Every finding on record at Roseville Point Health & Wellness Center

Based on interview and record review, the facility failed to ensure a grievance was resolved for one of four sampled residents (Resident 4), when Resident 4's reported missing clothes were not replaced since May 2026.This failure decreased the facility's potential to settle grievances in a timely manner.Findings:A review of Resident 4's Face Sheet, indicated he was admitted to the facility in April 2026 with a diagnosis of sepsis (a life-threatening blood infection) and was discharged to an assisted living facility 12 days after.A review of Resident 4's Order Summary Report, dated 4/16/26, indicated Resident 4 was incapable of making health care decisions, and Resident 4's daughter was appointed as the Responsible Party (RP).During a concurrent interview and record review on 7/28/26 at 3:10 p.m. with Licensed Nurse (LN) 1, Resident 29's Inventory Sheet (IS) dated 4/16/26 was reviewed. LN 1 stated she met with Resident 29's RP on 4/28/26 and confirmed that a pair of pajamas, two shirts and a pair of joggers were found to be missing according to the IS. LN 1 further stated she formally reported the grievance concerning the missing items to the social services department for further action.During a concurrent interview and record review on 7/28/26 at 2 p.m. with the Assistant Social Services Director (ASSD), Resident 29's IS dated 4/16/26, Theft /Loss Report (TLR) dated 4/27/26, and the Social Services progress notes were reviewed. ASSD confirmed a grievance had been reported by a nursing staff member concerning Resident 29's missing clothing items and stated she communicated to the RP that the missing clothing items could not be located, and the facility would proceed with replacing them. ASSD added she notified the Social Services Director (SSD) the investigation's outcome more than five weeks ago in order to be resolved. ASSD further stated she did not follow up on the actions taken by SSD after the initial report and there were no available SSD progress notes documented in Resident 4's chart to tell if a resolution was completed.During a concurrent interview and record review on 7/28/26 at 3:15 p.m. with the Administrator (ADM), Resident 4's IS dated 4/16/26 and the TLR dated 4/27/26 were reviewed. ADM confirmed an IS had been completed for Resident 4 from his admission on [DATE] and discharge on [DATE] which indicated LN 1 signed with the RP that three items were missing from the IS list. ADM stated after the staff investigation has been completed, the TLR was signed on 5/4/26 and a resolution was decided that only the lost clothing items that were listed in the IS will be replaced. ADM acknowledged that Resident 4's missing clothing items were not found and have not been replaced by the facility.A review of the facility's policy titled, Grievances and Complaint, revised in October 2025, indicated, The Facility Administrator is the Grievance Official responsible for overseeing grievance process . through to their conclusion . If follow up is required, the Grievance Official is responsible for ensuring that the follow up action is taken in a timely manner.

Based on interview and record review, the facility failed to ensure two of six sampled residents' (Resident 2 and Resident 4) were free from physical abuse and neglect when:1. Resident 1 physically grabbed Resident 2's arm and refused to release it; and,2. Resident 3 pushed Resident 4's arm, and Resident 4 was not assessed, monitored or that the physician was notified following the incident. These failures resulted in Resident 2 becoming agitated and placed Resident 4 at risk for an undetected injury or change in condition due to the facility's failure to assess, monitor, and notify the physician after a witnessed incident of resident to resident physical abuse.Findings:1. Resident 1 was admitted to the facility in late 2025 with diagnoses that included a stroke with right sided weakness, and difficulty speaking.Resident 2 was admitted to the facility in late 2024 with diagnoses that included end stage kidney failure, muscle weakness and difficulty walking.During a review of Resident 2's Minimum Data Set (MDS, an assessment tool), dated 2/12/25, the MDS showed a Brief Interview for Mental Status (BIMS, a cognitive screening tool) score of 15/15 which indicated Resident 2 had intact cognition.During a review of Resident 1's progress note (PN), dated 5/19/26 at 9:31 p.m. ,the PN indicated, .This writer noted a commotion and two agitated residents in a verbal altercation screaming and cursing at each other.Staff members were trying to de-escalate the situation. However, [Resident 2] was noted cursing and yelling, and kept trying to walk towards [Resident 1] who this writer was holding close to station 2. [Resident 2] kept insultingand (sic) using unpleasant gestures, He was visibly agitated and not listening to any nursing staff members.[Resident 1].was also very agitated trying to turn his w/c [wheelchair] towards [Resident 2].After about 10 minutes of redirecting residents and de-escalating the situation, [Resident 2] stated he wanted to call the police and press charges against [Resident 1] for assault for grabbing him by his arm.During a review of Resident 2's PN dated 5/19/26 at 10:28 p.m. the PN indicated, .[Resident 2] became involved in a verbal altercation with another resident while ambulating around the facility hallway when the other resident held on his hand firmly and got agitated later leading to verbal altercation.During a review of Resident 2's Care Plan Report [CP], dated 5/19/26, the CP indicated, Resident involved in resident-to-resident altercation related to resident agitation m/b [manifested by] verbal abuse.During an interview on 7/1/26 at 12:39 p.m. with Resident 2, Resident 2 stated he was wheeling down the hallway when Resident 1 grabbed his forearm and would not let go. Resident 2 stated when he pulled his arm away Resident 1 swung his arm toward him and they began yelling at each other, using profanity.During an interview on 7/1/26 at 3:29 p.m. with Licensed Nurse (LN 1), LN 1 stated he observed Resident 1 grab Resident 2's arm as Resident 2 wheeled past him down the hallway. LN 1 stated Resident 2 became angry and there was an argument between the two residents.During an interview on 7/2/26 at 12:40 p.m. with the Director of Nursing (DON), the DON confirmed the progress notes indicated a physical and verbal altercation occurred between Resident 1 and Resident 2. The DON stated residents have the right to be free from abuse and be safe in their environment.2. Resident 3 was admitted to the facility in early 2025 with diagnoses that included left hip joint infection, and muscle weakness.During a review of Resident 3's MDS, dated [DATE], the MDS showed a BIMS score of 15/15 which indicated intact cognition.Resident 4 was admitted to the facility in early 2019 with diagnoses that included dementia, and a mental condition that causes extreme shifts in mood, energy and activity levels.During a review of Resident 4's MDS, dated [DATE], the MDS showed a BIMS score of 5/15 which indicated severe cognitive impairment.During a review of a witness statement from Certified Occupational Therapy Assistant (COTA) dated 5/26/26, the statement indicated, [COTA] witnessed [Resident 4] reach w/L [with left] hand for [Resident 3] soda. [Resident 3] hit [Resident 4] L forearm with moderate force using R [right] hand to prevent [Resident 4] from drinking his soda. [Resident 4] pulled his arm back after being struck and held his arm.Notified cart nurse, administrator, and supervising nurse.During an interview on 7/1/26 at 1:32 p.m. with Resident 3, Resident 3 stated Resident 4 is always grabbing for stuff, and when Resident 4 grabbed for his can of soda Resident 3 pushed Resident 4's hand away.During a review of Resident 4's electronic health record, there was no documented evidence that the resident was assessed, monitored or his physician was notified following the incident. There was no care plan for the witnessed abuse incident, either. During an interview on 7/2/26 at 1:15 p.m. with the DON the DON confirmed the witness statement from the COTA in regard to the incident between Resident 3 and Resident 4. The DON confirmed there was no nursing assessment, physical assessment, care plan or physician notification for the witnessed abuse incident. The DON stated she expected the nurse to assess the resident and make phone calls to the physician and responsible party. The DON stated there should be a care plan to document the change of condition, as abuse was a change in condition and the resident should be monitored for any injury or psychosocial distress.During a review of the facility's policy and procedures (P&P) titled, Abuse Prevention and Management, dated 6/12/24, the P&P indicated, The Facility does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation, and/or mistreatment.PURPOSE: To address the health, safety, welfare, dignity and respect of residents.During a review of the facility's P&P titled, Change in Condition, dated 8/25/22, the P&P indicated, .The Licensed Nurse will assess the change of condition and determine what nursing interventions are appropriate.A Licensed Nurse will notify the resident's Physician.and legal representative or an appropriate family member when there is an.Incident /accident involving the resident.Licensed Nurse will document the following.date, time, and pertinent details of the event and the subsequent assessment in the medical record.Update the Care Plan to reflect the resident's current status.A Licensed Nurse will communicate any changes in required interventions to the care team.A Licensed nurse will document each shift for at least seventy-two [72] hours when there is a change in the resident's condition.Documentation pertaining to a change is the resident's condition will be maintained in the resident's medical record.

Based on interviews and record review, the facility failed to exercise reasonable care to protect residents' personal property from loss for two of six sampled residents (Resident 1 and Resident 3) when staff did not properly inventory and safeguard Resident 1's hearing aids and Resident 3's clothing and toiletries.These failures contributed to the loss of Resident 1's hearing aids and the loss of Resident 3's clothing and toiletries and placed the residents' other property at risk for loss or theft.Findings:Resident 1 was admitted to the facility in February of 2026 with diagnoses that included cellulitis (infection of the skin).Resident 3 was admitted to the facility in December of 2025 with diagnoses that included acute kidney failure.A review of Resident 1's Personal Effects Inventory Form [a facility document that lists residents' belongings and anything of value they brought in], undated, indicated that Resident 1's hearing aids were not inventoried on admission and at any point during his stay.During Resident 3's record review, Resident 3 did not have a Personal Effects Inventory Form in her medical record.A review of Resident 1's, admission Summary, dated 2/26/26, indicated, He has hearing aids (L&R) [left and right].A review of Resident 1's Minimum Data Set (MDS, a standardized assessment tool used in skilled nursing facilities), dated 3/4/26, indicated Resident 1 was using his hearing aids during the assessment.During an interview on 5/26/26 at 1:14 p.m. with Resident 3, Resident 3 indicated that, since she was admitted , she has had some pants and toiletries such as shampoo go missing. Resident 3 further indicated that her items were never inventoried on her inventory sheet (Personal Effects Inventory Form) and the facility never reimbursed her for these lost items.During an interview on 5/26/26 at 2:56 p.m. with the Social Services Assistant (SSA), the SSA indicated that residents' inventory sheet should have been filled out on admission but could also have been updated at any time by staff.During an interview on 5/26/26 at 4:24 p.m. with Charge Nurse 1 (CN 1), CN 1 indicated that on admission, she would have handed the inventory sheet to a CNA to fill out and, if she had received a blank inventory sheet, she would have questioned why it was not filled out.During an interview on 5/27/26 at 10:03 a.m. with the Case Manager (CM), the CM confirmed that Resident 1's inventory sheet on discharge was blank. The CM further explained that facility staff were responsible for ensuring residents' belongings were properly inventoried and tracked.During an interview on 5/27/26 at 11:10 a.m. with the Administrator (ADM), the ADM indicated that if a resident had lost an item listed on their inventory sheet, the facility would have tried to reimburse the resident for the fair market value of the item.During an interview on 5/28/26 at 9:59 a.m. with Certified Nursing Assistant 3 (CNA 3), CNA 3 indicated that she had noticed that Resident 3 had about three of her pants go missing. CNA 3 further indicated that Resident 3 had complained to her about her missing clothing and searched for the pants in Resident 3's room and in the laundry room, but she was unable to find Resident 3's pants.During an interview on 5/28/26 at 10:43 a.m. with the Medical Records Staff (MRS), the MRS indicated that staff never filled out an inventory sheet for Resident 3.During a review of the facility's policy and procedures (P&P) titled, Personal Property, revised 10/25, the PNP indicated, Upon admission, the Certified Nursing Assistant (CNA)/designee will conduct a personal property inventory of the resident's property.The personal property inventory will be signed and placed in the medical record.A copy of the written inventory shall be provided to the resident/resident representative.Subsequent items brought into or removed from the Facility shall be added to or deleted from the personal property inventory by the facility at the request of the resident/resident representative.The IDT [interdisciplinary team] will review the resident's personal property inventory, as applicable.

Based on interviews and record review, the facility failed to protect one of seven sampled residents (Resident 2's) right to be free from physical and verbal abuse when Certified Nursing Assistant 1 (CNA 1) threw Resident 2 face down on her bed and called her a derogatory name. This failure had the potential to cause physical and mental harm to Resident 2.Findings:Resident 2 was admitted to the facility in December of 2025 with diagnoses that included spinal stenosis in the lumber region (the narrowing of the spaces within the spine, which puts pressure on the spinal cord and nerves).A review of Resident 2's medical record titled, IDT [Interdisciplinary team] Note, dated 5/6/26, indicated, IDT met to discuss allegation of physical abuse from a pm cna [Certified Nursing Assistant] to the Resident. It was reported by the witness cna [CNA 2] that Resident was found lying face down on the fall mattress @ [at] 1910 inside her room, another cna [CNA 1] came (Perpetrator) to assist but instead grabbed Resident's arm and stated 'Come here you old Chinese lady' then threw the Resident face-first sideways on the bed, then proceeded to pick her up by the back of the collar and pants then threw her onto the bed again but positioning her on the bed.During an interview on 5/27/26 at 9:30 a.m. with Charge Nurse 2 (CN 2), CN 2 indicated that if a staff member threw a resident face down onto their bed and made derogatory comments, she would have considered that to be abuse.During an interview on 5/27/26 at 10:14 a.m. with CNA 2, CNA 2 indicated that on 5/5/26, during her evening shift at approximately 7 p.m., she walked into Resident 2's room and found Resident 2 on the floor mat beside her bed. CNA 2 indicated that, she then asked CNA 1 for assistance in getting Resident 2 back into bed during which CNA 1 grabbed Resident 2 by her arm and threw her onto the bed. CNA 2 further indicated that CNA 1 then grabbed Resident 2 by her pants and collar and threw her face down onto her bed again causing Resident 2's feet to strike the bed's footboard. CNA 2 further reported that during this incident, CNA 1 said, Come here, you old Chinese lady.During an interview on 5/27/26 at 11:10 a.m. with the Administrator (ADM), the ADM confirmed that residents in the facility have the right to be free from abuse.During a review of the facility's policy and procedures (P&P) titled, Abuse Prevention and Management, revised 5/24, the PNP indicated, The facility does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation, and/or mistreatment.

Based on observation, interview, and record review, the facility failed to ensure appropriate Gradual Dose Reduction (GDR) practices for a psychotropic medication (a drug prescribed to affect the mind, emotions or behavior) for one of 5 sampled residents (Resident 5) when Resident 5's dose of quetiapine (a psychotropic medication) was increased, and the GDR was documented as unsuccessful without any supporting clinical documentation to justify the dose increase.This failure resulted in the potential for unnecessary medication use and avoidable adverse effects for Resident 5.Clinical record review indicated that Resident 5 was admitted to the facility in December 2021 with diagnoses including dementia (memory loss condition), major depressive disorder (long term depression), and anxiety disorder (ongoing excessive worry or nervousness).A review of Resident 5's Physician Orders, dated 9/25/25, indicated a dose increase for quetiapine 50 mg (milligram-unit of measure) to give 1.5 tablets (75 mg) by mouth at bedtime for BPSD (Behavioral and Psychological Symptoms of Dementia, the changes in behavior, emotions, or mental state that residents with dementia experience) MB (Manifested By, shown by) physical aggression. Resident 5's quetiapine dose was increased from 50 mg to 75 mg at bedtime.A review of Resident 5's monthly Medication Administration Records (MAR) indicated that Resident 5 received 75 mg of quetiapine every night at bedtime.During a concurrent record review and interview on 5/21/26 at 11:47 a.m. with Licensed Nurse (LN) 2, the facility's former interim director of nursing, LN 2 stated that according to Resident 5's monthly behavioral monitoring records for June, July, August, and September 2025, the resident did not exhibit any behaviors around the time the quetiapine dose was increased. LN 2 also stated that he created a progress note dated 9/1/25 after the maintenance staff reported that the resident appeared agitated and nearly grabbed another resident's wheelchair after he was touched. Upon follow-up, the resident was already in his room with a Certified Nursing Assistant (CNA), who reported that the resident had been combative when she attempted to assist him. LN 2 stated he was able to calm the resident, and the CNA assisted the resident back to bed.During another interview on 5/21/26 at 12:46 p.m. with LN 2, LN 2 stated there were no psychiatry chart notes completed or scanned to resident 5's chart related to the quetiapine dose increase in September of 2025.During an interview on 5/21/26 at 2:06 p.m. with the facility's Nurse Practitioner (NP) 2, NP 2 stated that she increased the resident's quetiapine dose on 9/25/25 based on a progress note. NP 2 noted that the resident did not like being touched, was not a threat to others, and did well when approached appropriately. She stated she felt safe and comfortable providing care for him. NP 2 added that if the resident had been hitting staff or was combative, she would have transferred him to a memory unit. She also noted that the September 2025 dose increase was the reason the GDR attempt was documented as failed in Resident 5's psychiatry chart notes dated 12/23/25 and 2/4/26.A Review of Resident 5's psychiatry chart notes, dated 12/23/25, stated, no behaviors; failed GDR: Seroquel [brand name for quetiapine], described any failed GDR: Seroquel, but did not provide any description of the failed GDR. A Review of Resident 5's psychiatry chart notes, dated 2/4/26, stated, no behaviors; failed GDR: Seroquel, described any failed GDR: Seroquel, but again provided no description of the failed GDR. During an interview on 5/20/26 at 2:03 p.m. with the facility's Regional Consultant (RC), the RC stated that Resident 5 did not have notable behaviors over the last 12 months. The psychotropic medication evaluations were required to be conducted monthly to address Gradual Dose Reduction (GDR). The RC further acknowledged that the GDR Interdisciplinary Team (IDT) meetings were not being held consistently and that the facility was required to implement a Quality Assurance Performance Improvement (QAPI) plan to ensure appropriate GDR assessments.A review of quetiapine's Prescribing Information (PI), dated 1/2022, indicated that elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Quetiapine was not approved for the treatment of patients with dementia-related psychosis. In addition, the PI also stated, somnolence (a state of drowsiness or heightened sleepiness) was a commonly reported adverse event reported in patients treated with quetiapine.A review of the facility Policy and Procedures (P&P) titled, Psychotropic Medication Use, dated 10/2017, the P&P indicated, .before initiating or increasing an antipsychotic medication for enduring conditions, the target behavior must be clearly and specifically identified and monitored objectively and qualitatively, in order to ensure the behavioral symptoms are. persistent or likely to reoccur without continued treatment. not due to environmental stressors.that can be addressed to improve the psychotic symptoms or maintain safety.not due to psychological stressors, anxiety or fear stemming from misunderstanding related to his or her cognitive impairment that can be expected to improve or resolve as the situation is addressed.After initiating or increasing the dose of an antipsychotic medication, the behavioral symptoms much be reevaluated periodically to determine the effectiveness of the antipsychotic and the potential for reducing or discontinuing the dose.

Based on observation, staff interview, and facility document review, the facility failed to implement pharmaceutical policies and procedures for a census of 87 when the refrigerator E-Kits (Emergency kits containing emergency medications for immediate use) had not been replaced within 72 hours after being used. This failure had the potential to result in emergency medications not being available when needed for the residents.During an inspection of the facility's medication room on 5/18/26 at 11:33 a.m., two emergency kits in the medication refrigerator were found to be previously opened and not replaced. A 3 ml (milliliter, unit of measure) glargine insulin pen (medication used to treat high blood sugar level) had been taken out of E-kit box #3116 on 4/3/26. A 3 ml glargine insulin pen had been taken out of E-kit box #2550 on 4/8/26. Both the E-kit boxes were still stored in the medication refrigerator without any glargine insulin. During an interview on 5/18/26 at 11:35 with Licensed Nurse (LN) 1, LN 1 acknowledged both refrigerator e-kit boxes had been previously opened on 4/3/26 and 4/8/26 and were not replaced with new sealed boxes to ensure all emergency medications were available for the residents.During an interview on 5/19/26 at 9:46 a.m. with the facility's Regional Consultant (RC), the RC stated that open E-kits needed to be replaced by the pharmacy within 24-72 hours to ensure emergency medications were available for resident use. During a review of the facility's policy and procedure (P&P) titled, Medication Ordering and Receiving From Pharmacy, dated 8/2014, the P&P indicated, .the used sealed kits are replaced with the new sealed kits within 72 hours of opening.

