Every finding on record at Royal Palms Post Acute

Based on observation, interview, and record review, the facility failed to ensure a sufficient number of skilled nurses who provide wound care treatment within the facility was adequate for 5 of 6 sample residents (Resident 2, 3, 4, 5, 6) who required wound care treatment. This deficient practice had the potential to result in delayed wound healing, worsening of wounds, infection, pain, and a decline in the residents' overall condition. During a record review of Facility Skin and Wound Report dated 8/14/2026, indicated a total of sixty-six active wounds. During a record review of the Nursing Staffing Assignment and Sign- In Sheets dated 8/5/26, 8/6/2026, 8/10/2026,8/11/2026/8/12/2026,8/13/2026,8/14/2026/8/17/2026 and 8/18/2026, the Sheet indicated one treatment nurse / licensed vocational nurse (LVN) was assigned on reviewed shift each day. Further review of the staffing assignment sheet dated 9/19/2026 revealed no treatment nurse/ LVN was assigned. During a record review of the facility's Treatment Nurse - LVN job description updated 11/1/2024, the description indicated the treatment nurse was responsible for providing specialized skin care to residents under the supervision of the Attending Physician, Director of Nursing (DON, or Medical Director. The Treatment Nurse's responsibilities include providing primary skin care and management of skin disorders and lesions, conducting weekly skin assessments and documenting and tracking changes. Further indicating the LVN treatment nurse will provide treatments and therapeutic services as prescribed by physicians, including management of decubitus ulcers, providing preventive skin care, completing weekly skin reports for the DON and collaborating with the medical Director, DON , and wound care consultants regarding resident care. The Job description further indicated the Treatment Nurse was expected to organize, prioritize, and meet deadlines and provide comprehensive skin care and therapeutic services in accordance with physician orders and regulatory standards. During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE] for orthopedic (including the bones, joints, muscles) aftercare following surgical amputation, gangrene (death of tissue), and cutaneous abscess (collection of pus within the skin) of right foot. During a review of Resident 2's Minimum Data Set (MDS- comprehensive assessment and care screening tool) dated 8/19/2026, the MDS indicated Resident 2 was cognitively intact (mental processes) in daily decision - making and indicated Resident 2 required only supervision while performing most tasks of daily living such as eating, oral hygiene, toileting and showering. During a review of Resident 2's care plan titled The Resident has actual impairment to skin integrity of the right 5th toe stump related to surgical status post amputation dated 8/14/2026, with a goal to minimize risks of complications to surgical stump of right 5th toe. The care plan intervention indicated treatment of right fifth toe stump surgical wound to be done everyday shift for wound management. During a review of Resident 2's Treatment Administration record (TAR) for the month of August 2026 , the TAR indicted physician ordered treatment dated 8/15/2026 for treatment of right 5th toe stump surgical wound: to be cleansed with Dakins ( antiseptic solution) and apply Medi- honey ( a medical grade honey wound treatment) and calcium alginate( absorbent wound dressing ) , then cover with ABD ( abdominal pad highly absorbent sterile dressing) pad, wrap with rolled gauze and then secure with tape every day shift for wound management . During a review of Resident 3's AR, the AR indicated Resident 3 was admitted to the facility on [DATE] with a diagnosis to include cellulitis (bacterial infection of the deeper layers of the skin and tissues underneath it) of right lower limb. During a review of Resident 3's MDS dated [DATE], the MDS indicated resident 3 may have difficulties with memory or recall and requires maximal assistance (helper does more than half the effort) with activities that include toileting hygiene, showering, lower body dressing and putting on / taking off footwear. During a review of Resident 3's care plan titled The resident has diabetic ulcer of the right heel dated 7/6/2026, the care plan indicated a goal for complications related to ulcer to be minimized. The care plan interventions indicated right heel diabetic ulcer treatment every day shift for wound care management and as needed for dislodged dressing. During a review of Resident 3's care plan titled Chronic Venous Hypertension with Ulcer Problem: impaired skin integrity dated 5/13/2026, the care plan indicated a goal to promote wound healing with interventions to perform wound care per orders