During a review of facility's policy and procedure (P&P) dated 4/2023, the P &P indicated the facility promotes appropriate use of antimicrobials by helping select the appropriate agent, dose, duration, and route of administration to improve patient outcomes, optimize the treatment of infections and reduce adverse events associated with antibiotic use. 45269

41699 45269 Based on observation, interview and record review, the facility failed to ensure six of seven sampled residents (Residents 39, 45, 20, 11, 68 and 27) were free of unnecessary physical restraints (devices that limit a patient's movement) by failing to: 1. Ensure six of seven residents (Residents 39, 45, 20, 11, 68 and 27) were free from physical restraints. 2. Follow the Physical Restraint Elimination Assessment (assessment used by the facility for restrained residents to determine whether they are candidates for restraint reduction, score of 0-20 is a priority candidate, 21-35 good candidate, and 35 and above is a poor candidate) for Residents 39, 45, 20, 11, 68 and 27, monthly to assess for the need of physical restraint continued used. 3. Release physical restraint every two (2) hours for 15 minutes to ensure good blood circulation (the flow of fluid, especially blood) to upper extremities and assess skin integrity (the skin being whole, intact, and undamaged) for Residents 39, 45, 20, 11, 68 and 27. 4. Use least restrictive measures (restraint that allows the most freedom of movement while still protecting the resident) prior to use of physical restraints per facility's policies and procedures (P&P), titled Physical Restraints for Residents 39, 45, 20, 11, 68 and 27. 5. Ensure soft wrist restraints (soft material or fabric fit around the limbs [arm or leg] of an individual to limit movement and to prevent the dislodgment of tubes, lines, and catheters) were applied correctly and secured in proper position to Resident 39 and 20's bed frame per manufacturer guidelines (instructions provided by maker of a product to provide detailed insight into how to equipment should be used). These deficient practices placed Residents' 39, 45, 20, 11, 68 and 27, at risk for impaired blood circulation with possible formation of venous stasis ulcers (medical condition characterized by impaired blood flow in the veins), skin injuries including pressure ulcer (an injury that breaks down the skin and underlying tissue) and psychosocial harm from not being treated with respect and dignity. On 12/12/2023 at 4:57 p.m., the Director of Nursing (DON) and Nurse Manager 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 due to six residents, Residents 39, 11 and 27 on right soft mittens (used to prevent residents from pulling out any essential lines or tubes) and right soft wrist restraints, 20 on left soft mittens and left soft wrist restraints, Resident 45 on bilateral soft mittens and 68 on right soft mitten, failed to follow the Physical Restraint Elimination Assessment for all 6 residents, failed to release physical restraint every two (2) hours for 15 minutes for all six residents, failed to use least restrictive measures prior to use of physical restraints for all six residents and failed to ensure soft wrist restraints were applied correctly for Residents 39 and 20. The facility's DON, and Nurse Manager were notified of the seriousness of the risk of physical restraints. An IJ Removal Plan was requested from the facility's staff. On 12/14/2023 the facility submitted an acceptable IJ Removal Plan. On 12/14/23 at 6:21 p.m., the DON and Core Leader were notified the IJ was removed after on-site validation of the implementation of the IJ Removal Plan via observations, interviews, and record review. The IJ Removal Plan included the following: 1. Facility management rounded on 12/12/2023 on Resident 39, 20,11, and 27 to validate appropriate restraint placement and securement to the bed was in the quick-release manner, per manufacturer's guidelines. 2. Facility management rounded on 12/12/2023 on Resident 45 and 68 to validate appropriate restraint placement. 3. Physician's orders stating needs for physical restraints were reviewed for Resident 39, 45, 20, 11, 68 and 27 on 12/12/23. 4. Nursing assessments on continued need for restraints reviewed for Resident 39, 45, 20, 11, 68 and 27 on 12/12/23. 5. Alternatives for physical restraints were attempted and documented within restraint non-violent flowsheet every shift for Resident 39, 45, 20, 11, 68 and 27 on 12/12/23 and 12/13/23. 6. Peripheral, neurovascular (involving both nerves and blood vessels), and skin assessments performed and documented every two hours for Resident 39, 45, 20, 11, 68 and 27 on 12/12/23 and 12/13/23. 7. Physical restraints released for 15 min every two hours and documented for Resident 39, 45, 20, 11, 68 and 27 on 12/12/23 and 12/13/23. 8. Trial off physical restraints conducted on 12/14/23 from 8:15 am to 8:25 am to evaluate the continued necessity for restraints for Resident 39. Right hand mitten and right soft wrist restraint were removed for Resident 39. Resident 39 failed trial on 12/14/23. 9. Trial off physical restraints conducted on 12/13/23 from 2:00 pm to 2:30 pm to evaluate the continued necessity for restraints for Resident 45. Bilateral soft mittens were removed. Resident 45 tolerated trial off restraints. Trial continues per facility's policy and procedures. 10. Trial off physical restraints conducted on 12/13/23 from 10:30 pm to 10:35 pm to evaluate the continued necessity for restraints for Resident 20. Right hand mitten and right soft wrist restraints were removed for Resident 20. Resident 20 failed trial on 12/13/23. 11. Trial off physical restraints conducted on 12/13/23 from 8:05 pm to 8:15 pm to evaluate the continued necessity for restraints for Resident 11. Right hand mitten and right soft wrist restraints were removed for Resident 11. Resident 11 failed trial on 12/13/23. 12. Trial off physical restraints conducted on 12/13/23 from 8:55 pm to 9:09 pm to evaluate the continued necessity for restraints for Resident 68. Right hand mitten was removed for Resident 68. Resident 68 failed trial on 12/13/23. 13. Trial off physical restraints conducted on 12/13/23 from 7:45 pm to 7:49 pm to evaluate the continued necessity for restraints for Resident 27. Right hand mitten and right soft wrist restraints were removed for Resident 27. Resident 27 failed trial on 12/13/23. 14. Least restrictive restraint attempted on 12/14/23 at 12:15 pm, right soft wrist restraint removed. Resident 39 tolerating will continue to monitor. 15. Least restrictive restraint attempted for Resident 20 on 12/14/23 at 12:45 pm, right soft wrist restraint removed. Resident 20 failed. 16. Least restrictive restraint attempted for Resident 27 on 12/14/23 at 12:15 pm, right soft wrist restraint removed. Resident 27 failed. 17. Reviewed side rails assessment form for Resident 39, 45,20,27,11 and 68 on 12/14/2023, which included recommendations to use bilateral padded upper and lower side rails. 