Based on interview and record review, the facility failed to act upon the Consultant Pharmacist (CP)'s recommendation for one of 5 sampled residents (Resident 5) when the facility did not address the need for a Gradual Dose Reduction (GDR) of quetiapine (a type of psychotropic medication).This failure resulted in the potential for unnecessary medication use and avoidable adverse effects for Resident 5.Clinical record review indicated that Resident 5 was admitted to the facility in December 2021 with diagnoses including dementia (memory loss condition), major depressive disorder (long term depression), and anxiety disorder (ongoing excessive worry or nervousness).A review of Resident 5's Physician Orders, dated 9/25/25, indicated an order for quetiapine 50 mg (milligram-unit of measure) to give 1.5 tablets (75 mg) by mouth at bedtime for BPSD (Behavioral and Psychological Symptoms of Dementia, the changes in behavior, emotions, or mental state that residents with dementia experience) MB (Manifested By, shown by) physical aggression.A review of Resident 5's monthly Medication Administration Records (MAR) indicated that Resident 5 received 75 mg of quetiapine every night at bedtime.During an interview on 5/20/26 at 2:03 p.m. with the facility's Regional Consultant (RC), the RC stated that Resident 5 did not have notable behaviors over the last 12 months. The psychotropic medication evaluations were required to be conducted monthly to address Gradual Dose Reduction (GDR). The RC further acknowledged that the GDR Interdisciplinary Team (IDT) meetings were not being held consistently and that the facility was required to implement a Quality Assurance Performance Improvement (QAPI) plan to ensure appropriate GDR assessments. A review of the facility's CP recommendation report regarding the GDR for Resident 5's quetiapine 75 mg, dated 12/23/25, showed that the recommendation was not reviewed and the record reflected no physician-documented consideration of risks, benefits, or clinical factors unique to the resident.During an interview on 5/21/26 at 2:21p.m. with the CP, the CP stated that a GDR request for Resident 5 was submitted to the facility on [DATE], but it was declined without providing any clinical rational. The CP stated that the plan was to resubmit the GDR recommendation.A Review of Resident 5's psychiatry chart notes, dated 12/23/25, stated, no behaviors; failed GDR: Seroquel [brand name for quetiapine], described any failed GDR: Seroquel, but did not provide any description of the failed GDR. A Review of Resident 5's psychiatry chart notes, dated 2/4/26, stated, no behaviors; failed GDR: Seroquel, described any failed GDR: Seroquel, but again provided no description of the failed GDR. A review of quetiapine's Prescribing Information (PI), dated 1/2022, indicated that elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Quetiapine was not approved for the treatment of patients with dementia-related psychosis. In addition, the PI also stated that somnolence (a state of drowsiness or heightened sleepiness) was a commonly reported adverse event reported in patients treated with quetiapine.A review of the facility Policy and Procedures (P&P) titled, P-NP106 Behavior/Psychoactive Medication Management, dated 2022, the P&P indicated, Evaluation: The Behavior Management/Psychoactive Review Committee will review the following and make recommendations based on the resident's need.A review of the facility's Quality Assurance Performance Improvement (QAPI) form, date initiated 4/28/26, showed that under improvement plan, it indicated, during this meeting the team shall review: a. pharmacy recommendations.The facility's Pharmacist Medication Review policy was not provided.

Based on interviews and record reviews, the facility failed to ensure accurate and consistent medical record documentation for two of 27 sampled residents (Resident 26 and Resident 11) when: 1. A physician ordered wound care treatment for Resident 26 were not entered or documented on the Treatment Administration Records (TAR) and,2. Resident 11's Advance Health Care Directive (AHCD, a legal document that outlines your medical preferences) was incomplete; and, These failures increased the potential for miscommunication among staff that could lead to unmet needs for Resident 26 and Resident 11. Findings: 1. Resident 26 was admitted to the facility on February of 2026 with a diagnoses which included Acute Hypoxic Respiratory Failure (a sudden, life-threatening condition where the lungs cannot adequately transfer oxygen into the bloodstream, Quadriplegia (a partial or total loss of sensory and motor function in all four limbs and the torso, typically caused by a spinal cord injury in the neck) and Pressure Ulcer of Sacral Region (a skin and tissue damage over the tailbone or lower spine). A review of Resident 26's Order Summary Report (ORS) indicated, Resident (Resident 26) is capable of making healthcare decisions. A review of Resident 26' Minimum Data Set (MDS, a standardized assessment tool used in nursing homes), dated 04/22/26, the MDS indicated, Resident [Resident 26] has a pressure ulcer/injury.Is the resident at risk for developing pressure ulcers/injuries? 1. Yes. Skin and Ulcer/Injury Treatments, Pressure ulcer/injury care. A review of Resident's 26 Care Plan (CP) indicated, Documented Pressure Ulcer.Evaluate skin.Evaluate ulcer.Provide skin care per facility guidelines.Resident at risk for uti [urinary tract infection] and pressure ulcers.Resident will be monitored. A review of Resident 26's Treatment Administration Record (TAR) for January, February, March, April, and May 2026 revealed several instances of missing documentation for the following treatment orders. For the order, 'Tx Nurse: Right Heel. Clean with NS.for unstageable pressure ulcer injury,' documentation was missing on 1/21/26, 1/29/26, 2/5/26, 2/9/26, 2/14/26, 2/15/26, 2/16/26, 2/17/26, 2/18/26, and 2/19/26. For the order, 'Tx Nurse: Left Heel.every day shift,' documentation was missing on 1/29/26, 2/19/26, 2/6/26, 02/9/26, 02/14/26, 02/15/26, 02/16/26, 02/17/26, and 02/18/26. For the order, 'Tx Nurse: Right inner knee.Stage 2 pressure injury,' documentation was missing on 1/19/26. For the order, 'Tx Nurse: Sacrum.Stage 2 pressure injury,' documentation was missing on 1/25/26, 1/28/26, 2/6/26, 2/9/26, 2/13/26, and 2/19/26. For the order, 'Tx Nurse: Coccyx.Stage 2 pressure injury,' documentation was missing on 3/26/17, 3/22/17, 3/3/26, 3/7/26, 3/10/26, and 3/13/26. For the order, 'Tx Nurse: Right Foot.Stage 2 pressure injury,' documentation was missing on 3/3/26, 3/7/26, and 3/17/26. During an interview with Resident 26 on 05/20/26 at 1:27 p.m., Resident 26 confirmed that he had wounds that required treatment in the facility and stated that he expected the nurses to perform his wound treatments. During a concurrent interview and record review with the Treatment Nurse (TN) on 5/20/26 at 1:52 p.m., the TN stated that treatments performed on residents should be documented as soon as possible after completion. The TN confirmed that Resident 26 had an active wound care order and acknowledged that she failed to document the treatments on the following dates: March 3, 4, 10, 17, 11, and 25, and May 7 and 13. During a concurrent interview and record review with Licensed Nurse (LN) 2 on 5/21/26 at 8:34 a.m., LN 2 confirmed the findings and explained that documentation verified completion of a treatment order and that the absence of documentation indicated the treatment was not performed. LN 2 further stated that signing the resident's TAR represented best practice. During a concurrent interview and record review with the Regional Consultant (RC) on 5/20/26 at 2:16 p.m., the RC confirmed the findings and stated that staff should document services provided to residents immediately. This included medication administration and wound treatments. The RC expected staff to follow the facility's policy and added that documentation ensured care was provided according to each resident's specific needs. A review of the facility's policy and procedures (P&P) titled Skin Integrity Management, revised 6/27/24 indicated, Treatments administered will be documented in the resident medical records. A review of the facility's P&P titled Completion and Correction, effective date 3/25/26 indicated, The Facility will work to complete and correct medical records.to provide the highest quality and accuracy in documentation. 2. Resident 11 was admitted to the facility in late 2025 with diagnoses that included dementia and cognitive communication deficit. During a review of Resident 11's OSR, order date 12/1/25, the OSR indicated, Resident is incapable of making healthcare decisions.r/t dementia. During a review of Resident 11's AHCD, the AHCD was undated, unwitnessed, and signed by Resident 11. During a concurrent interview and record review on 5/20/26 at 11:07 with the Social Work Consultant (SWC), the SWC confirmed the document was undated and signed by Resident 11, who was incapable of making healthcare decisions. The SWC stated the AHCD was not an accurate or valid part of the medical record. The SWC stated it was important to have an accurate AHCD to ensure the resident's wishes were followed and to identify who was responsible for making healthcare decisions. During a concurrent interview and record review on 5/21/26 at 11:58 a.m. with the RC, the RC stated the AHCD for Resident 11 was invalid. The RC he expected the AHCD to be completed and accurate before it was placed into Resident 11's medical record. During a review of the facility P&P titled, MR04 Completion & Correction, dated 3/26, the P&P indicated, The Facility will work to complete and correct medical records in a standardized manner to provide the highest quality and accuracy in documentation. Purpose: To ensure that medical records are complete and accurate.

Based on interviews and record review, the facility failed to follow professional standards of quality for four of the 27 sampled residents (Resident 26, Resident 52, Resident 32 and Resident 6 when:1. Staff did not accurately enter a physician's order for tracheal/oral suctioning into Resident 26's medical record;2. Resident 52's oxygen tubing was not changed as ordered by the physician; and3. Staff did not change the enteral feeding tubing for Residents 6 and 32 as ordered by the physician.These failures placed Resident 6, Resident 26, Resident 32, and Resident 52 at risk for infection and placed Resident 26 at additional risk for respiratory complications. Findings: 1. Resident 26 was admitted to the facility on February of 2026 with a diagnoses which included Acute Hypoxic Respiratory Failure (a sudden, life-threatening condition where the lungs cannot adequately transfer oxygen into the bloodstream, Quadriplegia (a partial or total loss of sensory and motor function in all four limbs and the torso, typically caused by a spinal cord injury in the neck) and Pressure Ulcer of Sacral Region (a skin and tissue damage over the tailbone or lower spine). A review of Resident 26's Order Summary Report (OSR) indicated, Resident (Resident 26) is capable of making healthcare decisions. A review of Resident 26' Minimum Data Set (MDS, a standardized assessment tool used in nursing homes), dated 04/22/26, the MDS indicated that Resident 26 had a BIMS (Brief Interview for Mental Status) score of 10 out of 15 which indicated a moderate cognitive impairment. A review of Resident's 26 Care Plan (CP) indicated, Risk for Ineffective Airway Clearance.Resident Will Maintain Airway Patency.Ineffective Airway Clearance.Resident Will be Free of Respiratory Distress. A review of Resident 26's Order Summary Report (OSR) indicated the following physician's order: Assess resident for the need to suction trach [trachea]/oral secretions Q2H [every 2 hours] and PRN [as needed] and may suction the resident for excessive trach/oral secretions. The order had a start date of 4/21/26. In contrast, the facility's written order in OSR directed staff to perform the suctioning assessment every 4 hours, rather than every 2 hours as ordered by the physician. During a concurrent interview and record review with the Regional Consultant (RC) on 5/19/26 at 11:00 a.m., the RC confirmed the findings and stated that physician orders, including Nurse Practitioner orders, must be accurately entered into PointClickCare (PCC, electronic health record) by the licensed nurses (LN). The RC added that if an order was entered incorrectly, such as the suctioning order in this case, it may result in respiratory concerns for the residents. During a concurrent interview and record review with Licensed Nurse (LN) 2 on 5/21/26 at 8:34 a.m., LN 2 stated the facility verified the orders after the initial nurse entered them into PCC for confirmation. LN 2 emphasized that entering orders correctly and accurately in the health record was important for resident safety. LN 2 confirmed that the breathing orders indicated above were entered incorrectly. During a concurrent interview and record review with the Nurse Practitioner (NP) on 5/21/25 at 10:11 a.m., the NP confirmed the findings and stated that the breathing treatment orders were based on each resident's condition. She stated that nurses entered the orders and reviewed them. The NP further stated that no one could change the orders without her consent or the consent of a medical doctor. She stated that she had not been informed that some breathing treatment schedules were being entered differently from how they were ordered. She denied the existence of any facility policy requiring suctioning every 4 hours and stated that suctioning frequency depended on the resident's condition. A review of the facility policy and procedures (P&P) titled, Physician Orders, revised 11/16/22 indicated, The licensed nurse will confirm that the physician orders are clear, complete and accurate.verify all physicians orders are complete and accurate. A review of the facility P&P titled, Telephone Orders, revised 6/26/25 indicated, Only a licensed nurse (RN or LVN) may accept telephone order from a provider.The documentation must include.full order details. A request was made for the facility's P&P for breathing treatments, assessments and related cares. The facility was unable to provide the requested document. 2. Resident 52 was admitted to the facility in early 2026 with diagnoses that included acute respiratory failure, life threatening infection, and two progressive chronic lung diseases. During a review of Resident 52's OSR order date 3/24/26, the OSR indicated, Change 02 [oxygen] tubing [tube that connects the oxygen to the resident] every night shift every Sunday. During a review of Resident 52's Treatment Administration Record [TAR] dated 5/1/26–5/31/26, the TAR indicated the oxygen tubing was changed on 5/3/26, 5/10/26, and 5/17/26. During concurrent observation and interview on 5/18/26 at 10:01 a.m. with the Director of Respiratory Therapy (DRT), of Resident 52's oxygen tubing, the oxygen tubing had a paper tab with Resident 52's name and was dated 4/27/26. The DRT confirmed the tubing had been dated three weeks earlier. The DRT stated the policy was to change oxygen tubing once a week on Sunday night, noted tubing was changed to prevent infection, and stated she expected it to be changed per policy. During a concurrent interview and record review on 5/21/26 at 8:20 a.m. with the DRT Resident 52's TAR (Treatment Administration Record) and a photo of the oxygen tubing (dated 4/27/26), the DRT confirmed the order to change the oxygen tubing was marked as completed on 5/3/26, 5/10/26 and 5/17/26. The DRT confirmed staff had not changed the oxygen tubing according to physician orders. During a concurrent interview and record review on 5/21/26 at 11:58 a.m. with the RC, of Resident 52's TAR and a picture of the oxygen tubing dated 4/27/26, the RC confirmed physician orders were not followed. The RC stated he expected that when staff signed the TAR, it meant the task was completed. During a review of the P&P titled P NP94 Oxygen Therapy, dated 10/25, the P&P indicated, .Oxygen equipment shall be maintained as follows: The tubing and mask should be changed at least every 7 days and labeled with the date of change. 3. A review of Resident 6's admission record indicated that Resident 6 was admitted with diagnoses that included a gastrostomy (a feeding tube in the stomach) and dysphagia (difficulty swallowing). A review of Resident 6's Order OSR, dated 5/4/26, the OSR indicated, Enteral Feed Order every night shift. Change tubing syringe daily. During a concurrent observation and interview on 5/18/26 at 10:18 a.m. with LN 2, LN 2 confirmed that Resident 6's enteral tubing attached to the flush bag was labeled 5/17/26 0500. LN 2 stated that night shift should have changed the tubing during their shift as ordered to prevent infection. During a concurrent observation and interview on 5/19/26 at 1:30 p.m. with LN 5, LN 5 confirmed that Resident 6's enteral tubing was still labeled 5/17/26 0500. LN 5 stated she did not check the label before spiking a new enteral formula and should have changed the entire tubing system. A review of Resident 32's admission record indicated that Resident 32 was admitted with diagnoses that included gastrostomy and dysphagia. A review of Resident 32's OSR, dated 4/28/26, the OSR indicated, Enteral Feed Order every night shift. Change tubing syringe daily. During a concurrent observation and interview on 5/18/26 at 11:42 a.m. with LN 7, LN 7 confirmed that Resident 32's enteral tubing attached to the flush bag was labeled 5/17/26 0430 LN 7 stated night shift nurses should change the tubing as ordered. LN 7 also stated the tubing was only good for 24 hours and not changing it could cause gastrointestinal symptoms, such as diarrhea. During an interview on 5/21/26 at 8:35 a.m. with the Infection Prevention Nurse (IPN), the IPN stated that they expected night shift nurses to follow the doctor's orders for changing the enteral feeding tubing. The IPN also stated that if night shift did not change it, then day shift should complete it. A review of the facility's P&P titled Enteral Feedings, effective 9/7/23, the P&P indicated, Changed feeding bag and tubing every 24 hours.

Based on observation, interview, and record review, the facility failed to ensure medications were stored properly for a census of 87 when Resident 55's opened inhaler (used to administer medication by breathing in) stored in the medication cart 1 was not dated when opened,This failure placed Resident 55 at risk of receiving ineffective, expired or outdated medication.During an inspection of medication cart 1 on 5/18/26 at 11:20 a.m., a box of budesonide and formoterol (a multidose inhaler containing two medications used to treat breathing issues) 80/4.5 mcg (microgram, unit of measure) was observed to be stored without an open date label. During an interview on 5/18/26 at 11:23 a.m. with Licensed Nurse (LN) 1, LN 1 stated there was no open date on the label to determine the product's expiration date. Furthermore, LN 1 stated that expired medications may lose efficacy and may not be beneficial to the residents. During an interview on 5/19/26 at 9:48 a.m. with the facility's Regional Consultant (RC), the RC stated that the open date needed to be documented on the multidose inhaler to know the product's expiration date and to minimize the risk of using expired medications.During a review of the budesonide and formoterol inhalation manufacturer box and label, the box and label indicated, discard within 3 months after removing from foil pouch [opening].During a review of the facility's policy and procedure (P&P) titled, Medication Storage in the Facility, dated 4/2008, the P&P indicated, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations.outdated, contaminated, or deteriorated medications.are immediately removed from stock, disposed of according to procedures for medication disposal.

Based on observations, interviews, and record review, the facility failed to keep an effective infection prevention and control program for a census of 87 residents when: Licensed Nurse (LN) 5 entered a contact precaution room (Resident 6) without wearing the required personal protective equipment (PPE, clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments); and Respiratory Therapist (RT) did not change PPE after providing care between residents (Resident 6 and Resident 71).These failures increased the risk of infections and cross contamination for the residents. Findings:1. A review of Resident 6's medical record showed the resident was first admitted in October 2025. The record also showed that on 2/28/26, Resident 6 tested positive for Candida auris (C. auris, a fungus that spreads easily in healthcare settings and can cause outbreaks), and on 5/10/26, the resident was diagnosed with Pseudomonas aeruginosa (P. aeruginosa, a bacteria can cause infection in the blood, lungs, urinary tract, or other parts of the body after surgery).During an observation on 5/18/26 at 10:15 a.m., Resident 6's room is a three resident room and on the door has a contact precaution signage posted.During a concurrent observation and interview on 5/19/26 at 1:30 p.m., LN 5 entered Resident 6's room without wearing an isolation gown while touching the enteral flush bag. LN 5 stated that she should have put on the isolation gown before entering Resident 6's room.During an interview on 5/21/26 at 8:35 a.m., the Infection Prevention Nurse (IPN) stated that Resident 6 was on contact precautions and that staff were expected to wear the appropriate PPE before entering any contact precaution room. The IPN further stated this helped prevent staff from spreading organisms to other residents or staff, especially when many residents were immunocompromised.2. A review of Resident 71's medical record showed the Resident 71 was admitted in February 2025 with a diagnosis of ventilator dependence. On 2/8/26, the diagnosis of carrier of infectious disease was added, and on 5/10/26, the medical record indicated carrier of carbapenem resistant Acinetobacter baumannii (CRAB, is a species of bacteria that cause variety of different type of infections that don't respond to common antibiotics and some are resistant to all available antibiotics).A review of Resident 71's Order Summary Report (OSR) dated 5/7/26 indicated, Contact precaution d/t [due to] C. auris.During a concurrent observation and interview on 5/20/26 at 9:39 a.m., the RT put on PPE before entering a multi resident room. The RT provided care to Resident 6 but did not change PPE before checking Resident 71's ventilator (a machine that helps a person breathe). The RT then returned to Resident 6. The RT acknowledged they should have removed their PPE before touching Resident 71's ventilator to prevent cross contamination.During an interview on 5/21/26 at 8:35 a.m., the IPN stated that in a multi resident room, staff were expected to change PPE before caring for another resident, even if the residents were roommates. The IPN further stated that staff should never use the same gown and gloves for more than one resident because it could spread infections or microorganisms.A review of the Centers for Disease Control and Prevention (CDC) 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, updated September 2024, indicated, Healthcare personnel caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. Donning PPE upon room entry and discarding before exiting the patient's room is done to contain pathogens.

Based on observation, interview and record review, the facility failed to ensure equipment was maintained in working order when the arm rests of two wheelchairs (Resident 11 and Resident 35) out of 54 wheelchairs in use in the facility were in disrepair. This failure increased the potential for discomfort and skin tears to resident forearms. Resident 11 was admitted to the facility with diagnoses which included muscle weakness and difficulty in walking.During a review of Resident 11's Minimum Data Set (MDS, an assessment tool), dated 3/18/26, the MDS indicated Resident 11 was alert and oriented, able to make her needs known.During a review of Resident 11's care plan (CP) titled [Resident 11] has an ADL [Activities of Daily Living] self-care performance deficit r/t [related to].DIFFICULTY IN WALKING. revised 2/14/26, the CP indicated independent with.wheelchair mobility.During a concurrent observation of Resident 11's wheelchair armrests and interview with the Director of Staff Development (DSD) on 5/18/26 at 11:50 a.m. in the facility dining room, the DSD verified the observation and said, It should be reported to maintenance as soon as possible.During a concurrent observation and interview with 5/18/26 at 1:29 p.m. Maintenance standby (MS 2) verified the observation of the disrepair of Resident 11's wheelchair armrests and said, The staff should notify the maintenance department when armrests are in disrepair.During an interview on 5/18/26 at 1:37 p.m. with Certified Nurses Assistant (CNA) 1 , CNA 1 was asked about the armrests and said, I didn't notice [Resident 11's wheelchair] armrests were in disrepair.During an interview on 5/18/26 at 1:43 p.m. with CNA 2, CNA 2 was asked about Resident 11's wheelchair armrests and said, I did notice [Resident 11's wheelchair] armrests were worn but I didn't report it because I never saw maintenance.I didn't put it on the computer yet.Resident 35 was admitted to the facility in the winter of 2025 with diagnoses which included muscle weakness, low back pain and a history of falling.During a review of Resident 35's MDS, dated [DATE], the MDS indicated Resident 35 had moderate memory impairment.During a review of Resident 35's [PT] Physical Therapy Evaluation and Plan of Treatment [PT eval], dated 5/19/26-6/14/26 , the PT eval indicated Resident uses a wheelchair and/or scooter.YesDuring an observation on 5/18/26 at 9:49 a.m. of Resident 35 in his room, Resident 35's high back wheelchair had extensive damage to both armrests. Multiple pieces of the waterproof cover was worn and missing with the padding showing through.During a concurrent observation and interview on 5/18/26 at 10:13 a.m. with Licensed Nurse 4 in Resident 35's room, LN 4 verified both armrests of Resident 25's highback wheelchair were heavily damaged and in poor repair. LN 4 stated and that it probably couldn't be sanitized.During an interview on 5/20/26 at 9:25 a.m. with CNA 2, CNA 2 said, If the upholstery is broken and sticking up, the resident could get scratches on his outer arm.During an interview on 5/20/26 at 9:27 a.m. with LN 5, LN 5 was asked about damaged wheelchair armrests of Resident 11 and Resident 35 and said, .I never noticed the arm rests were worn out so I didn't report it to maintenance.During an interview with the Regional Consultant (RC) on 5/20/26 at 9:33 a.m., the RC was asked his expectations for the maintenance of equipment and said, All resident equipment should be maintained in working order, including the armrests of wheelchairs which should be clean and in good repair.During a review of the facility policy and procedure (P&P) titled Maintenance Service, revised 1/1/12, the P&P indicated The Maintenance Department is responsible for maintaining the.equipment in a safe and operable manner at all times.

Based on observation, interview and record review, the facility failed to maintain a functional, accessible communication system that allowed one of 27 sampled residents (Resident 28) to easily request staff assistance from his bedside when there was no call light or bell within reach.This failure increased the risk Resident 28 would not have to ability to call for help in an emergency or when needing assistance. Findings: Resident 28 was admitted to the facility in the summer of 2024 with diagnoses which included hemiplegia (paralysis) of the left side and hemiparesis (weakness) of the right side, respiratory failure, seizures, chronic pain, dysphagia (difficulty in swallowing).During a review of Resident 28's Minimum Data Set (MDS, an assessment tool), dated 3/26/26, the MDS indicated Resident 28 had moderate memory impairment and was dependent with most activities of daily living (ADLs).During a review of Resident 28's care plan (CP) titled, [Resident 28] is at risk for fall and self injury related to medical conditions affecting strength, balance & endurance.hemiplegia.h/o [history of] of fall.seizure disorder.impaired mobility.chronic pain., revised 10/8/24, the CP indicated Be sure The (sic) resident's call light is in reach.The resident needs prompt response to all requests for assistance.During an observation on 5/18/26 at 3:46 p.m. Resident 28 was observed laying on his back in bed with no call light or bell within reach.During a concurrent observation and interview on 5/18/26 at 3:49 p.m. with Licensed Nurse (LN) 6, LN 6 was asked to find Resident 28's call light and verified there was no call light in place. LN 6 stated, I didn't even notice he did not have a call light or bell.During a concurrent observation and interview on 5/18/26 at 3:52 p.m. with Certified Nurses Assistant (CNA) 3, CNA 3 was also asked to find Resident 8's call light or bell. CNA 3 verified Resident 28 had no call light or bell & the wires meant to be connected to the call light cord were covered and sticking out of the box. CNA 3 verified there was no alternative means to call staff for assistance such as a bell and said, Maintenance has been going around replacing call lights. Staff checks him regularly or he'll call you when you're walking by.During a concurrent observation and interview on 5/18/26 at 3:57 p.m. with Maintenance Standby (MS 2), MS 2 said [Maintenance Supervisor, MS 1] . was fixing it [3 days prior]. He must not have finished. MS 2 verified the call light box had covered wires visible with no call light cord attached and no bell observed at Resident 28's bedside.During an interview 5/19/26 at 7:09 a.m. with MS 1, MS 1 said, The nurses should have given them a bell.During an interview on 5/20/26 at 7:25 a.m. with Resident 28 laying in bed, Resident 28 indicated, if he couldn't I can't reach the call light, he'd call staff that were passing. I think I was without a call light for one week. It was a problem.During an interview in a facility communal room on 5/20/26 at 9:33 a.m. with the Regional Nursing Consultant (RC), RC was asked his expectations for having a call system in place for residents and said, The call light should be in reach at all times and if it's not working, the resident should be provided with an alternate means to call staff such as a bell.During a review of the facility policy and procedure (P&P), titled .Communication - Call System, dated 2022, the P&P indicated The Call (sic) alert device will be placed within the resident's reach.If the call alert system cannot be repaired immediately, an alternative call alert process will be put in place (i.e. tap bells.etc.).

Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 1) was free from abuse when Activity Assistant (AA) 1 aggressively yelled at and grabbed Resident 1's shoulder.This failure had the potential to cause psychosocial harm to Resident 1.Findings:A review of Resident 1's clinical record indicated that the resident was admitted to the facility in March 2026 with diagnoses including dementia with agitation (a condition in which a person has memory and thinking problems and also becomes easily upset, restless, angry, or difficult to calm down) and metabolic encephalopathy (a change in how the brain works that can cause confusion, memory problems, or difficulty thinking clearly).A review of Resident 1's Minimum Data Set (MDS-assessment tool) dated 3/11/26 showed a Brief Interview for Mental Status (BIMS, a cognitive screening tool) score of 0/15, which indicated severe problems with thinking and memory.During an interview on 4/27/26 at 10:39 a.m. with Interim Director of Nursing (IDON) 1, IDON 1 stated that Resident 1 had been discharged from the facility and was confused. IDON 1 stated that on 4/3/26, Resident 1 was in the Activity room and repeatedly stood up and touched other residents. AA 1, using a powerful voice, told Resident 1 to stop what he was doing while grabbing Resident 1's shoulder to assist him back into his wheelchair.During an interview on 4/27/26 at 12:46 p.m. with Resident 2, Resident 2 stated that Resident 1 kept standing up and holding onto the table, causing it to shake. When Resident 1 was about to grab another resident, AA 1 yelled at Resident 1 while grabbing Resident 1's shoulder and pulled him back into his wheelchair. During an interview on 4/27/26 at 12:53 p.m. with Resident 3, Resident 3 stated that Resident 1 was being difficult, would not sit down, and kept standing up and walking around the table. AA 1 asked Resident 1 several times to sit down, and when AA 1 became frustrated, AA 1 began yelling at Resident 1 and placed Resident 1 back into his wheelchair. During an interview on 4/27/26 at 1:50 p.m. with Business Office Manager (BOM) 1, BOM 1 stated that they heard shouting coming from the Activity room. BOM 1 recalled AA 1 yelling, Stop this, and Don't do that. When BOM 1 left the office to investigate, they witnessed AA 1 aggressively wheeling Resident 1 out of the Activity room, likely taking Resident 1 back to his room. BOM 1 stated that AA 1 appeared visibly frustrated.During a phone interview on 4/27/26 at 2:29 p.m. with BOM 2, BOM 2 stated that initially they did not know which resident AA 1 had been speaking to aggressively. However, when AA 1 wheeled the resident, they realized it was Resident 1. BOM 2 added that if staff members talked or yelled aggressively at a resident, it was considered a form of abuse.A review of the facility's operational manual titled Reporting Abuse, revised 1/08/2014, indicated, The Facility will ensure that the residents have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.

Based on observation, interview, and record review, the facility failed to follow proper infection control procedures for one of six sampled residents (Resident 1), when Certified Nurse Assistant (CNA) 1 and CNA 2 provided care to Resident 1 without wearing the appropriate personal protective equipment (PPE- worn to protect against hazards like infections).This failure decreased the facility's potential to prevent the spread of infection among vulnerable residents.Findings:A review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility in March 2024 with diagnoses including a gastrostomy (a surgical procedure into the stomach to insert a feeding tube for long-term nutrition.) and stenosis of the larynx (buildup of scar tissue in the throat).During an observation on 3/4/26 at 10:34 a.m. in Resident 1's room, a sign outside the door indicated Resident 1 was on enhanced barrier precautions (EBP- infection control measures in nursing homes requiring staff to wear gowns and gloves during high-contact care for residents at high risk of spreading multi-drug resistant organisms). Resident 1 was being transferred from her bed to the wheelchair by CNA1 and CNA 2. Both CNAs did not wear gowns during the transfer.During an interview on 3/4/26 at 10:38 a.m. with CNA 1 and CNA 2, both CNAs confirmed they were not wearing gowns during the transfer. CNA 1 stated she was aware that Resident 1 was on EBP precautions and should have worn a gown. CNA 2 stated he should have been wearing a gown because it could spread an infection to other residents.During an interview on 3/4/26 at 10:40 a.m. with Licensed Nurse (LN) 1, LN 1 confirmed Resident 1 was on EBP precautions and stated CNAs should have been wearing the proper PPE to minimize the risk of passing an infection to other residents.During an interview on 3/4/26 at 10:45 a.m. with the Infection Preventionist (IP), IP expected staff to wear the proper PPE and follow the precaution signs that were outside of the door. IP stated it was important to follow EBP precautions to reduce the risk of spreading an infection among residents.A review of the facility's policy and procedure (P&P) titled, Infection Control - Policies & Procedures, dated 1/12/12, indicated, The facility's infection control policies and procedures are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. P&P further indicated, Staff are trained on the infection control policies and procedures upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control.

Based on observation, interview, and record review, the facility failed to protect one of five sampled residents (Resident 1) from misappropriation of property and exploitation by a staff member that took money from Resident 1's personal bank accounts without consent. This failure resulted in financial loss totaling to $12,773 and emotional distress to Resident 1.Findings:During a review of Resident 1's admission records, the records indicated Resident 1 was admitted to the facility in February 2024 with diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity), and problems related to housing and economic circumstances. Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool) indicated Resident 1 had moderate cognitive impairment (noticeable memory problems).During a review of Resident 1's Theft/Loss Report, dated 9/9/25 and completed by Resident 1's cousin, the report indicated, Description of Missing Item(s): wallet w/ [with] ID [identification card], ATM card [automated teller machine card, a card that enables access to financial accounts through a bank machine].Facility Action Taken to Find Missing Item:.SS [Social Services] ask [Resident 1] where and when the last [sic] [Resident 1] saw her wallet. [Resident 1] mentioned the money.During a review of Resident 1's SBAR (situation, background, assessment, recommendation - a communication tool used by healthcare workers when there is a change of condition among the residents), dated 9/9/25, the SBAR indicated, .1. [Resident 1] alleged staff [MRC - Medical Records Coordinator] took her wallet. 2. [Resident 1] Alleged a staff [MRC] borrowed money from [Resident 1] and never paid [Resident 1] back.During a review of Resident 1's Interdisciplinary Team (IDT) Notes, dated 9/10/25, the notes indicated, .On 9/9/25 at about 2:30pm, [Resident 1's] cousin reported to SSD [Social Services Director] that allegedly one of the staff [MRC] borrowed $2000 from [Resident 1] and did not pay [Resident 1] back.During a review of Resident 1's Psychosocial Note, dated 9/10/25, the note indicated, .[Resident 1's cousin] went on to tell [SS] that he believed a staff member [MRC] borrowed $2000 and promised repayment.[SS] interview [sic] [Resident 1] to confirm the cousin report. [Resident 1] agreed with the statement [Resident 1's] cousin made. While talking about its [sic] [Resident 1] started to cry.During a review of Resident 1's Psychosocial Note, dated 9/11/25, the note indicated, .[SS] went with [Resident 1] to the Bank to get the bank statements. while at the bank [Resident 1] started to breakdown and started crying. [Resident 1] got the statement, and it shows that someone has been taking money from [Resident 1's] account for that past 6 months.During a review of Resident 1's Psychosocial Note, dated 9/12/25, the note indicated, .This morning, SS checked in with [Resident 1] to see how [Resident 1] was doing. [Resident 1] became emotional and began to cry.During a review of Resident 1's Physician Note, dated 9/12/25, the note indicated, .I [physician] was notified of an incident about employee [MRC] stealing patient money. [Resident 1] tells me [Resident 1] trusted the employee and believed [MRC] was helping [Resident 1]; however, [Resident 1] found out [MRC] was taking [Resident 1's] money without her permission.During a telephone interview on 9/12/25 at 12:27 p.m. with MRC, MRC stated, I gave [Resident 1] a black wallet because [Resident 1] was holding the cards on [Resident 1's] hands.I gave it around May for [Resident 1's] birthday. The MRC further stated, .[Resident 1] has it [wallet] and doesn't want to show it to the cousin because [cousin] will take it. The MRC stated that she never owed money to Resident 1, and Resident 1 did not give her access to Resident 1's wallet, online accounts, cards or PIN numbers (personal identification number, a secret numerical code used to verify identity for secure transactions and access to accounts).In contrast to MRC's statement that she did not have access to Resident 1's bank accounts, a review of Resident 1's savings account bank statement, dated 2/19/25 to 3/19/25, indicated MRC's name withdrawing money from Resident 1's account. The statement indicated the following withdrawal dates with MRC's name with the corresponding amount withdrawn, with a total of $8,530:- 2/20/25 - $200- 2/21/25 - $200- 2/21/25 - $500- 2/21/25 - $100- 2/21/25 - $300- 2/24/25 - $300- 2/24/25 - $400- 2/24/25 - $500- 2/24/25 - $500- 2/24/25 - $500- 2/24/25 - $1,000- 2/24/25 - $500- 2/24/25 - $500- 2/26/25 - $500- 2/26/25 - $500- 2/27/25 - $500- 3/3/25 - $300- 3/3/25 - $500- 3/3/25 - $200- 3/3/25 - $500- 3/7/25 - $30During a review of Resident 1's checking account bank statement, dated 2/25/25 to 3/25/25, the following withdrawals were identified indicating MRC's name with the corresponding amount withdrawn, with a total of $1,560:- 2/27/25 - $300- 3/3/25 - $500- 3/3/25 - $300- 3/3/25 - $300- 3/5/25 - $100- 3/6/25 - $60During a review of Resident 1's checking account bank statement, dated 3/26/25 to 4/24/25, the following withdrawals were identified indicating MRC's name with the corresponding amount withdrawn, with a total of $2,683:- 3/26/25 - $50- 3/26/25 - $10- 4/3/25 - $1,350- 4/3/25 - $600- 4/3/25 - $650- 4/7/25 - $23During a concurrent interview and bank statements record review on 9/12/25 at 1:12 p.m. with the SSD, the SSD stated that Resident 1's cousin reported on 9/9/25 that Resident 1's wallet was missing. The SSD stated that he spoke with Resident 1 and was told that MRC borrowed $2000 from Resident 1. The SSD stated he went with Resident 1 to the bank and requested bank statements. The SSD confirmed that based on the bank statements, money was being sent to MRC online and that MRC had access to Resident 1's online banking. When asked how the SSD confirmed that MRC was transferring money from Resident 1's account to MRC's own account, the SSD stated, .because [MRC] name was there [on the bank statements] . The SSD stated Resident 1 cried upon seeing the bank statements and that Resident 1 denied that Resident 1 was aware of the transactions.During a concurrent observation and interview on 9/12/25 at 2:39 p.m. with Resident 1 in her room, Resident 1 stated, Somebody told me that they've taken some money from my account.I thought that they are going to give it back but they didn't.It was a girl named [MRC's name].[MRC] worked here.I [Resident 1] got close to [MRC], [MRC] found my wallet in my purse, and [MRC] told me [MRC] had it and that [MRC] took some of the money and [MRC] took the card.[MRC] said she would pay me back but [MRC] didn't.It happened a few months ago.[MRC] said she needed it and that [MRC] would give it back. When asked how she felt about what happened, Resident 1 stated, Not good. Resident further stated, [MRC] told me [MRC] had some of the money and that [MRC] would return it.Spoke with the bank, they thought it was me [Resident 1] withdrawing the money.I was stupid. Resident 1 was observed crying and stated, I feel like I can't stop crying.During an interview on 9/12/25 at 2:53 p.m. with the Administrator (ADM), the ADM stated she saw the bank statements and confirmed that the staff member's name was in the transactions. The ADM stated, .they [staff] know that they cannot receive gifts from residents.it was happening since February. The ADM further stated Resident 1 was crying and Resident 1 cannot accept that Resident 1 trusted MRC and stated, .[Resident 1] trusted the individual [MRC].according to [Resident 1], [Resident 1] had a debit card and shared the pin to [MRC]. The ADM further stated, .we have zero tolerance that will involve residents in a disadvantaged position.expectation is to ensure residents are free from any type of abuse.During an interview on 9/12/25 at 3:22 p.m. with the Director of Nursing (DON), the DON stated she was told by Resident 1 that MRC borrowed money from Resident 1 by debit card a couple of months ago. The DON was told by Resident 1 that Resident 1 gave the card and pin number, and that Resident 1 made a mistake and did not know MRC was .going to take that much . The DON stated Resident 1 was consistent with her allegations. The DON further stated Resident 1 cried when Resident 1 saw the bank statements. The DON stated, This is very unfortunate.The expectation is to protect the residents from any type of abuse including financial abuse.During a review of the facility's policy and procedure (P&P) titled P-AN01 Abuse Prevention and Management, revised 5/30/24, the P&P indicated, .i. Exploitation is defined as taking advantage of a resident for personal gain, using manipulation, intimidation, threats, or coercion.k. Misappropriation of resident property and financial abuse are defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.During a review of the facility's P&P titled AN01 Abuse Prevention and Management, revised 5/30/25, the P&P indicated, The Facility does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation, and/or mistreatment.

Based on interview and record review, the facility failed to ensure one of six sampled residents (Resident 2) was free from abuse, when Resident 3 touched Resident 2's groin area. This failure decreased the facility's potential to maintain Resident 2's highest practicable physical, mental, and psychosocial well-being.Findings:A review of an admission record indicated Resident 2 was admitted to the facility in July 2024 with diagnoses including cognitive communication deficit (difficulty communicating) and dementia (a progressive decline in memory, thinking, reasoning, executive function). A review of Resident 2's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/21/25, indicated a Brief Interview of Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of five out of 15 with memory problems and severe cognitive impairment. A review of an admission record indicated Resident 3 was admitted to the facility in October 2024 with diagnoses including aphasia (a disorder that makes it difficult to speak) and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body).A review of Resident 3's MDS, dated [DATE], indicated a BIMS score of 14 out of 15 with intact cognition.During an interview on 9/2/25 at 2:20 p.m. with Activity Assistant (AA), AA stated while she was conducting facility activities in the activity room on 9/1/25 around 10 a.m., she observed Resident 3 touching with his left hand Resident 2's lap near the groin area. AA immediately gestured Resident 3 to stop and separated him from Resident 2. During an interview on 9/2/25 at 3:30 p.m. with the Administrator (ADM), ADM confirmed Resident 3 touched Resident 2's lap near the groin area and stated the incident was witnessed by AA. A review of the facility's policy titled, Abuse Prevention and Management, dated 6/12/24, indicated, The Facility does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation, and/or mistreatment.

Based on interview and record review, the facility failed to report immediately to the Department an alleged incident of sexual abuse for one of six sampled residents (Resident 2), when the Department received the facility's report of alleged sexual abuse after two hours of occurrence. This failure had the potential to cause a delayed response by enforcement agencies to ensure Resident 2's safety.Findings:A review of an admission record indicated Resident 2 was admitted to the facility in July 2024 with diagnoses including cognitive communication deficit (difficulty communicating) and dementia (a progressive decline in memory, thinking, reasoning, executive function). A review of an admission record indicated Resident 3 was admitted to the facility in October 2024 with diagnoses including aphasia (a disorder that makes it difficult to speak) and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body). During an interview on 9/2/25 at 2:20 p.m. with Activity Assistant (AA), AA stated while she was conducting facility activities in the activity room on 9/1/25 around 10 a.m., she observed Resident 3 touching with his left hand Resident 2's lap near the groin area. AA immediately gestured Resident 3 to stop and separated him from Resident 2. AA further stated she did not report the incident to proper agencies or notify her supervisor. A review of a document titled, Report of Suspected Dependent Adult/Elder Abuse (SOC 341), dated 9/2/25, indicated on 9/1/25 around 10 a.m. Resident 3 was seen sitting next to Resident 2 and moving his hand up and down touching Resident 2's private area. The report further indicated staff told Resident 3 to stop and escorted him out of the room. A review of a document titled, Fax Log, dated 9/2/25, indicated the facility faxed the SOC 341 to the Department on 9/2/25 at 9:59 a.m. During an interview on 9/2/25 at 3:30 p.m. with the Administrator (ADM), ADM stated the expectation was to report the alleged sexual abuse incident immediately within two hours. A review of the facility's policy titled, Abuse Prevention and Management, dated 6/12/24, indicated, The facility will report all allegations of abuse and criminal activity as required by law and regulations to the appropriate agencies . Reports of resident abuse, mistreatment, neglect, exploitation, injuries of an unknown source, and any suspicion of crimes are promptly reported and thoroughly investigated.