18. Assess resident for risk for entrapment and document by 12/15/23. Findings: 1.During an observation on 12/11/2023 at 11:55 a.m. at Resident 39's bedside, Resident 39 was observed non-verbal with a soft wrist restraint on the right wrist, a soft mitten restraint on the right hand and all four siderails up on the bed. During a review of Resident 39's Admission Record (Face Sheet) the Face Sheet indicated Resident 39 was admitted on [DATE] with diagnoses including respiratory failure (a condition in which your blood doesn't have enough oxygen), tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck) and cerebral vascular accident (CVA[ an interruption in the flow of blood to cells in the brain]) with left arm weakness. During a review of Resident 39's Minimum Assessment Set (MDS - a standardized assessment and care screening tool) dated 11/10/2023, the MDS indicated Resident 39 had severe cognitive (ability to learn, remember, understand, and make decisions) and memory impairment for daily decision making. Resident 39 had impairment (weakness) on both arms and was dependent for all activities of daily living (ADL- consist of eating, dressing/grooming, bathing/personal hygiene, mobility (ambulation and transfer), elimination [toileting]). The MDS indicated Resident 39 used one limb (right arm) physical restraints on the right upper extremity. During an observation on 12/11/2023 at 10:24 a.m. at Resident 45's bedside, Resident 45 was observed with bilateral (both) mitten restraints to the hands. During a review of Resident 45's Admission Record (Face Sheet) the Face Sheet indicated Resident 45 was admitted on [DATE] with diagnoses including respiratory failure, dementia (a condition characterized by progress loss of intellectual functioning with memory impairment), and status post fall. During a review of Resident 45's MDS dated [DATE], the MDS indicated Resident 45 had severe cognitive impairment for daily decision making. Resident 45 had impairment on both arms and was dependent for all ADL. The MDS indicated Resident 45 had bilateral (both) hand restraints. During a review of Resident 20's Admission Record (Face Sheet ), the Face Sheet indicated Resident 20 was admitted on [DATE] and readmitted on [DATE] with diagnoses including deep venous thrombosis (blood clot formed in the deep vein of the body), history of traumatic brain injury (damage to the brain that disrupts normal functioning caused by an outside force, typically such as a violent blow to the head), functional quadriplegia (complete immobility to move due to physical disability or frailty), gastrostomy (opening into the stomach from the abdomen for the introduction of food), presence of tracheostomy, and history of CVA. During a review of Resident 20's MDS dated [DATE], the MDS indicated Resident 20 had severely impaired cognitive skills and was dependent on staff members with bed mobility, bathing, personal hygiene, dressing and toileting. The MDS indicated Resident 20 was on upper limb restraint. During a review of Resident 20's Physician Order dated 10/19/2023 timed at 11:50 p.m., the Physician Order indicated an order to place left hand soft mitten (used to prevent residents from pulling out any essential lines or tubes) and left soft wrist restraints to prevent from pulling out tubes, release and check for redness, circulation, hydration, nutritional/elimination needs, hygiene, safety every two hours and perform range of motion ([ROM] is the extent of movement of a joint, measured in degrees of a circle) exercises until discontinued. During a review of Resident 11's Admission Record (Face Sheet), the Face Sheet indicated Resident 11 was admitted on [DATE] with diagnoses including history of hemorrhagic stroke (blood vessels rupture in or near the brain which can cause permanent damage to the brain), tracheostomy, chronic respiratory failure, ileostomy (opening in the abdomen to evacuate stool from the body), anoxic brain injury( blood flow and oxygen to the brain was interrupted which can cause damage to the brain),and dysphagia ( difficulty of swallowing). During a review of Resident 11's Minimum Data Set ([MDS] standardized assessment and care screening tool) dated 11/15/2023, the MDS indicated Resident 11 had severely impaired cognitive skills and was dependent on staff members with bed mobility, transfer from bed to wheelchair, bathing, toileting hygiene and personal hygiene. The MDS indicated Resident 11 had an indwelling catheter (flexible tube used to empty the bladder and collect urine in a drainage bag) and ostomy (creation of an artificial opening in the abdomen to allow for the elimination of body wastes). During a review of Resident 68's Admission Record (Face Sheet), the Face Sheet indicated Resident 68's was admitted on [DATE] with diagnoses including aneurysm (an abnormal bulge or ballooning in the wall of a blood vessel), subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain), cerebral edema (swelling of the brain), tracheostomy and gastrostomy. During a review of Resident 68's MDS dated [DATE] indicated Resident 68 had severe cognitive impairment and requires total assistance for bed mobility, dressing, toilet use and personal hygiene. The MDS indicated Resident 68 used limb (right arm) restraint daily. During a review of Resident 27's Admission Record (Face Sheet), the Face Sheet indicated Resident 27 was admitted on ,d+[DATE], with diagnoses including traumatic brain injury, epilepsy (seizure disorder - sudden, uncontrolled electrical activity in the brain that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness), dysphagia, respiratory failure tracheostomy and gastrostomy. During a review of Resident 27's History and Physical (H/P), dated 1/3/23, the H/P indicated, Resident 27 did not have the ability to communicate. During a review of Resident 27's MDS dated [DATE], the MDS indicated, Resident 27 had persistent vegetative state/no discernible consciousness (when a person is awake but is showing no signs of awareness). Resident 27 required extensive assistance (resident total dependent; full staff assistance) with bed mobility and extensive assistance with transferring, dressing, toilet use, personal hygiene and did not utilize a mobility device. The MDS indicated Resident 27 utilized a limb (right arm) restraint daily. 2. During a concurrent interview and record review on 12/12/2023 on 2:15 p.m. with the Nurse Manager (NM) 1, NM 1 stated Resident 39 Physical Restraint Elimination Record assessment score was 26. NM 1 stated a score of 21-35 means Resident 39 was a good candidate to have a trial to see if the restraints can be released. During a review of Resident 20's Physical Restraint Elimination Assessment, the Physical Restraint Elimination assessment indicated Resident 20 was assessed on 10/1/2023, 11/1/2023 and 12/1/2023 with a score of 22 (score of 22 was a good candidate for restraint reduction). During a review of Resident 20's Nurses Progress Notes dated 10/22/2023, at 12:59 p.m., the Nurses Progress Notes indicated the Resident 20 had episodes of pulling essential lines when restraints were released and was not a good candidate for restraints removal. There was no other documentation except for 10/20/2023 and 10/22/2023 regarding weekly assessment of restraint usage for the month of October 2023. During a review of Resident 20's Nursing Progress Notes for the month of November 2023, the Nursing Progress Notes indicated on 11/13/23, 11/19/2023, and 11/28/23 Resident 20 was not a candidate for restraint removal of hand soft mitten and soft wrist restraint due to pulling of essential lines (tracheostomy and gastrostomy tube) when restraints were removed. The Nursing Progress Notes indicated no weekly assessment was done for the week of 10/29/2023 and 11/5/2023. During a review of Resident 20's Nursing Progress Notes for October, November and up to December 11, 2023, the Nursing Progress Notes indicated no trial of restraint removal or least restrictive restraint was attempted and was documented. During a review of Resident 11's Physical Restraint Elimination Assessment, the Physical Restraint Elimination Assessment indicated on 8/1/2023, 9/1/2023, 10/1/2023 and 11/1/2023 Resident 11's score was 24. The Physical Restraint Elimination Assessment indicated a score of 24 was a good candidate for restraint reduction. During a review of Resident 11's Restraints Progress Notes for the month of October 2023, the Restraints Progress Notes indicated weekly assessment for restraint use was performed on 10/1/2023, 10/15/2023, 10/22/2023, and 10/29/2023.The Progress Notes indicated no weekly assessment done for the week of 10/8/2023. During an interview on 12/12/2023, at 2:17 p.m. with Nurse Manager (NM) 1, NM 1 stated Restraints Elimination Assessment was used to determine if a resident (in general) on restraints was a good candidate for reduction or if restraints can be released from restraints. NM 1 stated the low score on the assessment indicates resident (in general) was a good candidate for restraints reduction. NM 1 stated the assessment of restraints were performed weekly by registered nurses' and the licensed nurses must be physically present to release the restraints, check the resident's skin and circulation. NM 1 stated unnecessary restraints could inhibit residents' mobility. 