Based on observation, interview, and record review, the facility failed to follow infection control practices for one of six sampled residents (Resident 6), when the Housekeeper did not apply the required Personal Protective Equipment (PPE, gloves, gown, and/or goggles/face shield if risk of splash and spray) while cleaning Resident 6's room. This failure had the potential to spread infection among vulnerable residents.Findings: A review of an admission record indicated Resident 6 was admitted to the facility in June 2022 with a diagnosis of stage 4 pressure ulcer (a severe deep open wound that extends through the skin and into the muscle, bone or tendons) to the sacrum (triangular shaped bone located at the base of the spine). During an observation on 9/2/25 at 10:31 a.m. inside Resident 6's room, the Housekeeper was observed not wearing the proper PPE while cleaning the room. Housekeeper stated he was aware that Resident 6 was on Enhanced Barrier Precaution (EBP, infection control intervention to reduce transmission of resistant organisms). During a concurrent observation and interview on 9/2/25 at 10:40 a.m. with Licensed Nurse 1 (LN 1) inside Resident 6's room, LN 1 confirmed there was a sign outside Resident 6's room indicating he was placed on EBP and the Housekeeper was not wearing a gown while cleaning Resident 6's room. LN 1 stated staff should follow the EBP when providing care to Resident 6. During a concurrent interview and record review on 9/2/25 at 12:35 p.m. with the Director of Staff Development (DSD), Resident 6's Physician Order was reviewed. DSD confirmed Resident 6 was placed on EBP due to his pressure ulcer. DSD stated the Housekeeper should have followed infection prevention and control practices by donning gloves and gown while cleaning Resident 6's room to prevent the spread of infection and decrease putting other residents at risk. A review of the facility's policy titled, Enhanced Barrier Precautions, revised in October 2024, indicated, . Enhanced Barrier Precautions . will be used in the facility . EBP is employed for resident care . at risk of transmission . include residents with chronic wound . Use of EBP by Environmental Services . EVS personnel should use gown and gloves while cleaning and disinfecting the environment around residents on EBP . cleaning and disinfecting high touch surfaces such as bed rails . bed side tables or stands on or near the resident's space.

Based on observation, interview, and record review the facility failed to maintain resident's right to privacy and confidentiality of personal and medical records for a census of 79 when documents with resident's personal information were found outside the facility unsecured.This failure had the potential for unauthorized access to residents' personal and medical information.Findings:During an observation on 8/25/25 at 9:22 a.m. by the facility's back patio, boxes of documents with resident's personal information were found on top of two carts unattended and unsecured.During a concurrent observation and interview on 8/25/25 at 11:25 a.m. with the Director of Nursing (DON), DON confirmed the documents laying outside by the back patio belonged to residents. DON stated the documents should have been secured, shredded, and properly disposed of to protect the residents' right to privacy.A review of the facility's policy titled, Resident's Rights-Quality of Life, revised in March 2017, indicated, The facility shall maintain an environment in which confidential clinical information is protected .A review of the facility's policy titled, Notice of Privacy Practices, revised in December 2012, indicated, The Facility has adopted a Notice of Privacy Practices . the use . of Protected Health Information (PHI) at the Facility, and the resident's rights regarding PHI.

Based on interview and record review the facility failed to ensure the safety for two residents (Resident 1 and Resident 2) after Licensed Nurse 1 witnessed Resident 1 slap Resident 2 on the face and did not separate Resident 1 and Resident 2 into different rooms. This failure resulted in Resident 1 obtaining a 4.5 centimeter (cm, a unit of measure) by 3.5 cm bruise along the right cheek and jaw due to continued exposure to the perpetrator. Findings: A review of Resident 1's admission record indicated admission to the facility on [DATE], with diagnoses which included neurocognitive disorder with Lewy Bodies (a type of progressive dementia that leads to a decline in thinking, reasoning, and independent function) and dementia with psychotic disturbance (the mental state where someone is not sure what is real or not). A review of a Minimum Data Set (MDS, an assessment tool), dated 3/4/24, indicated Resident 1 had a severe memory problem. A review of Resident 2's admission record indicated admission to the facility on [DATE], with diagnoses which included dementia with other behavioral disturbance (such as agitation, depression, and psychosis or loss of contact with reality). A review of an MDS, dated [DATE], indicated Resident 2 had a moderate memory problem. A review of Resident 1's progress note written by LN 1, dated 5/2/24 at 5:41 p.m. indicated, .[Resident 1] got up, entered roommate bed .and slapped [Resident 2] in the face .This patient's behavior escalates during evenings and nighttime. [Resident 1] has become more aggressive and combative . A review of Resident 2's progress note written by LN 1, dated 5/2/24 at 7:13 p.m. indicated, [Resident 2] had confrontation with roommate who suffers from dementia. Staff intervened and redirected both residents to their beds. Advised patient not to touch other residents. WCTM [Will continue to monitor]. A review of Resident 1's progress note written by LN 2, dated 5/3/24 at 7:01 a.m., indicated, During my morning rounds, I noticed a blue-purplish bruise on the right jawline, upper lip and lower lip. NP [Nurse Practitioner] was notified of the bruises found. Cold compress and x-ray order [sic]. Orders noted and carried out. A review of Resident 1's progress note written by LN 3, dated 5/3/24 at 12:27 p.m., indicated, At 11:00 am on 5/3/24. Head to toe skin assessment completed by two LNs and 2 CNAs [Certified Nursing Assistant] assisted with repositioning resident .informed [Resident 1] that will conduct skin assessment. Resident lying in bed alert and awake with no over s/sx [signs and symptoms] of pain, no episode of restlessness or aggressive behavior, she is calm, pleasant and cooperative. Right lower jaw reddish skin discoloration (4.5 cm [centimeters, a unit of measure] x 3.5 cm) right side of face down to right jaw greenish to reddish discoloration 4.5 x 4.0 cm redness to right jaw measures 2.0 x 3.0 cm left upper lip scratched with dry blood right lower lip reddish discoloration 92.0 x 1.0) right breast dark discoloration 91.0 x 1.0 cm) .left cheek scratch (2.0 x 0.5 cm) . A review of Resident 1's social service progress note, dated 5/3/24 at 12:52 p.m. indicated, [Resident 1] to be moved .as a plan of care after alleged Resident to Resident altercation filed on 5/3/24 .Will monitor for 72 hours post room change. A review of Resident 1's NP progress note, dated 5/3/24 at 1:26 p.m. indicated, .According to nursing staff, patient had altercation with other resident .I noted large bruise on the right jaw, bruises on the upper and lower lip, and bruise on inner thigh. There is no documentation how patient got those bruises .Changes: stat x-ray of jaw; monitor the bruises for worsening; patient is moved, monitor closely. A review of Resident 1's Interdisciplinary Team (IDT, a team of healthcare workers from different aspects of resident care) progress note, dated 5/3/24 at 6:36 p.m. indicated, [Resident] to [Resident] Altercation .Date of Incident: 5/2/24 .Allegation was witnessed by [LN 1], resident 1 slapping resident 2 on the face .According to [LN 1] documentation, resident 1 got up and went to resident 2's area and slapped her on the face. [LN 1] approached the event by getting in the middle to separate both and redirect. Based on interview of the [LN 1], she stated she received the last remaining punches on her abdomen. [LN 1] was successful in redirecting resident 1 and resident 2 to their appropriate beds. In a telephone interview on 5/24/24 at 9:55 a.m., the NP stated she was notified of Resident 1 and Resident 2's altercation the morning of 5/3/24. The NP stated the LN 1 was expected to move Resident 1 to a different room to ensure another altercation did not occur. In a telephone interview on 5/22/24 at 4:53 p.m., the Nurse Supervisor (NS) confirmed she worked the evening (PM) shift on 5/2/24 was not made aware of the altercation between Resident 1 and Resident 2 by LN 1. The NS stated nurses were expected to notify nurse supervisors of abuse so staff could find a room to move one of the residents to ensure their safety. The NS stated, I would have made sure they were both separated, and both monitored. In a telephone interview on 5/22/24 at 5:20 p.m., the LN 2 stated LN 1 had mentioned an incident between Resident 1 and Resident 2 had occurred on the evening of 5/2/24 but had not been specific as to what happened. The LN 2 stated when she rounded on Resident 1 and Resident 2, they were in the same room. The LN 2 stated she was shocked to see bruises on Resident 1's face. The LN 2 referred to Resident 1's chart, there was no documentation of what occurred to explain the bruises on Resident 1's face. The LN 2 also stated both Resident 1 and Resident 2 were confused but capable of getting out of bed by themselves and added both were not weak and could potentially cause damage to each other. In a telephone interview on 5/24/24 at 10:16 a.m., the Certified Nurse Assistant 1 (CNA 1) confirmed she was assigned to care for Resident 1. The CNA 1 denied moving either Resident 1 or Resident 2 to a different room during her shift on 5/2/24. The CNA 2 stated if a licensed nurse notified her of an altercation between resident roommates, the protocol was for the residents to be separated into different rooms to make sure they were safe while the nurses conduct the investigation. In a telephone interview on 5/24/24 at 10:27 a.m., the LN 1 stated on 5/2/24 during the PM shift she heard screaming. The LN 1 stated she and CNA 2 went to Resident 1's room and when they arrived Resident 1 was naked and hitting Resident 2. The LN 1 reported Resident 2 yelled, That woman is trying to hit me as she was pointing to Resident 1. The LN 1 also reported she had been kicked in the back by Resident 1 and stated CNA 2 was a witness to it. In a telephone interview on 5/24/24 at 11:04 a.m., the CNA 2 stated during his shift on 5/2/24. The CNA 2 stated he did not see any hitting or kicking from Resident 1 or Resident 2 that night. The CNA 2 verified Resident 1 nor Resident 2 were moved to another room during his shift on 5/2/24. In an interview on 6/3/24 at 2:51 p.m., the DON confirmed she was not informed by LN 1 she witnessed Resident 1 slap Resident 2 in the face. The DON stated had she been notified; she would have instructed LN 1 to collaborate with the NS to move either Resident 1 or Resident 2 to a different room. The DON stated if she had been unavailable, the LN 1 could have also notified the admissions department, the NS, and the Infection Preventionist (IP). The DON stated she expected the licensed nurse to separate residents to ensure safety and to monitor all residents involved in the abuse. The DON verified the LN 1 did not follow the facility ' s policy and procedure regarding abuse. A review of the facility's policy and procedure titled Reporting Abuse revised 1/8/14, indicated, .The facility will ensure that the resident has the right to be free from verbal, sexual, physical, and mental abuse .Facility Staff as Mandated Reporters .If the allegation [of abuse] is regarding a resident-resident altercation, the residents will be separated immediately, pending the investigation .Responding to an Allegation . If the allegation [of abuse] is regarding a resident-resident altercation, the residents will be separated immediately, pending the investigation.

Based on interview and record review, the facility failed to ensure necessary services were provided to avoid physical harm for one resident (Resident 1), for a census of 84, when: 1. Resident 1 had no care plan and monitoring for an identified behavior of biting his fingers and treatments for the bite wounds were not consistently provided as ordered by the physician; 2. Resident 1 did not receive treatments or interventions to prevent skin breakdown and to decrease the likelihood of developing pressure wounds (damage to the skin and underlying tissue caused by reduced blood flow to the area due to constant pressure on the area; also known as pressure ulcers); and 3. Resident 1 was not monitored while on antibiotic (anti-infectives, used to treat infections) and the primary physician was not notified of the worsening bite wounds on bilateral [both sides] hands/fingers. These failures resulted in Resident 1's admission to the acute care hospital for infected wounds on bilateral hands and pressure wounds on his buttocks. Findings: A review of the Admission Record indicated Resident 1 was initially admitted [DATE] and had a recent admission middle of December 2022, with diagnoses including acute and chronic respiratory failure (develops when the lungs cannot get enough oxygen into the blood) and acute and chronic congestive heart failure (occurs when the heart muscle does not pump blood efficiently as it should). A review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 12/21/22 indicated the following: -Resident 1 had short- and long-term memory problems; -Resident 1 was totally dependent on staff for Activities of Daily Living (ADL- self-care activities); -Resident 1 was frequently incontinent of bowel; and -Resident 1 was at risk of developing pressure wounds, he had no pressure wound on admission, and he had no other open areas on the skin on admission. A review of Resident 1's Braden Scale for Predicting Pressure Ulcer Risk dated 12/15/22 with a score of 14 indicating Resident 1 had moderate risk of developing pressure ulcer. A review of Resident 1's progress note dated 12/15/22 at 5:30 p.m., written by Licensed Nurse 1 (LN 1) indicated, admitted [Resident 1] .needs total care with adls [sic] .skin assessment done no wounds . A review of Resident 1's progress note dated 12/15/22 at 21:00 9 p.m., indicated, [Resident 1] . Combative to staff during assessment .otherwise skin intact .Spoke with wife .Wife aware of [Resident 1's] non-compliance behavior, also verbalized [Resident 1] with history of biting finger nails off, no episode noted at the moment . A review of Resident 1's progress note dated 12/17/22 at 7:24 p.m. indicated, .wife at bedside until 2100 [9 p.m.]. Checked and monitored resident with attempts to bite hand/fingers, No attempts on this shift noted. A review of Resident 1's Change in Condition Evaluation dated 12/18/22 (3rd day of admission) at 7:10 p.m., indicated, bite wound on back of right hand, index finger and thumb knuckle. Resident 1's primary physician was notified and there was a recommendation for wound care. A review of Resident 1's Treatment Administration Record (TAR) for December 2022 did not include wound care orders for the right index finger and thumb knuckle wound on 12/18/22. A review of Resident 1's progress note dated 12/18/22 at 7:35 p.m., indicated, [Resident 1] on COC [change of condition] for bite wound at his right index finger, Called on-call [Nurse Practitioner - NP]. Per NP to do wound care. A review of Resident 1's physician's orders indicated, there was no treatment order obtained on 12/18/22 for the bite wound on the right hand specifically on the right index finger and thumb knuckle. A review of Resident 1's physician order dated 12/21/22 (three days later) indicated, Saline Solution [solution with the same salt content as body tissues] .Apply to 2nd digit [index finger] of left hand topically [on the skin] every day shift for Wound Management [sic] .pat dry, apply dry dressing. A review of Resident 1's indicated there was no documented evidence of the date and time the wound on the 2nd digit of the left hand was identified. A review of another physician order dated 12/21/22 for Resident 1 indicated, Monitor 2nd digit finger for sign of [sic] symptoms of infection every shift any noted notify md. [medical doctor] every day and night shift . A review of Resident 1's Treatment Administration Record (TAR) for December 2022 for monitoring of second digit for signs & symptoms of infection indicated blank spaces/no signatures on 12/22, 12/23, 12/25, 12/31 on night shift and blank spaces on 12/27, 12/29, and 12/30 on day shift for the above treatment. A review of Resident 1's COMS - Skin Only Evaluation dated 12/22/22, indicated, . [Resident 1] received in bed .Allowed treatment nurse to assess injuries to bilateral 2nd finger. Noted traumatic wound on admission .Resident has poor impulse control attempt to get to finger to bite . A review of Resident 1's physician order dated 12/22/22, indicated, Betadine Solution [an iodine-based germ-killing solution] .apply to bilateral 2nd digit topically every day shift for Wound Management [sic] .cover with dry dressing. A review of Resident 1's TAR for December 2022 for the Betadine solution to bilateral 2nd digit indicated a blank space for 12/27 and 12/28/22. A review of Resident 1's physician order dated 12/23/22, indicated, OK FOR HAND MITTEN ON BOTH HAND X 14 DAYS FOR WOUND TO HEAL AND KEEP [Resident 1] FROM BITING SELF (FINGERS/HANDS). A review of Resident 1's progress note dated 12/25/22 at 7:54 a.m. indicated, [Resident 1] awake at 0300 [3 a.m.] .At 0445 [4:45 a.m.], [Respiratory Therapist] reported to this nurse that resident bit his right index finger. Old wound opened and was bleeding .Called and spoke to on-call [Nurse Practitioner] . [Resident 1] has order for mitten on both hand x 14 days for wound healing .Left a note for mittens to be ordered and consent to be signed by wife . A review of Resident 1's consents indicated there was no documented evidence an informed consent for hand mitten was obtained from Resident 1's wife from 12/23/22 to 1/3/23. A review of Resident 1's Medication Administration Record (MAR) from December 1-31, 2022, indicated, X for the order of hand mitten on both hands and a D/C [discontinue date] of 1/4/23. A review of Resident 1's TAR from December 2022 did not include an order for hand mitten. A review of Resident 1's care plan initiated 12/25/22 indicated, wound management on 2nd digit with interventions to monitor ulcer for signs of progression or declination, to notify provider if no signs of improvement on current wound regimen and to provide wound care per treatment order. A review of Resident 1's Shower Skin Inspection dated 12/26/22, indicated, reddened area on the buttocks. The document was signed by a CNA [Certified Nursing Assistant] and a licensed nurse. Review of Resident 1's medical record indicated there was no documented evidence of the primary physician being notified of Resident 1's reddened area on the buttocks and there was no treatment order obtained on 12/26/22. A review of Resident 1's progress note dated 12/27/22 at 18:03 [6:03 p.m.] indicated, . [Resident 1] had an episode of biting on fingers causing them to bleed. Wrapped fingers with kerlix [gauze wrap] and applied arm braces [used to prevent bending of the elbow so that fingers cannot reach the mouth] . A review of Resident 1's physician order dated 12/28/22, indicated, Collagen Hydrolysate Powder [collagen, or protein broken down into smaller units to assist in wound healing] .Apply to RT [right] Doral [sic, dorsal; upper/back side] foot topically every day shift for Truamatic [sic] wound left hand dorsal 2nd finger . The order was written for the right dorsal foot instead of the right hand [index finger]. A review of Resident 1's TAR for December 2022 for the Collagen powder treatment had blank spaces or no signatures on 12/29 and 12/30/22. The treatment was initiated on 12/31/22, three days after being ordered. A review of Resident 1's COMS - Skin Only Evaluation dated 12/28/22 indicated, .Wound rounds done .by wound MD . left hand distal [end section farthest from the hand] 2nd finger self inflicted trauma- 80% slough [dead tissue separating from living tissue] .Right hand dorsal 2nd finger, increased in size .mod [moderate] purulent [containing pus] drainage . A review of Resident 1's medical record indicated there was no documented evidence of Resident 1's primary physician being notified of the clinical changes on bilateral 2nd finger wounds. A review of Resident 1's physician order dated 12/28/22, indicated, Place bilateral weighted arm sleeves [used to help prevent inserting fingers into the mouth] daily, monitor every shift, if dislodged replace, every day and night shift for Management of bilateral 2nd finger injury. A review of Resident 1's TAR for December 2022 had blank spaces or no signatures on 12/29 and 12/30/22, on day shift for the bilateral weighted arm sleeves treatment. Resident 1's TAR for January 2023 had no signatures on 1/6, 1/8, 1/9 for day shift and no signature on 1/7 for night shift for the bilateral weighted arm sleeves. A review of Resident 1's Surgical Consult by the Wound Medical Doctor (WMD) dated 12/28/22, indicated the reason for the visit was to evaluate the wounds and Resident 1 continued to have the self-injurious habit of chewing on his fingers. The right dorsal 2nd finger had purulent drainage, necrotic tissue (dead tissue), 40 % slough, pre-debridement (before removing the dead tissue) measurement of 6 cm (centimeters, unit of measurement) x 4 cm x UTD (undetermined) with undermining (significant erosion occurs underneath resulting in more extensive damage beneath the skin surface) of 1.7 cm at 5 O'clock. The left-hand distal 2nd finger had no signs of infection, 80% slough, with pre-debridement (before removal of dead or injured tissue) measurement of 5 cm x 3.5 cm x UTD (unable to determine). The assessment and plan indicated protective devices were needed to prevent worsening injury or possible amputation. A review of Resident 1's medical record indicated there was no documented evidence of the primary physician being notified of Resident 1's wound on the right-hand dorsal 2nd finger having purulent drainage and necrotic tissue as documented by the WMD on 12/28/22. A review of Resident 1's Surgical Consult from the WMD dated 1/5/23 indicated the right hand dorsal second finger had signs of infection: purulent drainage, erythema (redness), malodorous (foul smelling) tissue, 100 % slough. The left-hand distal 2nd finger had no signs of infection with 90% slough. A review of Resident 1's Change in Condition Evaluation dated 1/5/23 indicated purulent drainage on right 2nd digit and the primary physician was notified on 1/5/23 at 7:34 p.m. There was no recommendation written. A review of Resident 1's physician order on 1/5/23 at 7:48 p.m., obtained by phone indicated, Doxycycline Monohydrate Suspension Reconstituted [antibiotic] 25mg [milligram, unit of measurement]/5ml [milliliters, unit of measurement]. Give 20 ml . two times a day for Right 2nd digit purulent drainage. A review of Resident 1's MAR for January 2023 indicated the antibiotic order was started on 1/6/23 at 8 a.m., over 12 hours from the time the antibiotic was ordered. A review of Resident 1's medical record indicated there was no documented evidence of Resident 1's primary physician being notified of the delay in the administration of the antibiotic. A review of Resident 1's physician order dated 1/11/23, indicated, Triad Hydrophilic Dress Paste [Wound Dressings] Apply to bilateral buttock topically every day shift for Wound Management [sic] . The treatment order was obtained 15 days after the reddened bottom was reported on 12/26/22. There was no assessment of the bilateral buttocks in the clinical records. A review of Resident 1's medical record indicated there was no documented evidence of monitoring of Resident 1's response to the antibiotic treatment from 1/6/23 to 1/10/23. A review of Resident 1's Change in Condition Evaluation dated 1/11/23 at 11:27 a.m. indicated, .Wound md [sic, physician] present on site Noted [sic] swelling to right hand related to wound infection to right 2nd digit, currentlytaking [sic] atb [antibiotic] .not effective .NP notified of wound, advise to send out [to hospital]. In a concurrent interview and review of Resident 1's medical record on 1/18/23 starting at 1:12 p.m., the Director of Nursing (DON) stated Resident 1's bite marks were present since admission on 12/15/22 and Resident 1 had no pressure wounds. The DON further stated Resident 1 was monitored for biting and they tried the puffy things for the arms. The DON confirmed Resident 1 had episodes of biting from the previous admission. The DON stated Resident 1 was sent out to the acute care hospital on 9/17/22 for possible aspiration (the accidental breathing in of food or fluid into the lungs) due to chewing on his fingers and on 9/19/22, Resident 1 was readmitted to the facility from his acute hospital stay and Resident 1 was observed to bite on his hands/fingers, lip and this created a wound to his right index finger. During the concurrent interview and review of Resident 1's medical record on 1/18/23 starting at 1:12 p.m., the DON was not able to provide documented evidence of Resident 1 being monitored for the biting of hands/fingers since 12/15/22. In a telephone interview on 1/24/23 at 3:04 p.m., the DON stated a new antibiotic order should be given within four hours. The DON further stated if the antibiotic was not available in the Emergency kit [E-kit - emergency medication supply], the facility should notify the physician for the antibiotic to be given the following day. A concurrent telephone interview and review of Resident 1's medical record was conducted on 1/25/23 starting at 3 p.m. with the LN 2. The LN 2 stated she was the treatment nurse from [DATE] to [DATE]. The LN 2 stated she was made aware from other licensed nurses of Resident 1's behavior of biting his fingers from his previous admission. The LN 2 confirmed Resident 1 had no behavior monitoring for biting of fingers. The LN 2 stated she observed Resident 1 with the arm weights and the LN 2 had no observation of Resident 1's use of hand mittens. The LN 2 confirmed she wrote Resident 1's COMS - Skin Evaluation Only dated 12/22/22. The LN 2 was unable to explain why she had the documentation on 12/22/22 when she was referring to the traumatic wounds on admission. The LN 2 stated she was not aware a new antibiotic order should be given within four hours from the time it was ordered. The LN 2 confirmed she received Resident 1's treatment order for his bilateral buttocks on 1/11/23 and the LN 2 further confirmed there was no assessment of Resident 1's bilateral buttocks on 1/11/23. The LN 2 stated if there was no signature on the treatment as scheduled, it means the treatment was not done on that day. In a concurrent telephone interview and review of Resident 1's medical record on 2/8/24 at 6:58 p.m., the LN 1 confirmed he did a whole body check on Resident 1 on 12/15/22 (day of admission) and there were no wounds noted. In a telephone interview on 2/16/23 at 10:38 a.m., the Wound Medical Doctor (WMD) stated she saw Resident 1 on 12/28/22 due to wounds on bilateral fingers. The WMD made a follow-up visit on 1/5/23 and she recommended the ATB. The WMD clarified she would normally recommend antibiotic, but she prefers the antibiotic to be ordered by the primary physician. The WMD further stated she saw Resident 1 on 1/11/23 and she noted a significant worsening of the wounds from her previous visit on 1/5/23 and the antibiotic was not effective. The WMD stated she does not communicate directly to Resident 1's primary physician. The WMD further stated, the facility staff should communicate the progress of Resident 1's wounds to his primary physician. In a telephone interview on 12/16/23 at 12:59 p.m., the primary care physician (PCP) stated Resident 1 was seen by the WMD and he did not communicate directly with the WMD. The PCP further stated if there was a problem with Resident 1's wounds, the facility staff needs to call the WMD unless a licensed nurse (LN) would request the PCP to assess the wounds. The PCP cannot recall an instance wherein a LN approached him to check Resident 1's wounds while he was in the facility. The PCP confirmed he did not assess Resident 1's wounds since the WMD was involved and the PCP did not know what happened with Resident 1's wounds. The PCP stated if the facility staff contacted him or his Nurse Practitioner (NP), the facility should have documentation in Resident 1's clinical record. The PCP stated his expectation was for the new antibiotic order to be given after a few hours and for the facility staff to notify the physician when the medication was not given in the required time frame. A concurrent interview and record review with the DON was conducted on 2/17/23 starting at 10:53 a.m. The DON confirmed there was conflicting information regarding whether Resident 1 was admitted with the bite wounds or not. The DON further confirmed Resident 1's discharge summary from the acute care hospital on 12/15/22 did not indicate wounds on bilateral index fingers. The DON stated the primary physician should have been notified when Resident 1 had moderate purulent drainage on the right dorsal 2nd finger. The DON confirmed the blank spaces in Resident 1's MAR and TAR for December 2022 and January 2023. The DON stated for the blank spaces, the licensed staff either forgot to document or did not provide the care or treatment as ordered. The DON further stated the facility staff should have monitored Resident 1's biting behavior and the interdisciplinary team (IDT) should have talked about possible interventions and conducted an evaluation when the interventions were not effective. Upon request by the department, the facility management was unable to provide documented evidence of wound care training for LN 2. In a telephone interview on 2/21/23 at 8:33 a.m., the Pharmacy Consultant (PC) stated a new antibiotic order should be administered within 4 hours to prevent further infection or sepsis. The PC further stated Resident 1's physician should have been notified the antibiotic in reconstituted form was not available in the E-kit and the physician could have changed the antibiotic order to a tablet form or a different antibiotic available in the E-kit. A review of Resident 1's History and Physical from the acute care hospital admitted d 1/11/23 indicated, [Resident 1] .brought in by ambulance for wounds on the bilateral hands .The wounds involve some portion of bilateral palm with soft tissue purulent drainage as well as Digits (esp. index fingers). Wounds look at least a few months old .He does not follow any commands and not able to move on his own. He was also found to have some pressure wounds on his buttocks .Xray of Right hand- Marked soft tissue loss/ulceration [break in the skin] of the second finger at the level of the remnant [remaining] middle phalanx [finger bone], with possible exposure of the bone .X-ray of Left hand- Amputation/partial absence of the distal aspect of the index finger distal phalanx. Possible osteomyelitis [swelling caused by infection of the bone] of what remains of this phalanx. A review of Resident 1's Orthopedic (bone specialist) Consult from the acute care hospital dated 1/12/23 indicated, .Assessment: . [Resident 1] presents with subacute (condition was new, not chronic) bilateral index finger partial amputations with open wounds .Plan: Recommend local wound care and IV [intravenous, administered into a vein] antibiotics . A review of Resident 1's Wound Care Consult dated 1/12/23 indicated the following: -Stage 3 pressure injury [full thickness tissue loss] to bilateral coccyx [tail bone] and right gluteal [muscles that make up the buttock area] was present on admission [to the hospital]; -Stage 2 pressure injury [partial thickness loss of tissue] to right gluteal was present on admission; -Full thickness wound to right second finger and palm of right hand; -Full thickness wound to left second finger; -Pressure injury on coccyx extends to right gluteal. Site measures 7cm x 6.5 cm x 0.3 cm (centimeters, unit of measurement) in total. There are also scattered ulcerations [break in the skin] to peri-anal [area around the anus] skin measuring 3cm x 3cm x 0.3cm. Wound beds are red and appear to be full thickness. Edges are irregular. Peri [groin]-wound with hyperpigmentation [skin is darker than surrounding skin] and epidermal [outer layer of skin] peeling. -There is a deflated blister to right gluteal measuring 1.5cm x 2cm. Base is pink and clean .Presents as a stage 2 pressure injury. -Right second finger with full thickness wound and partial amputation of middle phalanx .Base of wound pink and red. Distal wound to second finger measures 1.5cm x 2.8 x 1.5 cm. Skin flap at top of wound. Wound probes to bone. Peri-wound with erythema [redness] and edema [swelling]. -Palmar [palm side] aspect of right second finger with round, full thickness ulceration. Measures 1cm x 0.5cm x 0.7cm . Distal aspect at 6 O'clock probes through and communicates to wound on palm of hand .There is milky serosanguineous [serum (liquid protein rich fluid that, with blood cells, makes up the blood) with small amounts of blood] drainage at site. Edema and erythema to peri-wound. -Palm of right hand with small full thickness wound measuring 0.3cm x 0.3cm x 0.5cm with circumferential [encircles] undermining [erosion underneath the outwardly visible wound margins]. Superior [upper] aspect of wound at 12 O'clock probes through to wound on right second finger .Large amount of purulent drainage with palpation [touching/feeling]. Hand with erythema, edema, and maceration [skin damage caused by moisture]. -Left second finger with full thickness wound. Partial amputation of distal phalanx .Slight hypergranulation [tissue overgrowth] to wound bed. Peri-wound with edema and erythema. No active drainage or drainage with palpation. A review of Resident 1's Discharge Summary from the acute care hospital dated 2/6/23 indicated Resident 1 had sepsis [infection of the blood] as the principal problem. Further review indicated Resident 1 was diagnosed with bilateral index finger osteomyelitis (swelling caused by infection of the bone) and Staphylococcus epidermidis (normal skin bacteria) bacteremia (sepsis). The infectious disease physician was consulted and recommended amputation. Resident 1's family refused thus he was started on IV (intravenous) antibiotics until 2/24/23. A PICC (peripherally inserted central catheter, a flexible tube inserted into a vein in the upper arm threaded into a large vein above the right side of the heart) line was ordered for long term IV antibiotics. A review of the facility's policy and procedure titled, Skin and Wound Management, revised 1/1/2012, indicated, Facility Staff will take appropriate measures to prevent and reduce the likelihood that residents will develop pressure ulcers and other skin conditions. All Nursing Staff is responsible for the prompt reporting of any skin related conditions to the Licensed Nurse. The Licensed Nurse will notify the Attending Physician promptly at the first occurrence of a pressure ulcer or other skin related problems .CNAs will complete body checks on resident's shower days and report unusual findings to the Licensed Nurse .Treatments for skin problems, wounds, and non-pressure ulcers will be assessed and documented by a Licensed Nurse . A Licensed Nurse will report any changes in resident's skin condition to the attending physician, Director of Nursing Services .Interdisciplinary Team .Skin Committee .The Director of Staff Development will provide in-service training to all staff on skin conditions as required .Licensed Nurses will be familiar with the fundamentals of wound care .The facility may utilize the Skin Monitor Tool .to audit and assess the success of the Skin and Wound Management Program .Licensed nurses will document effectiveness of current treatment of wounds and non-pressure ulcers in the resident's medical record on a weekly basis. A review of the facility's policy and procedure titled, Showering and Bathing revised 1/1/2012, indicated, .Report any broken skin, cut, skin discoloration or reddened areas to the Charge Nurse .Update the resident's Care Plan as needed. A review of the facility's policy and procedure titled, Behavior Management revised 1/16/20, indicated, .When a resident exhibits mood/behavioral symptoms, the IDT will assess the resident's mood and behavior status and document in the medical record .The IDT will convene to discuss care plan interventions and document the IDT recommendations and recommendations in the medical record .The IDT will document the interventions attempted and the resident's responses . A review of the facility's policy and procedure titled, Change of Condition Notification, revised 4/1/2015, indicated, .The Facility will promptly .consult with the resident's Attending Physician .when the resident endures a significant change in their condition caused by .A significant change in the resident's physical .and/or . A significant change in treatment. A review of the facility policy and procedure titled, Comprehensive Person- Centered Care Planning, revised 11/2018, indicated, .The baseline care plan must include the minimum healthcare information necessary to properly care for each resident immediately upon their admission. It should address resident-specific health and safety concerns to prevent decline or injury, and would identify needs for supervision, behavioral interventions, and assistance with activities of daily living as necessary .The baseline care must be completed within 48 hours from the resident's admission . A review of a policy titled Provider Pharmacy Requirements from Skilled Nursing Pharmacy, effective April 2008, indicated, .Medications which should be promptly available such as anti-infectives .are available within 4 hours. Upon request by the department, the facility management was unable to provide policy and procedure for following physician.

Based on interview and record review, the facility failed to provide safe, competent nurse staffing to one of two sampled residents (Resident 1) experiencing distress in a sub-acute unit (a unit supporting medically fragile residents who require special services, such as inhalation therapy, tracheotomy care, intravenous tube feeding, and complex wound management care), when: 1. A ventilator (a machine that mechanically moves air in and out of the lungs) and oxygen were applied without a physician's order; 2. A respiratory care plan was not developed or implemented; 3. Licensed Nurses (LNs) 1 and 2 did not deliver oxygen via the necessary route when the resident was in respiratory distress; 4. LNs 1 and 2 did not recognize the need for immediate transfer of Resident 1 to a GACH (General Acute Care Hospital); and 5. LNs competency for tracheostomy (a hole that surgeons make through the front of the neck and into the windpipe) and ventilator care was not assessed, demonstrated, or documented as completed. These failures resulted in Resident 1 going into a prolonged hypoxemic (below normal level of oxygen in the blood) state which required transfer to a GACH and placement in an ICU (Intensive Care Unit). Findings: A review of Resident 1's face sheet indicated Resident 1 was admitted to the facility in the summer of 2022 with diagnoses including dependence on respirator (ventilator), quadriplegia (paralysis of all four limbs) and dysphagia (difficulty in swallowing). 1. A review of physician orders for Resident 1, on 11/23/22 at 7 a.m., indicated Resident 1 did not have any orders related to his ventilator and oxygen administration. In an interview, on 11/23/22 at 7 a.m., the Director Of Nursing (DON) confirmed there were no physician's orders in place for the resident's ventilator and oxygen administration. The DON stated physician's orders for oxygen and ventilator type and setting should have been in place and failure to have a physician order could result in a negative physical and psychological outcome for the resident. A review of the facility's policy titled, Mechanical Ventilation, undated, indicated, .Mechanical ventilator may be only applied to a resident, weaned off, or discontinued with a written or verbal physician order. 2. A review of Care Plan for Resident 1, on 10/13/22, at 1:40 p.m., indicated a care plan had not been established for Resident 1's ventilated dependency (when a person can't breathe on their own and depends on a ventilator machine to assist in breathing). In a phone interview, on 11/23/22 at 7 a.m., the DON stated a basic care plan must be developed involving the resident's diagnoses to guide and facilitate his care. The DON acknowledged Resident 1 did not have a respiratory care plan and stated failure to plan a resident's care could result in inconsistencies in care delivery. A review of the facility's policy titled, Comprehensive Person- Centered Care planning, dated 11/2018, indicated, To ensure that a comprehensive person-centered care plan is developed for each resident. 3. A progress note, written on 7/22/22 at 4:53 p.m. by LN 2, indicated Resident 1 was having shortness of breath and his oxygen level was at 88-90% on 10 liters (L, a unit of measurement) per minute via oxygen concentrator (oxygen concentrators take in air from the room and filter out nitrogen, leaving an oxygen enriched gas for use by people requiring medical oxygen due to low oxygen levels in their blood). The note indicated LN 2 called a non-emergent ambulance service to transport Resident 1 to a GACH and did not call emergency services. This led to a 37-minute delay of transport from the facility to the GACH for Resident 1. A GACH's ED (Emergency Department) provider note, dated 7/22/22, indicated, Code critical was alerted .In ED patient was found to be tachypneic [fast breathing], and hypoxic ABG [arterial blood gases] 7.46 PH [normal range of PH is 7.35 to 7.45] PO2 [partial pressure of oxygen]- 77 on 100% FIO2 [the fraction of inspired oxygen (Normal atmospheric oxygen at room air is 21%)], aspiration pneumonia with mucus plugging [mucus that accumulates in the lungs can plug up, or reduce airflow in, the larger or smaller airways. In the smaller airways, it can collapse the airway and oxygen levels will be negatively impacted over time] . In an interview, on 7/22/22 at 11:30 a.m., the Director of Respiratory Therapy (DRT) stated the ventilator dependent patient should have received 100 percent oxygen via an oxygen tank to provide effective oxygenation when the resident was in respiratory distress. The DRT stated an oxygen concentrator would not have provided enough oxygen (Oxygen concentrator can deliver oxygen only up to 10 L/ minute versus oxygen tank can provide up to 25 L/minute when high flow oxygen is needed). A review of the facility's policy titled, Mechanical Ventilation, undated, indicated, To facilitate the safe, consistent application and management of positive pressure mechanical ventilation of positive pressure mechanical ventilation for residents requiring the use of positive pressure mechanical ventilation . to allow for the manual delivery of ventilations and oxygenation to the resident who is unable to maintain their own respirations with their own efforts, either in an emergency or when temporarily disconnected from the mechanical ventilator . the manual resuscitator bag is to be used to manually ventilate and oxygenate the resident in the event of a medical emergency. 4. A review of a nurse's progress note, written on 7/22/22 at 5:30 p.m. by LN 2, indicated Resident 1 had been transported to a GACH by ambulance; 37 minutes after LN 2 noticed Resident 1 was short of breath. In an interview, on 7/22/22 at 7 a.m., the DON stated the nursing staff should not have used a regular ambulance to transport the resident to GACH facility. She also stated Resident 1 was in respiratory distress which was an emergent situation. The DON stated nurses should have called 911 emergency services and expedited the transfer of the resident in respiratory distress to the GACH. The DON stated a delay in the resident's transfer could have caused hypoxia and negatively impacted the resident. In an interview, on 11/23/22 at 4:45 p.m., the Medical Director (MD) stated when a resident's oxygen levels were low and continued to decline, he expected the resident was to be transferred by 911 emergency services immediately to a GACH. The MD further stated a delay in transfer could cause hypoxia and organ damage due to a lack of oxygenation. 5. In an interview on 10/13/22 at 1:15 p.m., the DON stated the nurses should be trained by RT for trach care, responding to alarms and ventilator training. The validation of training and competency should be in their employee file. In a concurrent interview and employee personal file and competency review on 10/13/22 at 2 p.m., Director of Staff Development (DSD) stated she could not provide any documented evidence if LN 2 received any ventilator or trach training. In a concurrent interview and employee personal file and competency review on 10/13/22 at 2:10 p.m., DSD stated LN 1 was a registry employee and could not provide any documented evidence if LN was competent to care for trach and vent dependent residents. In an interview on 11/21/22 at 11:58 a.m., the LN 2 stated he doesn't feel safe and comfortable in taking care of ventilator dependent residents without a RT in the building. He also stated he never received any training on managing the residents on ventilators. In an interview on 11/22/22 at 5:01 p.m., the LN 1 stated she was a registry employee and the facility never provided her any training or competency to care for ventilator dependent residents. She also stated she only knew how to suction the resident through their tracheostomy tube and clean the tracheostomy site. She further stated she was not trained for emergent situations and the supervisor and RT were expected to assist her in any emergency. In an interview, on 10/13/22 at 1 p.m., the DON stated LNs 1 and 2 should have been trained in tracheostomy and ventilator care and suctioning. In a concurrent interview and record review, on 10/13/22 at 3 p.m., the DSD stated she could not provide any documented evidence LNs' 1 and 2 competencies in respiratory care had been assessed and documented. A review of the facility's policy titled, SUBACUTE PROGRAM POLICY AND PROCEDURES, undated, indicated, To assure the provision of skilled subacute care to the residents on the unit .all licensed nursing staff will have their subacute skill competencies evaluated and validated within thirty days of hire and then on an annual basis at the time of their yearly performance review .