3. During a review of Resident 39's Physician Order dated 3/9/2022, indicated Resident 39 with right hand soft mitten and release every two hours for blood circulation check, redness, and safety, and to apply a right soft wrist restraint and to release every two hours for blood circulation check, redness, and safety. During a review of Resident 39's Restraint Every Two-Hour Monitoring record (documentation log used when residents are in restraints) dated 12/9/2023 timed at 6 a.m. through 12/14/2023 timed at 6:15 p.m., the licensed nurses documented that Resident 39's behavior was calm in response to the restraints. During a review of Resident 39's Restraint Every Two-hour Monitoring record dated 12/9/2023 timed at 6 a.m. through 12/13/2023 timed at 4 a.m., indicated no documentation of Resident 39's right soft mitten and right soft wrist restraints were released every two hours for 15 minutes for blood circulation check. During a review of Resident 39's Restraint Every Two-hour Monitoring record dated 12/11/2023 timed at 6 p.m. through 12/12/2023 timed at 8 a.m., indicated no documentation of Resident 39 was monitored every two (2) hours while on a right soft wrist restraint, and right-hand mitten restraint for blood circulation, and skin integrity. During a review of Resident 45's Restraint Every Two-hour Monitoring record dated 12/9/2023 at 10 a.m. through 12/14/2023 at 6:00 a.m., the licensed nurses documented that Resident 45's behavior was calm in response to the restraints (bilateral soft mittens). During a review of Resident 45's Restraint Every Two-hour Monitoring record dated 12/11/2023 at 12 a.m. through 12/11/2023 at 6 a.m., indicated no documentation that Resident 45's bilateral soft mittens were released every two hours for 15 minutes to check for circulation. During an interview on 12/13/2023 at 8:53 a.m., with Certified Nursing Assistant (CNA) 3, CNA 3 stated, Resident 68 right hand soft mitten should be released every two (2) hours for 15 minutes and during resident care and reapply after resident care was done. CNA 3 stated Resident 68 right hand soft mitten was not released during resident care. During an observation on 12/13/2023 at 9:29 a.m., Resident 68 was observed with a right-hand soft mitten. During an observation on 12/13/2023 at 11:31 a.m., Resident 68 was observed with a right-hand soft mitten. During an observation on 12/14/2023 at 9:03 a.m., Resident 68 was observed with a right-hand soft mitten. During an observation on 12/14/2023 at 11:08 a.m., Resident 68 was observed with a right-hand soft mitten. During a review of Resident 11's Physician Order dated 8/16/2022, timed at 5:17 p.m., the Physician Order indicated to apply right hand mitten and right soft wrist restraint due to poor safety awareness secondary to poor cognition related to history of hemorrhagic stroke until discontinued. The Physician Order indicated to release the right soft restraint and right-hand mitten every two hours for 15 minutes and as needed for activities of daily living, skin, and blood circulation check. During a review of Resident 11's Care Plan titled Restraints dated 8/2/2022, the Care Plan indicated to monitor for episodes of agitation (feeling of uneasiness) or anxiety (feeling of worry or nervousness), assess for less restrictive measures or devices prior to restraint use, check proper placement, release, and check for circulation, hygiene, and impaired skin integrity every two hours as interventions. During a review of Resident 11's Restraint Every Two-hour Monitoring record dated 12/11/2023, indicated Resident 11 was not monitored from 8:26 p.m. to 6:00 a.m. on 12/11/2023. The Restraint Every Two-hour Monitoring record indicated monitoring was resumed on 12/12/2023 at 8:00 a.m. During an interview on 12/14/2023, at 11:52 a.m. with Director of Staff Development (DSD), DSD stated CNA and licensed vocational nurses (LVN) do a visual check of residents on restraints for proper placement every hour, and Hourly Patient Care Rounds log was posted on the door of the resident's room. DSD stated either the LVN or CNA will sign in after hourly checks and the registered nurses check if the LVN had completed the Hourly Patient Care Rounds logs. During a review of Resident 11's Hourly Patient Care Rounds log for residents at risk for removing essential lines from 11/2/2023 to 11/28/2023, the Hourly Patient Care Rounds log indicated hourly rounds were not signed on the following dates and times: 11/2/2023 from 7 a.m. to 10 a.m. and 6:00 p.m. 11/3/2023, at 5p.m. and 6:00 p.m. 11/4/2023 at 5 a.m.,10 p.m. to 12 a.m. 11/5/2023 at 1a.m. to 6 a.m., 9 p.m., 11p.m. 11/6/2023 at 1 a.m. ,3 a.m. and 5 a.m.,9 p.m., and 11p.m. 11/7/2023 at 3 a.m., 5 a.m., 7 p.m., and 9 p.m. 11/8/2023 at 11p.m. 11/9/2023 at 1 a.m., 3 a.m., and 5 a.m. 11/10/2023 at 9 p.m. and 11 p.m. 11/14/2023 at 7 p.m. and 10 p.m. 11/15/2023 at 12 a.m., 4 a.m., 6 a.m. and 7 p.m. 11/16/2023 at 1 a.m. and 5 a.m. 11/18/2023 at 9 a.m., 7 p.m., and 10 p.m. 11/19/2023 at 2 a.m., 6 a.m. 4 a.m., 9 p.m. and 11 p.m. 11/20/2023 at 6 p.m. 11/21/2023 at 4 a.m., 5 a.m., and 6 a.m. 11/26/2023 at 6 p.m. During a review of Resident 27's Physician Order dated 12/1/23, the Physician Order indicated, release restraints every two hours and check for skin redness, blood circulation, hydration, nutritional. During a review of Resident 27's Care Plan titled Absence of Harm or Injury, dated 3/12/23, indicated interventions including check for proper placement of the right-hand soft mitten and right soft wrist restraint; release and check for redness, circulation, hygiene, and impaired skin integrity every two hours and as needed. During a review of Resident 27's Restraint Every Two-hour Monitoring record dated 12/6/23 timed at 10:00 p.m. and 12/8/23 timed at 10 p.m., indicated Resident 27 has no documentation of Resident 27's right soft wrist restraint were released every two hours for 15 minutes for blood circulation check. During an interview on 12/15/2023 at 9:14 a.m., with RN 6, RN 6 stated if right hand soft mitten was not release from Resident 68's hands every two hours for 15 minutes, there was a possibility that will lead to decrease blood circulation. If the Resident 68's restraints were too tight it can lead to skin irritation or even pressure ulcer. During an interview on 12/15/2023 at 11:15 a.m., with CNA 5, CNA 5 stated soft hand mittens should be release every two hours for 15 minutes to prevent wrist pressure that can lead to pressure ulcer. During an interview on 12/15/23 11:16 a.m. with Registered Nurse (RN) 5, RN 5 stated the Restraint Every Two-hour Monitoring record were used for restraint assessment for residents (in general) to check for circulation because if the resident (in general) has poor circulation it can cause poor tissue perfusion (oxygen-rich blood delivered to the tissues in the body) and extremity (part of a limb of the body) could become necrotic. RN 5 stated, residents (in general) could feel frustrated, helpless, and hopeless from wearing physical restraints. During an interview on 12/15/2023 at 12 p.m. with RN 5, RN 5 stated, restrains should be released every two hours to assess for blood circulation and assess if restraint was applied too tight. RN 5 stated if a restraint was applied too tight it can cause harm including impeding blood circulation to the extremity, decrease tissue perfusion and the part of the body restrained can become necrotic and die. RN 5 stated, the risk for using all three restraints (soft mittens, soft wrist restraints and four siderails up) will impede a resident's movement. RN 5 stated, resident (in general) could become frustrated being tied up with a wrist restraint, soft mitten and all four siderails in an up position. During an interview on 12/15/2023 at 12:19 p.m. with NM 1, NM 1 stated resident (in general) with soft mittens, soft wrist restraints could result in impaired blood circulation, loss of movement, stasis ulcer if the resident was not assessed every two hours for 15 minutes. NM 1 stated, a pressure ulcer could occur, or an existing pressure ulcer could worsen, if the restraints are not being released every two hours for 15 minutes or being assessed every two hours. NM 1 stated, if bilateral soft mittens are not removed or assessed every two hours for 15 minutes, it could result in a pressure ulcer or wound for a resident. 4. During a review of Resident 39's Care Plan titled Restraint Care dated 3/8/2018, indicated intervention included assess Resident 39 for least restrictive measures/devices prior to restraint use and to check for proper placement of restraints. The Care Plan indicated the goal was to discontinue the use of restraints on 6/8/2018. During a review of Resident 39's Nursing Progress Note dated 10/1/2023 at 10:22 a.m., indicated no documentation of least restrictive measures were used and unsuccessful prior to the continuation of the use of restraints (right hand soft mittens and right soft wrist restraint). During a review of Resident 39's Nursing Progress Note dated 10/15/2023 at 10:22 a.m., indicated no documentation of least restrictive measures were used and unsuccessful prior to the continuation of the use of restraints (right hand soft mittens and right soft wrist restraint). During a review of Resident 39's Nursing Progress Noted dated 11/5/2023 at 6:08 p.m., indicated no documentation of least restrictive measures were used and unsuccessful prior to the continuation of the use of restraints (right hand soft mitten and right soft wrist restraint). During a review of Resident 39's Interdisciplinary ([IDT] a group of healthcare professional who assess, coordinate, and mange each resident's comprehensive health care, including his or her medical, psychological, social, and functional needs) Team Conference dated 9/21/2023, 10/19/2023 and 11/14/2023, indicated no documentation of the least restrictive measures were used and unsuccessful for Resident 39 prior to the placement of restraints (right soft mitten and right soft wrist restraints). During an interview on 12/15/2023 at 9:41 a.m. with NM 2, NM 2 stated least restrictive measures should be used prior to the initiation of restraints. NM 2 stated the residents (in general) might feel frustrated or angry while being in restraints. During a review of Resident 45's Care Plan titled At risk for social isolation and physical impairment dated 7/31/2023, indicated Resident 45 had potential for injury related to physical restraint use and had on bilateral soft mittens since 11/7/2023. The care plan interventions indicated Resident 45 should be assessed for the least restrictive measures prior to restraint use. During a review of Resident 45's Restraints weekly progress notes dated 11/19/2023, 11/26/2023, 12/3/2023 and 12/11/2023, indicated no documentation of least restrictive measures were used and unsuccessful with the continued use of bilateral soft mitten restraints. During a review of Resident 68's Care Plan titled Restraint non-behavioral dated 07/11/2023, indicated care plan interventions includes evaluate on-going need of restraint by assessing less restrictive measures/devices prior to restraint use, assess at least monthly for continued use of restraints and possible reductions, assess resident's response to restraints, release and check for redness, blood circulation, hygiene, and impaired skin integrity every two hours and as needed. 5. During an observation on 12/11/2023, at 11:52 a.m. in Resident 20's room, Resident 20 was awake, calm, lying in bed with bilateral upper and lower bed rails (a barrier attached to the side of a bed) were up and padded. Observed Resident 20 had a left soft wrist restraint with white plastic buckle and hand mitten on the left wrist. The soft wrist restraint was tied in a knot and not tied in a quick release knot. During a concurrent observation and interview on 12/12/2023, at 12:30 p.m. with CNA 1, observed left soft wrist restraint of Resident 20 became tighter when head of bed was raised placed higher than thirty degrees. CNA 1 stated, CNAs make rounds to ensure the resident was repositioned, changed, restraint was in place and ensuring two fingers will fit under the soft wrist restraint and Resident 20's skin. CNA 1 stated LVN would assess the circulation and skin integrity every two hours. CNA 1 stated Resident 20 soft wrist restraints moved when the head of the bed was raised, and the soft wrist restraints got tighter on Resident 20's wrist. CNA 1 stated the facility was using a buckle to release the restraint instead of the quick release tie knot used in other facilities. During an observation on 12/12/2023, at 12:21 p.m. Resident 20 remained on four bedrails up, left-hand mitten and left soft wrist restraint with buckle was tied in a knot on the adjustable head part of the bed. During a concurrent observation and interview with on 12/12/2023 at 12:18 p.m. with LVN 12, observed Resident 39's restraint was tied in a knot on the bed. LVN 12 stated, the right wrist restraint was tied in the wrong place on a movable bed frame and there was a risk for injury for Resident 39. LVN 12 stated, it was the responsibility of the licensed nurses to assess and check placement of restraints (right soft mittens and right soft wrist restraint) every two hours. During a concurrent interview and record review on 12/14/2023 at 11:51 a.m. with the Director of Staff Development (DSD), the DSD observed the photo of placement of Resident 39's right soft wrist restraint and stated it was tied in the wrong place on the bed. The DSD stated the way Resident 39 restraint was tied; Resident 39 will not be able to use the call light to call for help. During an interview on 12/15/2023, at 12:22 p.m. with LVN 7, LVN 7 stated soft wrist restraint should not be tied on the adjustable head part of the bed because it could hurt the resident's wrist and tighten the restraint on the wrist, which had the potential to cause deep vein thrombosis (blood clot) due to poor circulation. During an observation 12/11/2023, at 11:39 a.m., observed Resident 11 lying in bed, asleep with tracheostomy to oxygen at 5 liters/ minute, right hand soft mitten, right soft wrist restraints with white plastic buckle and padded bilateral upper and lower bedrails were present and applied. Observed the right soft wrist restraint was tied tightly in a loop to the frame of the bed without using the method of a quick release knot. During a concurrent observation and interview on 12/11/2023, at 4:01 p.m. with Family Member (FM) 1, observed Resident 11's right soft wrist restraint and right-hand mitten were not present but padded bilateral lower and upper bedrails were in use. FM 1 stated she would release the right-hand mitten and right soft wrist restraint whenever she would visit because the staff members do not release the restraints most of the time that it would leave a mark on Resident 11's wrist. FM 1 showed a photo she took less than two weeks ago indicating a deep indentation on the right wrist. Observed the photo of Resident 11's right hand had skin discoloration and slight mottling (uneven, discolored patches on the skin due to lack of blood flow). During a review of Resident 11's Nursing Progress notes dated 11/22/2023 at 11:00 a.m., the Nursing Progress Notes indicated the FM expressed concerns about the tightness of right-hand soft mitten. The Nursing Progre [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, distributed, and served in a sanitary manner to prevent foodborne illness (also called food poisoning caused by eating contaminated food or eating food not kept at appropriate temperatures) by failing to: 1. Label multiple canned foods, meat products, and vegetables with opened date and received date. 2.Ensure Cook 2 did not repeatedly placed the plastic serving spoon in the soiled area and used it to transfer food to the plate. These deficient practices had the potential to result in foodborne illnesses and can lead to other serious medical complications and hospitalization for residents residing in the facility. Findings: During a facility kitchen tour observation on 12/11/2023 at 9:35 a.m., observed multiple canned foods with no received date, observed multiple seasoning goods that were opened but not labelled with open date. During an interview on 12/11/2023 at 9:40 a.m. with the Dietary Director, stated that all canned foods, meat products, and vegetables delivered to the kitchen pantry should have a received date and expiration date. During a facility kitchen tour observation on 12/11/2023 at 9:45 a.m., observed facility freezer and refrigerator with packed chicken breasts wrapped in a transparent plastic wrapper and vegetables with no receive date. During an interview on 12/11/2023 at 9:55 a.m., the Dietary Director stated that the facility kitchen freezer and refrigerator must have a uniformity of labeling foods and must stamp a date to all goods including dry goods and specially all kinds of meat once the package was open and must have an expiration date. During a tray line (a process of preparing and setting food for the residents in the facility) observation on 12/13/2023 at 11:43 a.m., observed Cook 2 serving plastic spoon and scoop and transferred food to the plate and placed the plastic serving spoon to the soiled area and repeated the process three times and did not change the spoon. During an interview on 12/13/2023 at 3:05 p.m., with the Dietary Director stated that the plastic spoon should not be use many times to transfer food from the tray line serving dish to a plate and place the spoon to the soiled and dirty area and use it repeatedly. The Dietary Director stated that it was an infection control issue. During an interview on 12/13/2023 at 2:19 p.m., with the Dietary Supervisor, the Dietary Supervisor stated that a serving spoon must stay in the serving dish and does not need to be place in a dirty area and be place back to the serving dish again and use the process repeatedly because it is an infection control issue. During a review of the facility's policy and procedure (P&P) titled Storage of Foods/Discard Dates Revised 10/2017, indicated to provide pull date guidelines to help ensure that safe, unspoiled foods are served to all our patients and other customers and all foods must be properly covered, labeled, and dated.

Based on observation, interview, and record review, the facility failed to ensure licensed and non-licensed staff practiced proper infection control measures while providing care to residents on contact precautions (measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident ' s environment) for 35 of 41 residents (73, 19, 96, 14, 1, 11, 75, 54, 86, 59, 7, 15, 87, 41, 84, 32, 64, 21, 53, 27, 35, 38, 101, 3, 6, 28, 48, 2, 10, 66, 354, 51, 97, 47, 205) with infections who were on contact isolation. The facility had six residents (4, 79, 91, 92, 62, and 82) that were not on contact isolation. According to the facility's document dated [DATE] titled, Resident Census and Conditions of Resident, the facility census was 109 residents. The facility failed to: 1. Ensure staff performed hand hygiene before and after residents' care. 2. Ensure staff sanitized (to free from dirt, germs), shared equipment before and after residents' use. 3. Ensure staff utilized personal protective equipment ((PPE) gowns, gloves, goggles for eye protection, and face masks) as indicated on the sign for 'Contact Isolation' signs posted outside the residents' room. 4. Ensure staff was removing PPE after having contact with a resident, the surrounding environment, medical equipment, and before leaving/exiting the contact isolation rooms. 5. Ensure staff were preventing hands and clothing from touching potentially contaminated environmental surfaces or items. 6. Ensure Environmental Services Staff (EVS 2) did not take the housekeeping cart inside a contact isolation room, and disinfect any supply brought to the rooms, at the end of the cleaning routine. On [DATE], the survey team identified an Immediate Jeopardy (IJ) related to lack of proper Infection Control practices and on the same day at 11:51 a.m., in the presence of Director of Nursing (DON) and Chief Executive Officer (CEO), the Survey Team called an IJ due to inadequate Infection Control practices. On [DATE] at 11:51 a.m., an Immediate Plan of Action (POA) was received and the corrective actions included the following: 1. Immediate education to all staff on proper infection control practices. 2. All equipment used with multiple residents (portable computer workstations, carts, environmental surfaces, etc.) would undergo disinfection and cleaning. 3. An audit tool was revised to include monitoring disinfection of multi-resident use equipment before and after use of a resident. On [DATE] at 2:07 p.m., the Team verified the corrective POA and accepted the POA. On [DATE] at 2:10 p.m., the IJ was lifted. Findings: On [DATE] at 8:51 a.m., during an interview, DON stated there were 35 residents requiring contact isolation precautions and 19 (1, 7, 10, 14, 15, 19, 35, 38, 41, 47, 51, 52, 66, 73, 86, 87, 97, 101, and 354) of the 35 residents had Carbapenem Resistant Pseudomonas Aeruginosa ((CPRA) a bacteria that causes infection) in sputum (thick mucus which is coughed up from the lungs). The remaining 16 residents (2, 3, 6, 11, 21, 27, 28, 32, 48, 53, 54, 59, 64, 75, 84, and 95) had different types of infections requiring contact isolation. On [DATE] at 9:57 a.m., during an observation, a contact isolation sign was posted outside room [ROOM NUMBER] instructing all staff and visitors to perform hand hygiene (a way of cleaning one's hands that substantially reduces potential harmful microorganisms on the hands), wear gown and gloves before entering the room, and clean hands before and after each resident care. During observation, below the contact isolation sign, there was a cart containing PPE to be used when entering the room. A medication cart was observed inside room [ROOM NUMBER] and the power cord was plugged in a power outlet inside the bathroom of room [ROOM NUMBER]. Concurrently, Licensed Vocational Nurse (LVN 6) was observed unplugging the medication cart power cord from the bathroom of room [ROOM NUMBER]. After leaving room [ROOM NUMBER], LVN 6 was observed removing PPE, then sanitized the hands. LVN 6 was observed wheeling the medication cart to Resident 59's room who was on contact isolation. LVN 6 failed to sanitize the Workstation on Wheels ((WOW) a portable computer mounted on a wheeled cart that has a keyboard, mouse and power cord) before taking it in to the Resident 59's room. On [DATE] at 10:16 a.m., LVN 6 was observed wearing PPE, wheeling the WOW inside Resident 59's room who was on contact isolation. LVN 6 was observed preparing and administering medication via gastric tube (([DEVICE]) a flexible tube inserted into the stomach to provide nutrition, medication and hydration) for Resident 59. LVN 6 was observed typing on the keyboard and using the mouse with the same gloves used to administer medications. LVN 6 was observed removing potentially contaminated gloves after administering medications and with bare hands, pushed the WOW out of Resident 59's room. LVN 6 failed to sanitize the hands, the WOW, keyboard and the mouse. 