An Immediate Jeopardy (IJ) situation was declared at 3:15 p.m. on 9/17/2021 regarding quality of care of residents requiring mechanical ventilation [a machine that breathes for a patient that cannot breathe on their own] which could potentially cause harm up to and including death to any or all current residents receiving the service or future residents admitted to the facility for that service. Facility leadership representatives including the Administrator (ADMIN), and Director of Nursing (DON), Vice President Operations & Business Development, Respiratory Therapy Consultant, Director of Staff Development (DSD), Regional Quality Assurance Executive, were notified of the IJ situation at 3:30 p.m. on 9/17/2021. A plan of correction was submitted to the Department which included the following: I. Admissions closed to the Sub Acute Unit on 9/17/2021; Physician orders for residents on the Sub Acute Unit on ventilators [vent] were reviewed for specific vent settings without ranges or qualifiers included in the order for each parameter in range by the physician and carried out by the licensed nurse and/or respiratory therapist; Residents on the Sub Acute Unit on ventilators plan of care was reviewed and updated for accuracy based on facility capability and updated order; Unstable residents requiring ABG [Arterial Blood Gas, a blood test to measure the acid-base balance of the blood, defined as the mechanisms the body uses to keep its fluids close to neutral pH] will be transferred to the hospital; A qualified MD [Medical Doctor] to meet the needs of the ventilator patients, AIMS Group [All Inclusive Medical Services] will assume care of the residents in the Sub Acute Unit effective 9/17/2021; II All current residents on a ventilator were reviewed for appropriate physician orders, monitoring, and care plan; III. On 9/17/2021, the facility leadership conducted an AD HOC QAPI [Quality Assurance Performance Improvement group] meeting to discuss how the facility will develop and implement admission criteria for the Sub Acute Unit to include vent settings, facility capabilities, equipment availability, and laboratory capabilities. The facility will remain closed to new admissions until the admission criteria is reviewed and accepted by the Department of Health; On 9/17/2021, the facility initiated development of a policy and competency related to acid-base monitoring by Registered Respiratory Therapists [RRT] using ETCO2 [end-tidal [MEDICATION(S)], a number that represents the partial pressure of CO2, which assesses ventilation] cable with VIVO65 [name of equipment]; On 9/17/2021, the RRT supervisor initiated training with all Sub Acute Unit staff on physician orders, monitoring, ventilator weaning, and acid-base monitoring by RRTs using an ETCO2 cable with VIVO65, assessment and documentation. To be completed by Monday 9/20/2021; Admission Criteria for the Sub Acute Unit was presented to the survey team at 6:55 p.m. After a Plan of Correction was reviewed and accepted by the Department, the facility leadership team was notified at 6:55 p.m. on 9/17/2021 that the IJ situation had been removed. Based on observation, interview, and record review, the facility failed to provide respiratory care and services consisting of qualified medical care, necessary equipment, and services to meet the needs of three of three sampled current residents (Resident 2, Resident 5, and Resident 6) and four of four closed resident records (Resident 1, Resident 3, Resident 4, and Resident 7) for a universe of seven residents that required mechanical ventilation when: A) Ventilator Settings: Physician orders for ventilator settings were not followed for Resident 1, Resident 2, Resident 3, Resident 5, and Resident 7, or physician orders did not provide specific settings for the machine or parameters to be used to adjust settings within a prescribed range for Resident 3, Resident 4, Resident 5, and Resident 6; B) Acid-Base Balance (a delicate balance of acids and bases in the body controlled and maintained primarily by the lungs that is required to maintain vital organ function. Mechanical ventilation has a direct effect on the levels of [MEDICATION(S)], which is the main acid in the body that is regulated with breathing): Necessary equipment (ETCO2 monitoring) or laboratory services (ABG analysis) were not available to detect changes in acid-base balance when Resident 1, Resident 2, Resident 3, and Resident 4 experienced acute changes in their acid-base balance and became unstable; C) Admission Criteria: Admission criteria was not established and used effectively to determine if the facility equipment had the capability to provide the necessary ventilatory support for Resident 1 and Resident 7; D) Care Plan: Respiratory care plans indicated under assess respiratory function/monitor, Arterial blood gas (ABG) testing was noted on care plans for Resident 1, Resident 3, Resident 4, and Resident 7 and the services were not avialable in the facility; and, E) Medical Care: The facility Medical Director lacked experience and knowledge in the management of residents on mechanical ventilators. These failures resulted in unplanned transfers and readmissions of residents to the general acute care hospital (GACH) for emergent treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] 1) [CONDITION(S)] (a condition in which the body is deprived of adequate oxygen supply) for Resident 1, and Resident 7, 2) acidosis (condition where there are too many acids in the blood which can cause death) for Resident 1, Resident 2, and Resident 3, 3) alkalosis (excessive alkaline condition in the blood which may cause tissue [CONDITION(S)]) for Resident 3, and Resident 4, 4) altered mental status for Resident 2, Resident 3, and Resident 4, 5) severe [CONDITION(S)] (a life-threatening condition when the body's response to an infection causes injury to its own tissues and organs) and pneumonia (a bacterial infection in the lungs) for Resident 2, and Resident 3. These failures posed significant risk of death for Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, and Resident 7, who required life support in the form of mechanical ventilation. Findings: Resident 1 (closed record): A- Ventilator Settings and B- Acid-Base Balance: A review of a Sub-Acute Care Admission Record (SACAR) indicated, Resident 1 was admitted to the facility in May 2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with the Medical Record Director (MRD) on 9/17/21 at 3 p.m., the MRD stated Resident 1 was admitted to the sub-acute unit on 5/13/21, and transferred back to the GACH on 5/15/21, requiring emergent medical treatment. The MRD stated Resident 1 returned to the sub-acute unit on 5/26/21, to subsequently be transferred back again to the GACH on 5/27/21, for being clinically unstable requiring emergent medical treatment. A review of the Medical Doctor (MD) order for Resident 1, dated 5/13/2021, indicated ventilator settings which included: SIMV (Spontaneous Intermittent Mandatory Ventilation - a type of volume control ventilation where the ventilator machine delivers a mandatory number of breaths with a set volume while allowing spontaneous breaths); VT (Tidal Volume - the specified volume of the breaths delivered by the ventilator) 440 (measured size of breath in milliliters); Rate of 16 (number of breaths delivered by the machine per minute); PSV (Pressure Support- a set level of pressure maintained in the system at all times to assist the patient with initiation of spontaneous breathing. Pressure support eases a patient's ability to overcome the resistance of breathing through the tube) of 14; Positive End-Expiratory Pressure of 5 (PEEP; the positive pressure that will remain in the airways at the end of exhalation to promote oxygenation); Fractioned Inspired Oxygen (FIO2; concentration of oxygen in the gas mixture) of 3 liters/minute (LPM, a measurement); Titrate O2 to keep O2 saturation (a measure of how much hemoglobin is currently bound to oxygen) greater than 92% (normal range is 95 to 100 percent. Values under 90 percent are considered low) PRN ('pro re nata', which means that the administration of medication is not scheduled. Instead, the prescription is taken as needed); monitor every 6 hours. A review of the Continuous Ventilator Flow Sheet (CVFS) for Resident 1 indicated the following: -On 5/14/2021, at 1 p.m., the FIO2 was noted as 3; -On 5/14/2021, at 3 p.m., the FIO2 was noted as (upward arrow) 4. There were no other parameters noted at this time, including an oxygen saturation level, and there were no corresponding narrative notes indicating why the FIO2 was increased (which was not consistent with the MD order); -On 5/14/2021, at 7:30 p.m., the FIO2 was noted as 4 with an SaO2 (saturation of oxygen) noted as 91; -On 5/15/2021, at an illegible time (prior to the 3:30 p.m. entry), the FIO2 was noted as 4 with an SaO2 of 75. There were no corresponding narrative notes or increase of FIO2 noted with relation to the low oxygen saturation of 75 (This was not consistent with the MD order); -On 5/15/2021, at 7 a.m., the FIO2 was noted as 4 and the SaO2 was noted as 98. -On 5/15/2021, at 1 p.m., there were no patient parameters noted, however there was a narrative note indicating pt [patient] got sent out to hospital due to low SpO2 [capillary oxygen saturation] 80 's, bagged [manual ventilation with a bag] pt until paramedics arrived. (There was no documentation of CO2 or ETCO2 noted on the CVFS of Resident 1 who experienced an acute acid-base imbalance as documented in hospital admission records.) A review of Resident 1's nursing progress note, dated 5/15/2021, at 4:14 p.m., indicated, Resident complained of difficulty breathing after checking patient when high pressure alarm sounded, patient was suctioned immediately as he stated he felt like he needed it, think [sic] clear mucous was suctioned. O2 sat was 80% upon assessment. RT [Respiratory Therapy] immediately bagged resident, O2 recovered to 95%, the resident then placed back on the vent [sic] but continued to complain of SOB [shortness of breath], resident was then bagged [manual ventilation with a bag] again and PRN [MEDICATION(S)] [breathing treatment with medication] was administered, resident was satting [oxygen saturation trend] 92% and continued to complain of SOB. I proceeded to call for ambulance assistance to transfer patient to hospital for further assessment of persistent SOB. DON [Director of Nurses], Administrator, and MD were notified. Patient family was also notified. A review of the GACH Intensive Care Unit (ICU) physician note for Resident 1, dated 5/15/2021 indicated, .Reason for ICU Admission: Acute on Chronic Respiratory Failure .presents today from long term care facility after staff noticed his oxygen saturation was in the 80%'s with complaints of dyspnea [labored breathing]. He was bagged on 100% by EMS [Emergency Medical System] with brief improvement of SpO2 to the 90%'s. In the emergency department his [CONDITION(S)] [a tube surgically placed in the trachea used to provide direct mechanical ventilation] cuff [balloon on outside perimeter of [CONDITION(S)] tube to direct airflow into the lungs and prevent leakage around the tube] was found to be deflated [results in air leakage and decreased volume of breaths delivered by the mechanical ventilator], was subsequently reinflated, but only offered transient improvement in oxygenation. He was hypotensive [low blood pressure] with BP 70-90's/50 [normal range defined as between 100 and 120 in adults over age 18- measured in mmHg (millimeters of mercury)], tachypneic [rapid shallow breathing], hypoxic with SpO2 88% on 100% O2 and PEEP 14, and had leukocytosis (21) [normal range 4-11 - a condition in which white cell is above normal range and a sign of infection] .This is a critically ill patient .It was my opinion as the attending physician/provider that the indicated support was medically necessary to treat a high probability of imminent or life threatening deterioration in the patient's condition which could have resulted in significant morbidity or mortality .Active Problems: Acute on Chronic Respiratory failure with [CONDITION(S)] and hypercapnia [term meaning high [MEDICATION(S)] in the blood that can cause acidosis] .Laboratory Data .WBC 5/15/21 1205 p.m.21 .ABG .pH [direct measure of acidity of the blood- normal range is 7.35-7.45- level below 7.35 represents acidosis which can cause death] 7.30, pCO2 [partial presure [MEDICATION(S)] level - normal range is 35-45 -level greater than 45 can cause acidosis and death] 64.5, pO2 [partial pressure - normal range is greater than 80] 60. B- Acid-Base Balance: During an interview on 9/17/21, at 12:15 p.m., when asked how patients were assessed after changes in ventilatory modes, Lead RT stated patient comfort level, minute ventilation [a measurement of patient's volume of breaths over a minute] and clinical signs of hypercapnia [high [MEDICATION(S)] which causes an acid-base imbalance and can be life threatening]. Lead RT stated that the best assessment of a patient after a change in ventilatory modes was an ABG, but the facility did not have the capability to obtain one. Lead RT stated the facility had equipment to measure end tidal CO2 but there was not a policy in place for use of the equipment in the facility and it was not used and/or documented consistently by the RRT. Lead RT further stated there was no process in place for determining or communicating a baseline CO2 reading for a newly admitted resident to enable the RRT staff to use the ETCO2 monitors to potentially detect changes in CO2. C- Admission Criteria: Review of Resident 1's GACH record document titled Inter-facility transfer record, dated 5/26/2021, included the following notation, Respiratory Care, O2 device, Ventilator, Ventilator settings .PRVC [Pressure regulated volume control - a pressure control breath not a volume control breath. With a PRVC breath, the ventilator computer is allowed to adjust applied pressure up or down in an attempt to hold tidal volume constant.] Rate 20, TV 500 ml [milliliter, a unit of measurement], FIO2 30% [approximately 3 LPM] PEEP 5 cm [unit of measure] .Suction/Airway clearance . Frequent suctioning . Review of Resident 1's sub-acute unit Physician Orders - Admission Respiratory Orders/ [CONDITION(S)] dated 5/26/2021, included the following ventilator orders: Mode ACPC [Assist Control Pressure Control - pressure controlled breath in which the machine cannot directly control tidal volume. The resultant tidal volume may be unstable when the patient 's breathing effort and/or respiratory mechanics change.] VT target 500ml, FIO2 - left blank, Rate 20, PSV 18, PEEP 7, monitor Q [every] 2 [hours] and PRN. A review of the CVFS for Resident 1 indicated the following: -On 5/26/2021, at 3 p.m., the mode was noted as ACVC and the FIO2 was noted as 6 LPM, SaO2 was noted as 95%, and PEEP 8 (which was not consistent with MD order for PEEP of 7). -On 5/26/2021, at 7 p.m., the mode was noted as PCVC and the FIO2 was noted as 5 LPM, SaO2 was noted as 98%, and PEEP 8 (which was not consistent with MD order for PEEP of 7). -On 5/27/2021, at 7:45 a.m., the mode was noted as ACVC, the heart rate was noted as 140 [normal range is 60-100], and PEEP 8 (which was not consistent with MD order for PEEP of 7). -On 5/27/2021, at 8:40 a.m., it was noted sent out. Review of Resident 1's nursing progress note, dated 5/27/2021, at 5:33 a.m., included the following notation: .Pt was admitted from [name of GACH] around 1430 [2:30 p.m.] per AM nurse. Pt requires vent [ventilator]setting called PRVC [Pressure regulated volume control] which the sub-acute vents do not have nor carry an equivalent mode. Pt has been on volume control mode with a PEEP of 8 with SpO2 between 91-98%. High pressure alarm will frequently alarm r/t [related to] excess secretions and pressure greater than 44. Pt does not complain of SOB [shortness of breath] nor shows any respiratory distress. Pt complains of severe anxiety with [CONDITION(S)] [heart rate greater than 100] between 110-140 and received [MEDICATION(S)] [medication to treat anxiety] prn at 0150 [1:50 a.m.] Pt continues to have [CONDITION(S)] and anxiety. Administered [MEDICATION(S)] [medication to treat anxiety] 1mg [milligram, a unit of measurement]at 0330 [3:30 a.m.]. Review of Resident 1's nursing progress note, dated 5/27/2021, at 10:17 a.m., noted the following: .upon assessment patient c/o [complained of] SOB, HR was 140 BP [blood pressure] 88/58, Temp 97.2, O2 sat 99%, patient stated persistently he was having a hard time breathing and did appear to be in distress. Spoke to MD and was advised that the patient should be transferred to acute care as this patient required acute care treatment. Patient was sent out at 0840 [8:40 a.m.] . During the interview on 9/17/21, at 12:15 p.m., with Lead RT, he also verified that the facility ventilators did not have the capability of providing PRVC ventilatory mode. He stated he was aware of cases when residents were sent/accepted/admitted to the subacute from the hospital that were on this mode in the GACH. Lead RT stated that the RRT on staff would have to find an alternative ventilator setting to stabilize an anxious resident. Lead RT stated that PC [pressure control or VC [volume control] had been attempted but had not been tolerated well on at least one occasion and the resident required return to the GACH quickly. Lead RT stated that the RRT on staff would make the decision on an alternative mode to set the ventilator and make a recommendation to the MD. Lead RT also stated that there was no formalized admission screening process for ventilator residents and that sometimes there would be a conversation with the admissions office staff and sometimes the ventilator settings would be reviewed. C- Admission Criteria & E-Medical Care: During an interview with MD 1 on 9/17/21, at 4:10 p.m., when asked about his experience with ventilators, he stated some but not much. MD 1 stated that he left the ventilator settings to the respiratory therapists and approved their recommendations because he did not know the settings. When asked to explain the difference between PRVC and VC, MD 1 stated it was a setting in the ventilator, and that he left the settings to the therapists. When asked who was responsible for ventilator setting orders or changes to settings, MD 1 responded that he relied on the inhalation group. MD 1 stated that so far it has been okay and there has been no need for a pulmonologist [lung specialist] or a physician qualified and experienced in managing ventilators. MD 1 stated he was not involved in decisions about accepting new admissions, but did not think that the admission person in the facility was qualified to make the decision. MD 1 stated that the nurses in the subacute should make decisions about accepting a new patient. B- Acid Base, C- Admission Criteria, & D- Care Plan: Review of a document in Resident 1's record titled Care Plan: Respiratory Care, dated 5/13/21, indicated the following; Assess respiratory function/monitor: .ABG/Labs/Chest X-Ray. During an interview with the Administrator (ADMIN) on 9/17/21, at 10 a.m., he stated that there was currently no facility policy or procedure in place for monitoring of ETCO2. ADMIN also stated that when a resident had arrived at the facility on ventilator settings that they could not do, the Medical Director would not give orders. ADMIN stated that there was no formalized admission exclusion criteria in place and he referenced a ghost policy that was used by the Director of Nurses (DON) and the Lead RT. B-Acid-Base Balance, C-Admission Criteria, & E- Medical Care: During an interview on 9/17/2021, at 11:45 a.m., with the DON, she stated she had no knowledge of any admission exclusion criteria nor of a ghost policy in use when admitting ventilator residents. The DON stated that the facility did not have a policy for ETCO2 monitoring. The DON stated that any change to ventilator settings required a physician order. The DON stated the RRT staff made recommendations for ventilator settings and the physician approved them. The DON verified that ABG's were not done by the Facility's contracted laboratory and were not performed at the facility by the RRTs. Resident 2 (current resident): Review of Resident 2's medical record revealed the following: An admission record indicated Resident 2 admitted to the facility in the Spring of 2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A- Ventilator Settings: Resident 2's ambulance transfer report, dated 8/27/2021, at 2 p.m., indicated Resident 2 was transported from the hospital back to the sub-acute facility, and her mechanical ventilator mode was SIMV, 40% (oxygenation), and PEEP 5. Review of Resident 2's document titled Admission Data Collection Tool, dated 8/27/2021, at 3:20 p.m., indicated Resident 2 returned to the facility by ambulance. The tool included an assessment of Resident 2's respiratory system, which indicated the resident's respirations were unlabored, regular, and no shortness of breath. The tool indicated the resident's lung sounds were clear throughout, and there was no cough or sputum present. The tool indicated the resident was receiving oxygen continuously by a mechanical ventilator through her [CONDITION(S)]. Review of Resident 2's document titled Physician Order - Admission Respiratory Orders/[CONDITION(S)], dated 8/27/2021, indicated, VENTILATOR RESIDENTS .Mode: PSV IP: 11 RATE: [blank] PS: 6 PEEP: 5 FiO2: 4 LPM Target VT: [blank] Monitor Q 4 . There was no documented evidence of a physician signature on the order. Review of Resident 2's document titled Continuous Ventilator Flow Sheet, dated 8/27/2021, indicated, Ventilator Setting Orders: Mode: PSV VT: [blank] PC: 10-15R/RATE: [blank] FiO2/LPM:4 PEEP: 5 PSV: 7 OTHER: Keep SpO2 > 92% . The RRT documentation on Resident 2's Continuous Ventilator Flow Sheet indicated the following: -At 2:23 p.m., the ventilator mode indicated PSV, IP 11, VT 400, heart rate 107, oxygen saturation 95%, respiratory rate 30, peak pressure 12, FiO2/LPM 4, PEEP 5, and PS 6. -At 5:30 p.m., the RRT drew a line through the flow sheet row of data and indicated the RRT suctioned Resident 2's airway. -At 7:25 p.m., the ventilator mode indicated PSV, IP 11, the VT was blank, heart rate 95, oxygen saturation 98, peak pressure 12, FiO2/LPM 4, PEEP 5, PS 6. -At 9:21 p.m., the RRT drew a line through the flow sheet row of data. -At 11:20 p.m., the RRT drew a line through the flow sheet row of data. -On 8/28/2021, at 1:35 a.m., the ventilator mode indicated PSV, IP 11, VT 252, heart rate 107, oxygen saturation 98%, respiratory rate 24, peek pressure 12, FiO2/LMP 4, PEEP 5, PS 6. -At 2:56 a.m., the RRT wrote a note at the bottom of the Continuous Ventilator Flow Sheet indicated the RRT increased PC to 15, due to low VT <200 mL [milliliters, a unit of measure]. (There was no corresponding MD order for increasing the PC.) -At 3 a.m., the ventilator mode indicated IP 15, and the RRT drew a line through the remainder of the flow sheet row. -At 5:30 a.m., the RRT drew a line through the flow sheet data row. Review of Resident 2's Continuous Ventilator Flow Sheet, dated 8/28/2021, indicated the following: -At 7 a.m., the RRT wrote, [Resident 2] sent out to hospital. There were no documented values on the flow sheet row. The RRT wrote a note at the bottom of the flow sheet indicating [Resident 2] got sent out to hospital due to not waking up. Review of Resident 2's nurse's note dated 8/28/2021, at 11:16 a.m., indicated, late entry for 8/27/2021: pt readmission from [name of hospital] arrived on 8/27/2021 @ [at] 1515 [3:15 p.m.] .returned with new ATB [antibiotic] order for PNA [pneumonia] .no s/s [signs or symptoms] of cardiopulmonary [heart and lungs] distress, resident denies dyspnea [difficulty breathing] . B- Acid-Base Balance: Review of Resident 2's nurse's note dated 8/28/2021, at 11:33 a.m., indicated, upon assessment of the patient on change of shift [day shift starts at 6:30 a.m.], resident was observed to be experiencing respiratory distress, the resident was unarousable, and unresponsive to any stimuli, pupils were sluggish [slow reaction to light shined in the eye]. MD [medical doctor] was notified and order was given to transfer patient out to the hospital .resident was transferred to [name of hospital] at approximately 0640 [6:40 a.m.] by ambulance. Review of Resident 2's Emergency Department (ED) provider note dated 8/28/2021, at 7:18 a.m., indicated, Resident 2 .was brought in by ambulance on code critical from SNF [skilled nursing facility] for altered level of consciousness. Patient was last seen normal by night SNF staff this morning at 0500 [5 a.m.] at her baseline, which is A&Ox4 [alert and orientated to person, place, time, and situation] and GCS 15 [Glasgow Coma Scale, a scale used to measure the level of consciousness where 15 is fully awake] and usually conversational. When new shift showed up at approximately 0700 [7 a.m.] they found patient altered and unresponsive with labored breathing. EMS [emergency medical services] note respiratory distress and patient is not responding to painful stimuli, GCS 6 per EMS. Review of Resident 2's laboratory tests done in the ED on 8/28/2021, included a venous blood gas (VBG, a test that measures [MEDICATION(S)] and pH in the venous blood for the purpose of assessing ventilation and/or acid-base status) test done at 7:19 a.m., which indicated Resident 2's blood pH was 6.99 (normal range 7.32 to 7.43), and her [MEDICATION(S)] was 154.7 (normal range 38 to 50). An ABG test done at 8:03 a.m., which indicated Resident 2's blood pH was 7.217, signifying acidosis, and her CO2 was 75.3, signifying hypercapnia. Review of Resident 2's document titled ICU [Intensive Care Unit] Admission H&P [history and physical], dated 8/28/2021, at 9:07 a.m., indicated, This is a [AGE] year-old female chronic ventilator dependent .was recently admitted and discharged yesterday from the ICU to a subacute facility- patient was found unresponsive over there and was apparently brought over to the ED. Patient was found to have a pH of 6.9 with a CO2 of 150 - after placing back on the ventilator - she appeared to be improved .Patient normally ventilator dependent, unclear what happened in the facility and why the CO2 is that high - I am concerned if facility has capacity to maintain ventilator support. A- Ventilator Settings: Review of Resident 2's sub-acute unit document titled Physician Order - Admission Respiratory Orders/[CONDITION(S)], dated 9/1/2021, indicated, .VENTILATOR RESIDENTS .Mode: SIMV PC IP: 12-20 RATE: 12-20 PS: 7-15 PEEP: 5-8 FiO2: 4 LPM .Monitor Q 4 . The volume total (VT) was blank. Review a Resident 2's Continuous Ventilator Flow Sheet, dated 9/1/2021, indicated, Ventilator Setting Orders .Mode: SIMV VC VT: 400 R/RATE: 12 FiO2/LPM: 4L PEEP: 7 PSV 15 OTHER: Keep SpO2 > 92% The RRT documentation on Resident 2's Continuous Ventilator Flow Sheet indicated the following: -At 5:10 p.m., the ventilator mode was SIMV/VC, the set VT 400/actual VT 403, heart rate 71, oxygen saturation 95%, set respiratory rate 12/actual respiratory rate 30, peak pressure 15, FiO2/LPM 4, PEEP 7, PS 15. (This was not consistent with the MD order that indicated SIMV/PC [pressure control] not SIMV/VC [volume control]). -At 7:02 p.m., the ventilator mode was SIMV/IP 12, actual VT 420, heart rate 64, oxygen saturation 99%, set respiratory rate 12/actual respiratory rate 20, peak pressure 12, FiO2 LPM 4, PEEP 5, PS 7. B- Acid-Base Balance: During a concurrent interview and observation with RRT 2 on 9/17/2021, at 9:50 a.m., at Resident 2's bedside, RRT 2 reviewed the mechanical ventilator settings for Resident 2. When asked if the mechanical ventilator had the capability of monitoring a resident's end tidal [MEDICATION(S)] level, RRT 2 stated the ventilators had the capability with the use of a cable attached to the machine. RRT 2 stated the therapists were unable to continuously monitor a resident's ETCO2 because the facility had only a couple of cables available for use. RRT 2 stated the therapists measured a resident's ETCO2 level once per shift and would document the level in a progress note. RRT 2 stated the facility did not provide on-site ABGs to detect changes in a resident's respiratory and acid-base status and stated the contracted lab did not perform ABGs either. RRT 2 stated the facility was not capable of providing care and services to residents in acute respiratory distress and needed to send them to the hospital. During an interview and concurrent record review with the Lead RT on 9/17/2021, at 7 p.m., the Lead RT reviewed Resident 2's Continuous Ventilator Flow Sheet for 8/27/21 and 8/28/21. The Lead RT stated he did not like it when the RRTs would draw lines through flow sheet rows and verified they should have written the ventilator settings and resident response values for Resident 2. The Lead RT stated the RRTs should have written more detailed notes when Resident 2 was having a change in condition in the early morning of 8/28/21. The Lead RT reviewed Resident 2's document titled ICU [Intensive Care Unit] Admission H&P [history and physical], dated 8/28/21, at 9:07 a.m., and stated he had not reviewed Resident 2's hospital documents and he was not aware her CO2 level was 150 when she transferred to the hospital on 8/28/21. The Lead RT stated a CO2 of 150 was really high. Resident 3 (closed record): A review of the SACAR indicated, Resident 3 was admitted to the facility in August 2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A-Ventilator Settings: A review of the MD's order for Resident 3 dated 8/27/2021, indicated ventilator settings, which included SIMV, PC, IP of 12 -20; Rate of 14; PS of 10-20; PEEP of 5-8; FIO2 of 3 liters/minute (LPM); monitor every 6 hours. Titrate O2 to keep O2 saturation greater than 92%. A review of Resident 3's Admission Data Collection Tool dated 8/27/2021, at 11:34 a.m., indicated Resident 3 was on 4 LPM of oxygen There was no notation of O2 saturation noted on the admission tool. A review of the CVFS for Resident 3 indicated the following: -On 8/27/21, at 4:20 p.m., Resident 3's CVFS noted a PEEP of 5 and a PS of 11. At 7:50 p.m., a note indicated a change in a PEEP to 8 and a PS of 11. There was no documented indication why the PEEP was increased, or if the desired effect was achieved with the change in settings. -On 8/28/21 for the whole 24 hours, Resident 3's CVFS noted a PEEP of 8 and a PS of 8. There was no indication noted on CVFS why or when the PS was changed. The PS noted was below the range reflected in the MD order. -On 8/29/21 and 8/30/21, Resident 3's CVFS noted a PEEP of 8 and PS of 8. -On 8/30/21, at 1 a.m., Resident 3's CVFS noted an FIO2 of 2 LPM. There was no indication when or why the FIO2 was changed. -On 8/31/21, at 8:45 a.m., and 2:20 p.m., Resident 3's CVFS noted a PEEP of 8 and a PS of 20 and FIO2 of 2LPM. There was no indication why PS was increased to 20. At 8:25 p.m. and 1:14 a.m., it was noted that the Resident had a PS of 8. There was no indication noted why the PS was decreased. -On 9/1/21, at 7:25 a.m., 1:35 p.m., 7:45 p.m., and 1:52 a.m., Resident 3's CVFS noted a PEEP of 8 and a PS of 8. (Th [TRUNCATED]

Based on clinical and administrative record review and professional associations scopes of practice, the facility failed to ensure that the appropriate professional was utilized to assess the nutritional needs of one of eighteen sampled resident (Resident 8). This deficient practice resulted in lack of identification of nutritional needs and delay in the intervention for medical nutrition therapy and severe weight loss of 25 pounds or 17% in less than six months. (Cross refer F692) Findings: Resident 8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 8 also had an unstageable pressure ulcer which is a full thickness tissue loss, in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed on right heel; Alzheimer's dementia, a progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain, depression and [MEDICAL CONDITION] a condition that develops when the blood lacks enough healthy red blood cells. There was an initial nutrition assessment conducted by the registered dietitian (RD) on 10/23/17. The resident's daily assessed need was 1575 to 1706 calories, 80 to 96 grams of protein and fluid of 1600 to 1920 cc. The RD indicated in her assessment that Resident 8 average percentage of meals eaten was 62 % of 12 meals. This translates to average intake of 1426 calories, based on the facility's regular diet. This intake is below the resident's assessed needs, therefore the RD recommended fortifying the diet to add 500 calories to the resident's diet. The RD also identified that the resident ate better with assist in the dining room. The RD did not describe the level of assistance observed or needed. The nutritional goal for Resident 8 was weight maintenance of 138 -146 lbs. The diet was changed on 10/29/17 to a fortified diet but the weight loss continued. The RD did not specify in an interview on (MONTH) 2, (YEAR) starting at 4:40 pm, what she meant by assistance with meals Record review of the comprehensive assessment (MDS) completed on 10/25/17 was inaccurate. The MDS indicated resident 8 did not have any depression but transfer papers from the acute care hospital indicated she had depression and was on medication for depression. She was also assessed to be independent and able to feed herself with set-up only. The assessment failed to identify that although the resident was physically able to feed herself she ate better with assistance (when fed). There was an interdisciplinary team conference held on 10/30/17. The weight loss was attributed to resolved [MEDICAL CONDITION], (a condition characterized by an excess of watery fluid collecting in the cavities or tissues of the body) deep tissue injury (A deep tissue injury is a unique form of pressure ulcer. The National Pressure Ulcer Advisory Panel defines a deep tissue injury as a pressure-related injury to subcutaneous tissues under intact skin. Initially, these [MEDICAL CONDITION] have the appearance of a deep bruise) and incision (due to surgery) related to fracture. The plan remained weekly weight and RD follow up. Resident 8's weight loss was immediate and consistent, losing weight every week the first month of admission. She lost 5.4 pounds dropping down to 137.2 pounds. On (MONTH) 8, (YEAR), there was a weight variance Committee Assessment completed by the activities director, social services, the food and nutrition director (DFN) and a licensed vocational nurse. All of whom do not have the scope of practice to conduct assessments. Development and updating a care plan would require a professional scope of practice for resident assessment. The activities director and social services designee are not health professionals and therefore conduct health care assessments. Review of the scope of practice for the CDM by the Certifying Board of Dietary Managers does not include conducting nutritional assessments. It allows members to perform some tasks including conduct routine nutritional screening and comply with Federal and State regulations related to effective nutrition services. The Director of Nursing (DON) in an interview on (MONTH) 3, (YEAR) at 10:05 AM, was asked about the make-up of the weight variance committee and lack of the participation of a registered nurse to ensure the proper professionals were present to conduct the meeting. The DON acknowledged the registered nurse needed to participate in the meetings. The DON in the concurrent interview indicated she is usually there to provide oversight to the licensed vocational nurse in the meeting. The DON further stated she would sign the form as proof of her participation. The DON did not sign the (MONTH) 8, (YEAR) notes by the team. The weight variance progress notes signed by all four (activities director, social services designee, director of food and nutrition and licensed vocational nurse) recommended the discontinuation of two medications (one was for depression) and continuation of weekly weights until weight stable and follow up with RD as needed for further fluctuations. There was no other interventions initiated including further assistance with meals. There had not been any assessment by the RD since (MONTH) (YEAR) initial assessment. The weight variance committee indicated Resident 8 was in a supervised group in the dining room. The intervention was not effective because Resident 8 lost an additional 9.4 lbs. from (MONTH) (YEAR) to (MONTH) weighing 129.4 lbs. on (MONTH) 4, (YEAR). Record review showed on (MONTH) 11, (YEAR), DFN completed and documented in the facility document titled Quarterly Nutritional Assessment. DFN stated resident 8's skin intact which was an error because according to wound care notes resident had an unstageable pressure ulcer. DFN documented in the same quarterly assessment Resident 8 had lost 10 lbs. or 7.19 % in 30 days, which is considered severe. (According the Centers for Medicare and Medicaid Services (CMS) State Operations Manual (SOM), a weight loss of 5 % in 30 days is significant, > 5 % is considered severe). DFN's plan was updated care plan will continue to monitor food preference. There was no analysis of the cause of the weight loss or new interventions to slow down or prevent further weight loss. 4.8 lbs. from (MONTH) to (MONTH) (YEAR). Resident 8 was not referred to the RD for consult when the weight loss continued. The RD's last assessment was the initial assessment that had been conducted in (MONTH) (YEAR). The last quarterly MDS dated [DATE] also inaccurately documented Resident 8 did not have any weight loss. By (MONTH) 4, Resident 8 had lost 13 lbs. or 9.2 % in less than three months. The weight loss should have triggered a change in condition assessment. The Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, provides guidance to skilled nursing facilities. The manual notes that a significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self- limiting;2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan Resident 8's weight loss continued with a weight loss of 4.8 lbs. in February. In (MONTH) 23, (YEAR) meeting, IDT stated intake stable, with 80 % of snacks consumed throughout the day, MD aware, [MEDICAL CONDITION] resolved. The MD progress notes dated 2/28/18 revealed the physician was aware of Resident's 8's weight loss and poor appetite. The MD documented not eating good. This was not in line with the IDT documentation of meals consumed as 100 % supplement and 70 % of meals. The medication for depression was reordered in (MONTH) according to Resident 8's Physician order [REDACTED]. In (MONTH) and (MONTH) (YEAR), Resident 8 lost 4.8 lbs. each month, weighing 119.8 lbs. in March. On (MONTH) 2, (YEAR), Resident 8 weighed 117.2 lbs. A total weight loss of 25.4 lbs. or 19.84 % in almost six months. On (MONTH) 9, (YEAR), a short Term Care plan related to weight loss was developed. There was an order to increase the Health Shakes to three times a day after the RD assessment. Mighty Shakes provide an additional 200 calories per meal. This would provide an additional 600 calories a day. Record review showed the DFN completed another quarterly assessment on 4/18/18. The DFN documented total weight loss 12 pounds in 90 days or 9.38 % in 90 days which is considered severe, weight loss of > 7.5 % is considered severe. The intervention was the same Updated care plan and food preferences. Meal observations were conducted by the surveyors on (MONTH) 2 and (MONTH) 3, (YEAR). On (MONTH) 2, (YEAR) at 12:45 PM, Resident 8 was observed in the dining room sitting across the table from another resident. There was staff in the dining room but none close enough to cue her to eat. She received a serving of roast beef, a serving of sweet potatoes, mixed vegetables with melted cheese, milk, ice cream and a biscuit. Resident 8 was observed taking a few bites of the beef. A few minutes later she wiped her mouth, put down her head, and did not continue to eat. On (MONTH) 2, (YEAR) at 4:40 PM, DFN stated she had observed Resident 8 on many occasions and acknowledged she requires some feeding assistance but otherwise eats well. DFN did not respond when she was asked why this intervention was not attempted or shared with the nursing staff. The DFN was interviewed about the quarterly assessments she had conducted and the lack of interventions to stop Resident 8's weight loss. DFN stated she believed she was qualified to conduct nutrition assessments because she was a CDM (Certified Dietary Manager). DFN did not become a CDM until (MONTH) 20, (YEAR). DFN conducted nutrition assessments in (MONTH) (YEAR). Review of the scope of practice for the CDM by the Certifying Board of Dietary Managers does not include conducting nutritional assessments. It allows members to perform some tasks including conduct routine nutritional screening and comply with Federal and State regulations related to effective nutrition services. According to California Business and Professions Code 2586, the registered dietitian is professional allowed to conduct nutrition assessments in health care facilities, it does not include the CDM. According to the Academy of Nutrition and Dietetics unique to RDs is the qualification to provide MNT (medical nutrition therapy). MNT is an evidenced-based application of the Nutrition Care Process (NCP), including: performing a comprehensive nutrition, assessment, determining the nutrition diagnosis, planning and implementing a nutrition intervention using evidence-based nutrition practice guidelines and monitoring and evaluating an individual's progress toward goals. The facility RD empowered the DFN to conduct the nutrition assessment through her validation of her competency to conduct annual and quarterly notes.