2. On [DATE] at 11:50 a.m., Respiratory Therapist (RT 4) was observed entering Resident 3's room, who was on contact isolation, without wearing PPE. RT 4 did not perform hand hygiene and did not wear PPE before entering Resident 3's room. While in Resident 3's room, RT 4 touched the cool aerosol bottle (part of the oxygen equipment) and Resident 3's [MEDICAL CONDITION] tubing (a breathing tube placed into the throat for breathing), with bare hands and then touched her own hair. RT 4 then walked out of Resident 3's room, wheeling the WOW cart without performing hand hygiene, and sanitizing the WOW. RT 4 was observed walking to and punching in a code on a keypad to enter the RT Clinical Supervisor's (RTCS) office. A review of Resident 3's Admission Records (Face Sheet), indicated Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 3's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated [DATE], indicated Resident 3 had long and short-term memory problems and was severely impaired in cognition (ability to learn, remember and make decisions) for daily decision making. A review of Resident 3's urine test collected on [DATE], indicated Resident 3 had Proteus Mirabilis (bacteria transmitted mainly through contact with infected persons or contaminated objects and surfaces) infection. A review of Resident 3's tracheal aspirate (respiratory secretions) test result, dated [DATE], indicated Resident 3 had Acinetobacter Baumann (bacterial infection that can be spread through direct contact with surfaces, objects, or the skin of people that are contaminated). On [DATE] at 10:57 a.m., during an interview, RT 4 stated, I am supposed to sanitize the equipment used and change gloves before and after resident's care to prevent spread of infection. 2. On [DATE] at 12:08 a.m., LVN 4 was observed inside Resident 92's room without gloves holding a scanner in one hand, touching Resident 92's blanket and arm, and proceeded to scan Resident 92's wristband identification barcode. Then, LVN 4 went outside the room, to the medication cart, proceeded to prepare Resident 92's medications, and went back inside the room to administer medications to Resident 92 without performing hand hygiene. LVN 4 donned (put on) clean gloves, checked Resident 92's nasogastric tube ((NGT) a tube placed into the stomach through the nose for nutrition, hydration and medication) placement and administered the medications. On [DATE] at 8:15 a.m., Resident 82 was observed with a [MEDICAL CONDITION] (a catheter that is inserted into the neck for the primary purpose of establishing and maintaining a patent airway and to ensure the adequate exchange of oxygen) that was connected to a ventilator (breathing machine). Certified Nurse Assistant (CNA 5) was observed walking through the hallway while wearing gloves and gown. Then, CNA 5 entered Resident 82's room and touched the privacy curtain and Resident 82 in preparation for a bed bath. CNA 6, who was also in Resident 82's room, was observed while wearing gloves, emptying Resident 82's urinal (urine container), and touching the privacy curtains with contaminated gloves. CNA 6, after emptying the urinal, did not change the gloves and performing hand hygiene, CNA 6 continued to assist with Resident 82's bed bath. CNA 6 finished assisting with the bed bath, took off the contaminated gloves, washed her hands, left the room, and was observed documenting at Station 2. On the same day at 8:28 a.m., CNA 6 was observed returning to Resident 82's room, wearing gloves from the isolation cart to assist CNA 5 with bed bath. CNA 6 failed to perform hand hygiene before assisting with Resident 82. 4. On [DATE] at 8:28 a.m., Resident 205 was in an isolation room. RT 4 was observed wearing gown, gloves, and using a pulse oximeter (a device that measures oxygen in the blood while placed on a finger) with Resident 205. RT 4 proceeded to document on the WOW with the potentially contaminated gloves. RT 4 left the room with the WOW and the pulse oximeter without first sanitizing them. RT 4 then entered Resident 2's room. 5. A review of the Admission Records indicated Resident 2 was admitted on [DATE], with [DIAGNOSES REDACTED]. A review of a Respiratory Culture Report, dated [DATE] indicated Resident 2 tested positive for Multi Drug Resistant ((MDR) bacteria resistant to multiple antimicrobial drugs) Escherchia Coli (bacteria commonly found in the intestines which causes severe abdominal cramps, bloody diarrhea and vomiting). 6. A review of the Admission Records indicated Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Admission Record indicated Resident 96 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 8:30 a.m., RT 1 was observed using the WOW inside Resident 1's Room, who was on contact isolation. RT 1 was typing wearing gloves used to provide respiratory care. RT 1 proceeded to go into Resident 96's room to provide respiratory care. RT 1 failed to remove the contaminated gloves, perform hand hygiene and sanitize the WOW in between care of Residents 1 and 96. On [DATE], at 8:30 a.m., during an interview, RT 1 acknowledged he should have performed hand hygiene (after removing gloves), and sanitized the WOW in between the care of Resident 1, and 96's care. 7. A review of the Admission Records indicated Resident 48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 8:31 a.m., during an observation, and interview, RT 5 was inside Resident 48's room, who was on contact isolation, using the WOW. RT 5 was wearing gloves, mask, and gown and was touching Resident 48's [MEDICAL CONDITION] tubing. During observation, RT 5 was typing, touching the computer screen and mouse, while wearing the contaminated gloves. During an interview about not abiding by proper infection control practices, RT 5 stated he just gave Resident 48 a breathing treatment. 8. A review of the Admission Record indicated Resident 19 was admitted [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 7:50 a.m., Certified Nurse Assistant (CNA 11) was observed going into Resident 19's room, who was on contact isolation, without wearing any PPE to provide morning care. 9. A review of the Admission Records indicated Resident 62 was admitted on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 8:30 a.m., CNA 7, while wearing gloves, was observed providing a bed bath to Resident 62. CNA 7 closed Resident 62's privacy curtain with the potentially contaminated gloves and continued bathing Resident 62. 10. On [DATE] at 8:40 a.m., RT 3 was observed outside Resident 19's contact isolation room with the WOW. Then, RT 3 went inside Resident 19's room, touched the privacy curtains with bare hands, and handed over a bottle of nourishment to LVN 7. RT 3 was observed leaving the room and documenting on the WOW. RT 3 failed to donne PPE before entering Resident 19's room, perform hand hygiene after leaving the room, and after using the WOW to document. During an interview on [DATE] at 1:28 p.m., RT 3 acknowledged he should have donned PPE before entering Resident 19's contact isolation room, perform hand hygiene and sanitize the WOW before using it. RT 3 stated what she had done, this is not proper infection control practice. 11. A review of the Admission Records indicated Resident 91 was admitted on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 8:45 a.m., RT 6 was observed wearing gloves while administering a breathing treatment to Resident 91. Then, RT 6 used the WOW outside the room to document (touched the keyboard, screen and mouse). RT 6 failed to perform hand hygiene and sanitize the WOW before going to assist Resident 96. 12. A review of the Admission Records indicated Resident 4 was admitted on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 8:05 a.m., during observation, CNA 4 and 8 were preparing Resident 4 for a bed bath, CNA 8 was wearing gloves and was touching Resident 4. With the potentially contaminated gloves, CNA 8 partially closed the privacy curtain, opened the bathroom door, turned on the water faucet, and removed clean linen from Resident 4's drawers. On [DATE] at 9:13 a.m., during an interview, CNA 4 stated We (CNA's 4 and 8) should have washed Resident 4's private parts last because it is not a clean area. 13. A review of the Admission Records indicated Resident 14 was admitted on [DATE] for [DIAGNOSES REDACTED]. On [DATE] at 1:10 p.m., RT 2 was observed inside Resident 19's, contact isolation room with the WOW. RT 2 typed information using the keyboard and mouse while wearing potentially contaminated gloves used to provide respiratory care for Resident 19. Then, RT 2 was observed going into Resident 14's contact isolation room. RT 2 failed to remove gloves, perform hand hygiene and sanitize the WOW in between providing care for Residents 19 and 14. On ,[DATE] at 1:25 p.m., during an interview, RT 2 acknowledged not removing the contaminated gloves, not washing hands and not sanitizing the WOW before proceeding to provide care for another resident. 14. On [DATE] at 8:30 a.m., EVS 2 was observed cleaning Resident rooms [ROOM NUMBER], which were designated as contact isolation rooms. EVS 2 pulled the housekeeping cart half-way into each room. EVS 2 did not sanitize the housekeeping cart between rooms. Concurrently, during an interview, EVS 2 stated she was not aware she needed to sanitize the cart before taking it to another resident room. On [DATE], at 2:24 p.m., during an interview, Environmental Services Manager (EVSM) stated when cleaning, the housekeeping cart should remain outside the residents' rooms. A review of the facility's policy titled Terminal Cleaning, revised on ,[DATE] indicated staff should park the cleaning cart outside the doorway to the room to allow easy access to supplies. Before leaving the room at the end of the cleaning routine, staff should wipe supplies with disinfectant. 15. A review of the admission records indicated Resident 79 was admitted on [DATE] for [DIAGNOSES REDACTED]. On [DATE] at 8:05 a.m., during a bed bath observation, CNA 4 was observed washing Resident 79's private area and buttocks before washing the legs with the same gloves and soapy water. During an interview on [DATE] at 9:13 a.m., CNA 4 stated, I am supposed to start washing the face followed by hands, armpits, chest, legs and private parts at the end. During an Antibiotic Stewardship interview on [DATE] at 7:54 a.m., Infection Preventionists 1 and 2 stated preventive infection control practices included hand hygiene before and after resident care, before and after putting and removing gloves, respiratory hygiene precaution (cough and sneeze in the elbow then hand hygiene), disinfection of medical equipment, and waste disposal. IP 1 stated, Housekeeping and all staff are expected to adhere to infection control policies, and Secret Shoppers (staff assigned to observe infection prevention compliance) monitor to ensure all care providers are compliant with hand hygiene and use of PPE. IPs 1 and 2 stated the facility had a documented procedure for disinfecting equipment but no monitoring was done to ensure medical equipment and shared medical devices were sanitized before and after residents' use. IPs 1 and 2 were not able to state how, who, and when equipment, including the WOW and pulse oximeter, were sanitized. During an interview on [DATE] at 9:20 a.m., IP 1 stated residents' infections are reported to the Quality Assessment and Assurance (QAA) committee as part of the Quality Assurance Performance Improvement (QAPI) Program every three months during QAA/QAPI meeting. IP 1 stated the facility did not trend for positive cultured microorganisms. During an interview on [DATE] at 11:32 a.m., DON stated the facility did not have a policy and procedure that described what the 'Secret Shoppers' jobs, and training consisted of. During an interview on [DATE] at 1:57 p.m., LVN 5 stated, she was designated as a secret shopper. LVN 5 stated, I check nurses, RT, physicians and all staff, if they perform hand washing before and after resident's care, and if they are placing the gowns on correctly. LVN 5 stated the IPs told her to check if the employees were performing hand hygiene. LVN 5 verified that IP did not instruct her to monitor equipment (WOW, medication and treatment carts, shower beds, and shower chairs) sanitization in between resident care. A review of the facility's undated document titled, Nursing Practice Alert Infection Prevention and Control indicated: 1. PPE will be used anytime when expecting contact with body fluids and environment contaminated with bodily fluids. 2. Good hand hygiene on room entry and exit, and prior to putting on and taking off gloves. 3. Strict hand hygiene on room entry and exit, and before contact with residents. 4. Disinfect/sanitize equipment after use with each resident. A review of the facility's Hand Hygiene/PPE Observation Tool, dated ,[DATE], indicated for all staff to observe hand hygiene before and after resident's care, PPE worn before entering and removed after exiting from resident's isolation room. A review of the facility's undated policy titled, Standard Precautions, indicated the following: 1. Staff are to change gloves when moving from a contaminated body (private parts) site to a clean body site during patient care. This does not make sense, please check, it should be from clean to dirty. 2. Remove gloves after contact with a patient and or surrounding environment including medical equipment. 3. Non-critical movable medical equipment not limited to keyboards, phones, must be cleaned and disinfected using approved disinfectants in accordance with manufacturers' instructions before use on another patient. 4. Remove PPE before leaving, exiting isolation room and ensure hands and clothing do not touch potentially contaminated environmental surfaces or items to avoid transfer of microorganisms. A review of the facility's policy titled Cleaning of Moveable Medical Equipment, dated ,[DATE], indicated moveable medical equipment is any equipment used for several residents is to be cleaned after each individual use. A review of the undated Infection Preventionist Job Description indicated one of the IP job functions is to collaborate with the infection prevention manager, to investigate clusters of infections or changes in patterns or infection. 