Based on observation, review of clinical records, resident and staff interviews, the facility failed to ensure that it met the nutritional needs of one of eighteen sampled residents (Resident 8). The facility failed to accurately assess, modify care plans and assist her during meals. These deficient practices resulted in an insidious and severe weight loss of 25.4 pounds or 17.8 % of her body weight in less than six months. Findings: Resident 8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 8 also had an unstageable pressure ulcer which is a full thickness tissue loss, in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed on right heel; Alzheimer's dementia, a progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain, depression and [MEDICAL CONDITION] a condition that develops when the blood lacks enough healthy red blood cells. Resident 8 who is 63 inches tall weighed 142.6 pounds (lbs.) on admission. Her physician ordered diet was a regular NAS (no added salt) diet. Record review showed there was an initial nutrition assessment conducted by the registered dietitian (RD) on 10/23/17. The RD calculated the resident's assessed daily need was 1575 to 1706 calories, 80 to 96 grams of protein and fluid of 1600 to 1920 cc (cubic centimeters-a unit of measure). The RD indicated in her assessment that Resident 8's average percentage of meals eaten was 62 % of 12 meals. Based on the average calories contained in the facility's regular diet of 2300 calories, described in the diet manual; this translates to average intake of 1426 calories. This intake was below the resident's assessed needs of 1575 to 1706 calories per day. The RD recommended fortifying (adding extra food or ingredients to food items to increase the calories without increasing the volume of food) the diet to add 500 calories to the resident's diet. The RD also identified that the resident ate better with assistance in the dining room. The RD did not describe in nutrition notes the level of assistance observed or needed such as cueing or feeding. The nutritional goal for Resident 8 was weight maintenance of 138 -146 lbs. The diet was changed on 10/29/17 to a fortified diet but the weight loss continued. During interview on (MONTH) 2, (YEAR) at 4:42 pm, the RD did not provide additional information on what she meant by eating better with assistance Review of the comprehensive assessment (MDS) completed on 10/25/17 was inaccurate. The MDS indicated she did not have any depression but transfer papers from the acute care hospital indicated she had depression and was on medication of depression. She was also assessed to be independent and able to feed herself with set-up only. The assessment failed to identify that although the resident was physically able to feed herself she ate better with assistance (when fed). There was an interdisciplinary team conference held on 10/30/17. The weight loss was attributed to resolved [MEDICAL CONDITION], deep tissue injury and incision (due to surgery) related to fracture. The plan remained weekly weight and RD follow up. Resident 8's weight loss was immediate and consistent, losing weight every week the first month of admission. She lost 5.4 pounds dropping down to 137.2 pounds. On (MONTH) 2, (YEAR), Resident 8 gained 1.8 lbs. weighed 139 lbs. On (MONTH) 8, (YEAR), there was a weight variance committee assessment completed by the activities director, social services, the food and nutrition director (DFN) and a licensed vocational nurse. All of whom do not have the scope of practice to conduct resident assessments. The activities director and social services designee are not health professionals and therefore conduct health care assessments. Review of the scope of practice for the CDM by the Certifying Board of Dietary Managers does not include conducting nutritional assessments. It allows members to perform some tasks including conduct routine nutritional screening and comply with Federal and State regulations related to effective nutrition services. The Director of Nursing (DON) in an interview on (MONTH) 3, (YEAR) at 10:05 AM, was asked about the make-up of the weight variance committee and lack of the participation of a registered nurse to ensure the proper professionals were present to conduct the meeting. The DON acknowledged the registered nurse needed to participate in the meetings. The DON in the concurrent interview indicated she is usually there to provide oversight to the licensed vocational nurse in the meeting. The DON further stated she would sign the form as proof of her participation. The DON did not sign the (MONTH) 8, (YEAR) notes by the team. The weight variance progress notes in Resident 8s clinical record showed all four: Activities, Social Services designee, DFN and licensed vocational nurse, signed and recommended the discontinuation of two medications (one was for depression) and continuation of weekly weights until weight stable and follow up with RD as needed for further fluctuations. There were no other interventions initiated, including further assistance with meals. The weight variance team did not refer Resident 8 to the RD for further nutrition assessment despite continual weight loss. The last assessment documented in the clinical record by the RD was the (MONTH) (YEAR) initial assessment. The weight variance committee indicated Resident 8 was in a supervised group in the dining room. The intervention was not effective as Resident 8 lost an additional 9.4 lbs. from (MONTH) (YEAR) to (MONTH) weighing 129.4 lbs. on (MONTH) 4, (YEAR). Record review showed on (MONTH) 11, (YEAR), DFN completed the facility document titled Quarterly Nutritional Assessment. DFN documented skin intact when Wound Assessment notes documented Resident 8 had an unstageable pressure ulcer. DFN also documented weight loss of 10 lbs. or 7.19 % in 30 days, which is considered severe. (5 % in 30 days is significant, > 5 % is considered severe). Her plan was updated care plan will continue to monitor food preference. Development and updating a care plan would require a professional scope of practice for resident assessment. The DFN did not have the qualifications to conduct resident assessments. There was no analysis of the cause of the weight loss or new interventions to slow down or prevent further weight loss. Resident 8's weight records documented an additional 4.8 lbs. loss from (MONTH) to (MONTH) (YEAR). The RD was not consulted. There was no documented intervention or care plan to address the continuing weight loss. The Director of Nursing (DON) in the (MONTH) 3, (YEAR) starting at 10:06 am stated according to the facility policy, only 5 lbs. weight loss are reported to the physician and the RD. Record review showed the last quarterly MDS dated [DATE] also inaccurately documented that Resident 8 did not have any weight loss. According to the monthly weigh record, by (MONTH) 4, (YEAR) Resident 8 lost 13 lbs. or 9.2 % in less than three months. The weight loss should have triggered a change in condition assessment. Resident 8's weight loss continued with an additional weight loss of 4.8 lbs. in February. Record review showed the (MONTH) 23, (YEAR) IDT meeting notes, the IDT noted in the resident's clinical record intake stable, with 80% snacks consumed throughout the day, MD aware, [MEDICAL CONDITION] resolved. There was no mention of the severity of Resident 8's weight loss. The DON who was a member of the IDT was interviewed on (MONTH) 3, (YEAR) starting at 10:06 AM. DON stated the assessment that intake was stable based on the review of Resident 8's meal percentage record. On (MONTH) 3, (YEAR) at 10:06 AM, the DON was interviewed about the facility's actions related to the Resident 8's weight loss. Concerns about why staff who were not able to assess based on their scope of practice were allowed to conduct weight variance and IDT meetings without the presence of a registered nurse was raised. Concerns about the lack of documentation in the Activities of Daily Living (ADL), with respect to the percentage of meal consumption, was also discussed. The DON stated the weight loss was possibly due to end-stage dementia and that resident receives staff assistance with meals. Record review showed MD (physician) progress notes on 2/28/18 revealed physician was aware of Resident's 8's weight loss and poor appetite. The MD documented not eating good. This was not in line with the IDT. Meal consumption was documented as 100 % of supplements and 70 % of meals. A review of the physician's order showed the medication for depression was reordered in (MONTH) when staff noticed she was more tearful and crying. In (MONTH) and (MONTH) (YEAR), monthly weight record showed Resident 8 lost 4.8 lbs. each month, weighing 119.8 lbs in March. On (MONTH) 2, (YEAR), Resident 8 weighed 117.2 lbs. A total weight loss of 25.4 lbs. or 17.8 % in almost six months. On (MONTH) 9, (YEAR), a short Term Care plan related to weight loss was developed. There was an order to increase the Health Shakes to three times a day. According to the nutrition information on the container, a carton of Mighty Shake (a serving) provide additional 200 calories per meal. This would provide an additional 600 calories a day. The DFN completed another quarterly assessment on 4/18/18. The DFN documented total weight loss 12 pounds in 90 days or 9.38 % in 90 days. Weight loss of greater than 7.5 % is considered severe (CMS State Operations Manual. The intervention was the same Updated care plan and food preferences. Based on the fortified diet and two supplements in a day (not counting the snacks documented at 100% three times a day), Resident 8 was provided a total of 3400 calories per day. With this amount of calories and assessed need of 1575 - 1706 calories per day, and facility staff documenting Resident 8 eating 100 % of supplements and 70 % of meals, it is difficult to explain why Resident 8 was losing weight. The documentation in the clinical record implied that Resident 8 consumes 400 calories from supplements (twice a day) and 1960 calories from meals, a total of 2360 calories a day at a minimum, Resident 8 should not have experienced any weight loss. RD acknowledged in an interview on (MONTH) 2, (YEAR) at 4:40 PM, based on the calculated caloric intake, Resident 8 should not be losing weight. Meal Observations were conducted on (MONTH) 2 and (MONTH) 3, (YEAR). On (MONTH) 2, (YEAR) at 12:45 PM, Resident 8 was observed in the dining room sitting across the table from another resident. There were staff in the dining room but none close enough to cue her to eat. She received a serving of roast beef, a serving of sweet potatoes, mixed vegetables with melted cheese, milk, ice cream and a biscuit. Resident 8 was observed taking a few bites of the beef. A few minutes later she wiped her mouth, put down her head, and did not continue to eat. At 1:12 PM, Resident 8 was observed to have eaten almost all her meat, ½ of the vegetables and left the other items untouched. This would be about 25% of the meal. The meal tray was taken away to the kitchen. Review of the facility form titled Activities of Daily Living (ADL) Documentation for (MONTH) (YEAR) for Resident 8 on (MONTH) 2, (YEAR) at 2:55 PM showed no documentation for the meal consumed. It was blank. The form was blank for meals consumed the day before. On (MONTH) 2, (YEAR) at 4:40 PM, the DFN was interviewed about the quarterly assessments she had conducted and the lack of interventions to stop Resident 8's weight loss. DFN stated she believed she was qualified to conduct nutrition assessments because she was a CDM (Certified Dietary Manager). DFN stated she had observed Resident 8 on many occasions and acknowledged she required some feeding assistance but otherwise ate well. DFN did not respond when she was asked why this intervention was not attempted or shared with the nursing staff. In a concurrent interview with the RD, who was present in the room, RD indicated that she had recommended the fortified diet and milkshakes to three times a day. In response to a question about how Resident 8 could consume the total number of calories reported by staff and still lose weight, RD stated Resident 8 should not lose weight. (During kitchen inspection, it was determined that the food and nutrition staff may not have provided the fortified diet as planned -cross Reference F806, F800) On (MONTH) 3, (YEAR) at 8:12 AM, documentation was still incomplete (blank) for (MONTH) 1 and (MONTH) 2, (YEAR) meals. On (MONTH) 3, (YEAR) at 8:15 AM, the surveyors watched Resident 8 eating breakfast in her room watching TV with no staff assistance. The surveyors observed the following items were on her tray: 2 slices of toast, 1 bowl of cold cereal, 1 egg, over easy, 1-4oz cup of milk, I carton of the strawberry milkshake (supplement), 1 serving of hash browns and 4 ounces Apple Juice. On (MONTH) 3, (YEAR) at 8:42 AM, CNA N1 was observed in the room with Resident 8. CNA N1 asked if Resident 8 would like to drink her milkshake and refused. Resident 8 stated I don't like pink, referring to the strawberry milkshake and pushed the CNA's hand away with the milkshake in it. Resident 8 ate about 42% of her meal. She ate 1 bowl of cold cereal, ½ slice of toast, 4oz cup of milk, ½ of the Apple juice. On (MONTH) 3, (YEAR) at 10:06 AM, the DON was interviewed about the facility's actions related to the Resident 8's weight loss. Concerns about why staff who were not able to assess based on their scope of practice were allowed to conduct weight variance and IDT meetings without the presence of a registered nurse was raised. Concerns about the lack of documentation in the Activities of Daily Living (ADL), with respect to the percentage of meal consumption, was also discussed. The DON stated the weight loss was possibly due to end-stage dementia and that resident receives staff assistance with meals. The DON stated Resident 8's weight loss was stable and that was why the referral was not made to the RD. Regarding the documentation of meals, The DON stated in the concurrent interview that facility staff have a chart to document meal intake percentages. She also stated there was another binder that included patient vitals, that the staff may have documented in (ADL Sheets). Review of the binder by the surveyor on (MONTH) 2, (YEAR) at 3:00PM showed information missing (blank) for lunch on (MONTH) 2, (YEAR). Surveyors checked the Meal Intake % Sheet for Resident 8 on (MONTH) 3, (YEAR) at 8:12 AM, percentage of meal consumed for lunch for (MONTH) 1, (YEAR) and for (MONTH) 2, (YEAR) breakfast and were still incomplete and dinner for (MONTH) 2, (YEAR) was documented as 70%. Breakfast for (MONTH) 3, (YEAR) was also blank. Observations on (MONTH) 2 and (MONTH) 3, (YEAR) regarding the limited or lack of assistance during meals was shared with the DON. The DON, during the concurrent interview, presented the ADL sheets which were now completely filled out. The ADL form indicated that for lunch on (MONTH) 2, (YEAR), Resident 8 ate 100 % of her meal. This amount was significantly different from the surveyor observation of 25%. This form also indicated that Resident 8 consumed 50 % of her breakfast on (MONTH) 3, (YEAR). When the observed amounts documented by the surveyor was shared with the DON, the ADL percentage was changed, not sure by whom, to read 30%. The DON called it an error and that the CNA had documented accidentally charted the wrong percentage for the resident in the record. A review of the ADL sheets for February, (MONTH) and (MONTH) (YEAR) showed two times that the resident ate less than 50% of her meals. The documentation of meals for (MONTH) (YEAR) averaged 79%, in (MONTH) (YEAR) 78% and in (MONTH) (YEAR) 82.5%. There was documentation on the ADL form Resident 8 ate 100 % of her snacks at 10 AM, 3PM, and 8 PM. Review of the Snack List for revealed that Resident 8 was not on the list of residents who received snacks at the times documented. A review of the physician's orders through (MONTH) 3, 2108 and snack list from the kitchen, showed there was no physician order for [REDACTED].>An interview was conducted with CNA N1 on (MONTH) 3, (YEAR) at 12:57 PM regarding documentation of Resident 8's meals. CNA N1 indicated he documented 100% because she gets snacks, although he acknowledged he did not see her get one. CNA N1 stated that Resident 8 does not eat well and that he always fed her whenever he provided care. A review of the facility policy and procedure (P/P) revised (MONTH) (YEAR) titled Evaluation of Weight and Nutritional Status stated the purpose of the policy as assessing the resident's nutritional status and the factors that put the resident at risk of maintaining acceptable parameters of nutritional status. Analyzing the assessment information to identify the medical conditions, causes and/or problems related to the resident's condition and needs. Defining and implementing interventions for maintaining or improving nutritional status or the lack of response to the interventions. Revising or discontinuing the approaches as appropriate or justifying the continuation of current approaches.

Based on observations, resident interview, staff interviews, clinical record review and document review, the facility failed to provide adequate supervision and assistance to prevent one of three sampled residents (1) from getting burned, when four cups of hot coffee spilled on Resident 1's lap. This failure resulted in burns on both of Resident 1's inner thighs. Findings: Resident 1 was initially admitted to the facility on [DATE] and most recently admitted to the facility on [DATE]. Resident 1 had multiple [DIAGNOSES REDACTED]. Review of physician's progress notes dated 9/12/12 indicated Resident 1 had moderate dementia and was not capable (of making decisions). Review of the MDS (minimum data set, an assessment tool) dated 9/6/12, indicated Resident 1 had: > Behavioral symptoms that were not directed toward others including; scratching self, pacing, rummaging, verbal/vocal symptoms like screaming and; > One-sided impairment of both upper lower extremities.Review of facility care plan for Resident 1 titled, "Cognitive/Neurological Deficit" dated 6/7/10 revealed: > [DIAGNOSES REDACTED]. >An approach to care dated "6/7/10," "3/12," "6/12," and "9/12" stipulated all staff will monitor closely for safety. Review of facility care plan for Resident 1 titled, "Functional Status, Musculoskeletal" dated 6/7/10 indicated: > "Left sided weakness, no movement on left side due to CVA, > Inability to perform independent ADLs (activities of daily living) and; > Impaired ROM (range of motion)." >An approach to care dated 7/12/12 stipulated, "Frequent visual checks to ensure safety." Review of "NURSES' PROGRESS NOTE(S)" dated 9/5/12 through 9/18/12 indicated under the section titled, "BODY CONTROL PROBLEMS; L (left) side paralysis" and on 9/5/12 under the section titled, "COGNITIVE STATUS; Deteriorated MD notified, (increased) confusion."Review of the "BEHAVIORAL MEDICINE EVALUATION & MANAGEMENT NOTE", dated 9/12/12 stipulated, under the section "Clinical Impressions" SLUMS (Saint Louis University Mental Status) showed clear dementia...with 17/30 score, indicating poor decision making capacity." and under the section titled, "PATIENT MANAGEMENT RECOMMENDATIONS TO STAFF; >Re-direct, reorient and reassure, PRN (as needed), >Staff to mon (monitor) behaviors and med (medication) effects."Review of the Social Service Progress Note dated 9/12/12 indicated, "Resident based on the report by psychiatry nurse practitioner on thought processes. ...Judgement poor."Review of nurses' notes written by the licensed nurse (LN)1, dated 9/24/12 at 1:45 p.m., indicated, "P(atien)t. was brought to me crying with coffee in her lap. She said it was burning. I took pt. in room...assessed skin for burns. Reddened area to inner thighs noted. MD notified. Cleanse(d) with NS (normal saline), pat dry, apply thermazine (a topical cream used to treat or prevent infections on areas of burned skin) daily x (for) 14 days per MD orders. Asked receptionist what happened, she reported, 'Pt asked for a fresh batch of coffee. She filled 4 cups of coffee and put them in her lap then rolled back and spilled hot coffee in her lap.' When I asked Pt she said she was getting coffee for other residents. ...RP (responsible party) notified."Review of physician's orders [REDACTED]. It further revealed these areas were to be cleansed with normal saline, patted dry, and have thermazene applied daily for 14 days.Review of physician's orders [REDACTED]. It further revealed this area was to be cleansed with sterile water, patted dry, apply Santyl ointment (used for removal of dead skin from wounds and burned areas), and cover with a dry dressing daily for 30 days. Review of a Surgical Consult by a physician's assistant (PA) for Resident 1 dated 10/2/12 included: >Wound 1 was located on the right medial thigh and was a result of trauma. It further indicated, "This irregular wound is a result of hot coffee spilled onto the thighs. The burn did produce bullae, (blisters filled with fluid) which did open. ...Now there is thin but adherent yellow slough (dead matter separated from living tissue). This is a subcutaneous (third of the three layers of skin) wound." Measurements of wound 1 were 11.5 cm (approx 4.5 inches) in length, 16.4 cm (approx 6.5 inches) in width and a depth of 0.1 cm. >Wound 2 was located on the left medial (toward the middle) thigh and was a result of trauma. It further indicated, "This irregular wound is...a mirror image of wound 1. It is a result of hot coffee spilled onto the thighs. ...This is a subcutaneous wound. Measurements of wound 2 were 11 cm (approx 4.25 inches) in length, 11 cm in width and 0.1 cm in depth.Review of physician's orders [REDACTED].Review of physician's orders [REDACTED].In an interview with Resident 1 on 10/24/12 at 9:40 a.m., she stated, "I was in the front lobby after lunch at 12:30 (p.m.). Coffee was comparable to (a drive through fast food venue years ago." She said she was helping three residents by getting them coffee, and it was an accident. She did not remember if any staff were in the lobby. Resident 1 said she had all four cups in her lap stacked up, and all had tight lids. She stated, "I lost control and it all spilled on me and burned my thighs."In a concurrent observation and interview with the Dietary Services Supervisor (DSS)10/24/12 at 10:45 a.m., the coffee in the lobby was discussed. The DSS stated the kitchen provided coffee for the front lobby. She further stated they always had coffee brewed and ready to refill the lobby coffee container. When asked by what means she measures food/liquid temperatures, she stated, "We have a digital thermometer. It is accurate." The temperature of coffee poured into a cup from the coffee maker in the kitchen was taken by the DSS. The temperature was 172 degrees.In a concurrent observation with the DSS on 10/24/12 at 10:50 a.m., the coffee temperature in the front lobby was taken by the DSS. The temperature was 174 degrees.In an interview with the Director of Nursing (DON) on 10/24/12 at 11:10 a.m., she stated the coffee in the front lobby was there for everyone. She acknowledged Resident 1 had a history of self-mutilating behavior. In a concurrent observation of Resident 1's wounds with the wound nurse (WN) 10/24/12 at 1:40 p.m., the wounds were measured by WN. The wound on the left inner thigh measured 7 cm long (approx 2.75 inches) by 4 cm (approx 1.5 inches) wide with an open area 5 cm (approx 2.0 inches) long by 4 cm wide. The wound on the right inner thigh measured 6 cm (approx 2.5 inches) long by 5 cm wide with an open area 4.5 cm (approx 1.75 inches) long by 2.5 cm (approx 1.0 inch) wide.In an interview with Resident 1's physician, on 10/24/12 at 2 p.m., He said coffee in the front lobby is a good thing, but he was concerned about residents trying to get coffee for themselves.In an interview with LN1 on 10/24/12 at 2:30 p.m., he said he was the nurse in charge of Resident 1 on the day of her burn. He stated if residents had advanced skills with ADLs he would be okay with them getting their own coffee from the front lobby, but Resident 1 liked to advocate for herself and over exaggerated her independence and ability.In a concurrent interview on 10/24/12 at 3:30 p.m., with the administrator (Admin), director of staff development (DSD), and DON, Resident 1's nursing care and inner thigh burns were discussed.>The functional status, musculoskeletal care plan for Resident 1 was discussed with the DON. She acknowledged it indicated Resident 1 was unable to perform independent ADLs and required frequent checks to ensure safety. When asked if Resident 1 should be getting her own coffee, she stated, "No."> In an interview with the Administrator, he said that in the (undefined) past he observed Resident 1 in the front lobby getting coffee. During that observation, Resident 1 put a cup under her arm, set a second cup on the counter, filled the cup, set the second cup in her lap and took the cup from under her arm and filled it. The Administrator stated he intervened at that time because he did not want Resident 1 spilling coffee all over the lobby. When asked if that behavior by Resident 1 was expected to be put on the care plan, he stated, "We have all of these behaviors and we can't cover them all." The Administrator further stated Resident 1 was manipulative, had many behavior issues, and was unsafe. > When asked about the coffee in the front lobby, he said every resident that was capable of getting to the lobby could get their own coffee and they (the residents) would be penalized if the coffee was removed. He further acknowledged he was responsible for the safety of all residents in the facility. > The DSD reviewed the clinical record for Resident 1 and was unable to locate a care plan that addressed the issue of the front lobby coffee behavior. Both the DSD and DON acknowledged a care plan for this behavior should have been done.The American Burn Association Scald Injury Prevention Educator's Guide downloaded from http://downplaying/PDF/Unsafely/Scalding on 12/7/12 at 1:20 p.m., stipulated under the section titled, "High Risk Groups; Older adults, >Older adults...have thinner skin so hot liquids cause deeper burns with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred." Under the section titled, "People with Disabilities and special needs; >Individuals who may have physical, mental or emotional challenges or require some type of assistance from caregivers are at high risk for all types of burn injuries including scalds. ...Mobility impairments, slow or awkward movements, muscle weakness or fatigue, or slower reflexes increase the risk of spills while moving hot liquids. Burns to the lap are common when a person attempts to carry hot liquids or food while seated in a wheelchair. ... Changes in a person's intellect, perception, memory, judgment or awareness may hinder the person's ability to recognize a dangerous situation. ... or respond appropriately to remove themselves from danger" and in the chart titled, "Time and Temperature Relationship to Severe Burns" it stipulated a third degree burn will occur in one second with a water temperature of 155 (degrees) F (Fahrenheit, a unit of thermal measurement). During an additional observation of the facility on 10/25/12 at 4:46 p.m., a vacuum-type non-electric thermos was placed in the facility's lobby area by the receptionist. At 4:50 p.m., the temperature of the coffee was checked by the DSS using a digital thermometer. The temperature was 175 degrees F. According to the DSS, the coffee maker made coffee at 180 degrees F. At 4:55 p.m., the DON was advised of the temperature of the coffee in the lobby. She agreed it was too hot to be safe. In an interview with the DON on 10/25/12 at 5:10 p.m. she said the burn to Resident 1 would not have happened if the coffee was not in the front lobby or people had monitored it.