16. On (MONTH) 27, 2019 at 9:57 a.m., License vocational Nurse (LVN 6 ) was observed inside contact isolation room with WOW, power cord plug inside of the resident bathroom. LVN 6 was observed using keyboard and mouse with the same gloves that was used to provide care to the resident, then going into another contact isolation room. During an interview with Registered Nurse (RN 1) on (MONTH) 5, 2019 at 9:00 am acknowledged improper infection control practices by LVN 6. 17. On (MONTH) 28, 2019 at 8:30 a.m., Respiratory Therapist 1 (RT1) was observed inside contact isolation room with WOW; using keyboard and mouse with the same gloves that was used to provide care, then going into another contact isolation room. During an interview with RT 1 on (MONTH) 5, 2019 at 8:30 am acknowledged improper infection control practices. 18. On (MONTH) 1, 2019 at 7:50 a.m. Certified Nurse Assistant (CNA 11) was observe going into contact isolation room without wearing PPE. During an interview with CNA 11 on (MONTH) 2, 2019 at 1:10 pm, CNA 11 acknowledged the improper infection control practices. 19. (MONTH) 2, 2019, 2019 at 1:10 p.m., Respiratory Therapist (RT 2) was observed inside contact isolation room with WOW; using keyboard and mouse with the same gloves that was used to provide care, then going into another contact isolation room. During an interview with RT 2 on (MONTH) 5, 2019 at 1:25 pm acknowledged the improper infection control practices. 20. On (MONTH) 2, 2019 at 8:40 a.m., Respiratory Therapist (RT 3) was observed outside contact isolation room with WOW; then going inside the room touching the privacy curtain with bare hands giving LVN 7 a bottle of(NAME)Active ([MEDICATION NAME] dietary drink that help strengthen body's defense system) without gloves on. During an interview with RT 3 on (MONTH) 5, 2019 at 1:28 pm acknowledged the improper infection control practices.

Based on observation, interview and record review, the facility failed to follow its policy, the physician's order and implement a resident's plan of care, which included assessment and monitoring for the use of right wrist restraint (any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual can not remove easily which restricts freedom of movement or normal access to one's body) for one of 21 sampled residents (13). Resident 13, was observed right wrist improperly restrained, with the arm slightly bent and extended above her head, tied down under the bed in between the side rail, restricting movement and proper blood flow. This deficient practice resulted in Resident 13 being improperly restrained, causing pain and red bruise about a half inch wide around the resident's entire right wrist caused by the tight wrist restraint which could potentially cause joint, muscle and nerve damage. Findings: On July 20, 2017 at 3:50 p.m., during an observation, Resident 13 was lying in bed with a soft mitten on the right hand. A review of Resident 13's Admission Face Sheet indicated the resident was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. A review of Resident 13's informed consent for the use of restraints or prolonged use of a device form, dated April 12, 2017 indicated family member (FM 1) had verbally consented for the use of a soft wrist restraint, but the form was not signed by FM 1. The indication for the use of the soft restraint was documented for confusion manifested by pulling out lines. A review of the Resident 13's Minimum Data Set (MDS), an assessment and care screening tool, dated May 17, 2017, indicated the resident had moderate cognitive impairment with the ability to sometimes understand and be understood. The resident was non-ambulatory (did not walk) and required extensive assistance to being totally dependent on staff for care. The resident had a brief interview for mental status score of 11 (8-15 meant interviewable). According to the MDS, the resident had impairment on both sides of the upper and lower extremities. The MDS also indicated physical restraints including limb restraints were used daily while in bed and in the wheelchair. A review of Resident 13's physician's telephone order, dated July 3, 2017, indicated to use soft right wrist restraint. However, there was no documented reason, functional deficit or any related [DIAGNOSES REDACTED]. The order indicated to release the restraint and check for redness, circulation, hydration, nutritional, elimination needs, hygiene and safety every two hours. A review of Resident 13's care plan titled, Restraint/Seclusion Use for Patient Safety, dated July 25, 2017 indicated a right hand mitten to be used due to increasing episodes of self-scratching despite right soft wrist restraint. The goal was the resident would experience no physical injury and no complications from the use of the restraint. The staff's interventions included to check for proper placement of the restraint by; releasing and checking for skin redness, circulation, hygiene and impaired skin integrity every two hours and as needed. On July 26, 2017 at 10:52 a.m., Resident 13 was observed laying on her back with the right arm restrained, slightly bent and extended above her head, tied down under the bed in between the side rail while the resident was trying to move her arm. The resident was attempting to move her arm around but was unable to do so. During an interview on July 26, 2017 at 10:54 a.m., Resident 13 stated she was placed in the restraint so she would not hurt herself. On July 26, 2017 at 11 a.m., during a concurrent observation and interview, a Licensed Vocational Nurse (LVN 13) was brought to Resident 13's room and saw the resident restrained improperly. LVN 13 struggled to place her two fingers between the wrist restraint and resident's right wrist while trying to untie the restraint, which took her two minutes to release. After the restraint was removed, there was a red bruise about a half inch wide around the resident's entire right wrist. A review of the flowsheet data form titled Non-Violent or Non-Self Destructive Restraints, dated July 26, 2017 (timed at 12 p.m.,) indicated Resident 13's peripheral neurovascular (circulation to extremities) and skin check as WNL (within normal limits). However, there was no documentation on the form under signs of any injuries, even though the resident was identified with redness on the right wrist after the wrist restraint was removed an hour prior. On July 26, 2017 at 11:15 a.m., during an interview, LVN 13 stated she was unaware of who restrained Resident 13 incorrectly. LVN 13 stated the resident was not restrained properly and the restraint was too tight around the right wrist. LVN 13 stated when the side rail was lowered it would cause more tightness to the wrist restraint by pulling on the resident's right arm. On July 27, 2017 at 2:53 p.m., during an interview LVN 13 stated she did not document her assessment of finding Resident 13 improperly restrained resulting in discoloration to the right wrist, because she had reported it to the Registered Nurse (RN 5). On August 2, 2017 at 2:03 p.m., Resident 13's family member (FM 1) stated Resident 13 was not able to use her left arm and a hand mitten was being used for the right hand. FM 1 stated the restraint was removed when the family visited for a few hours every day, but the resident did not scratch or pull on any tubes during their visit. The facility's policy and procedure titled, Physical Restraints, with a revised date of July 2010, indicated restraints should be safely and appropriately used. The policy also stipulated to apply restraint so that the resident has as much motion as was safe and was easy removal for emergencies. The restraint should be applied so that the body part in restraint was in a normal anatomical comfortable position and circulation and nerve function were not impaired.