and monitor for infection. During a review of Resident 3's care plan titled Cellulitis of Right Lower Limb dated 8/2/2026, the care plan indicated the goal was to have infection resolved without complications and interventions to include wound care per physician orders. During a review of Resident 3's TAR for 8/12/2026, the TAR indicated physician ordered treatment date of 8/6/2026 for Santyl (used for removing dead tissue) Topical ointment to be applied to right anterior (front) lower leg topically everyday shift. The treatment administration field for August 12, 2026, was left blank, with no documentation indication the ordered treatment was administered. During a review of Resident 3's TAR for 8/12/2026 and 8/18/2026, the TAR indicated physician ordered treatment date on 8/6/2026 for Santyl topical ointment to be applied to Right Heel topically everyday shift. The Treatment administration field for 8/12/2026 and 8/18/2026 was left blank, with no documentation to indicate the ordered treatment was administered. During a review of Resident 3'sTAR for 8/12/2026, the TAR indicated physician ordered treatment date on 8/6/2026 for Santyl topical ointment to be applied to right posterior lower leg topically everyday shift. The treatment administration field for 8/12/2026 was left blank, with no documentation to indicate the ordered treatment was administered. Durin a review of resident 4's AR, the AR indicated Resident 4 was admitted on [DATE], with a diagnosis of Chronic (persists a long time) venous hypertension (increased pressure within the veins) with ulcer (open sore) of left and right lower extremity. During a review of Resident 4's History and Physical (H&P) dated 4/19/2026, the H&P indicated the resident has ability to understand and make decisions. During a review of Resident 4's MDS dated [DATE], the MDS indicated resident has moderate cognitive impairment(forgetful) and requires Maximal assistance with activities such as personal hygiene and dressing lower body. During a review of Resident 4's Order Summary Report , the Report indicated treatment was ordered on 4/20/2026 to monitor testicular edema (a buildup of extra fluid in the skin and tissues of the scrotum) on right side everyday shift. During a review of Resident 4's TAR for 8/18/2026, the TAR indicated physician ordered treatment date of 4/20/2026 to monitor testicular edema on right every day shift. The treatment administration field for 8/18/2026 was left blank, with no documentation to indicate the ordered treatment was completed. During a review of Resident 4's care plan titled Right Testicular Edema/ Male Genital Disorder dated 8/12/2026, the care plan indicated a goal that scrotal edema will remain stable or improved with an intervention to monitor swelling routinely, assess for pain and redness, and Report sudden size changes and encourage comfort positioning. During a review Resident 5's AT, the AR indicated Resident 5 was admitted on [DATE], with a diagnosis of infection following a surgical encounter and dehiscence of closure of surgical wound (separation or reopening of a closed surgical wound). During a review of Resident 5's H&P dated 6/29/2024, the H&P indicated Resident 5 does not have the capacity to understand and make decisions. During a review of Resident 5's MDS dated [DATE], the MDS indicated Resident 5 is cognitively intact ((mental capacity) and is totally dependent on staff for lower body dressing and putting on and taking off footwear. During a review of Resident 5's TAR dated 8/18/2026, the TAR indicated a treatment order for hibiclens (antiseptic agent used to reduce or kill bacteria) topical solution to be applied to back rashes everyday shift and an order for Mupirocin (antibiotic) topical ointment to be applied to back every day shift for rashes. The treatment administration field for 8/18/2026 for both treatments was left blank, with no documentation to indicate the ordered treatment was completed. During a review of Resident 5's TAR for 8/9/2026 , 8/12/2026 and 8/18/2026, the TAR indicated a treatment for mid chest surgical wound to be cleansed with normal saline, pat dry and to apply collagen power and calcium alginate then cover with dry dressing every day shift for wound management . The treatment administration field for 8/9/2026, 8/12/2026, and 8/18/2026 was left blank, with no documentation to indicate the ordered treatment was completed. During a review of Resident 5's TAR for 8/9/2026, 8/12/2026, and 8/18/2026, the TAR indicated treatment for Right lower abdomen reopened surgical wound to be cleansed with normal saline, pat dry, apply calcium alginate then cover with dry dressing every day shift for wound management. The treatment administration field for 8/9/2026, 8/12/2026, and 8/18/2026 was left blank, with no documentation to indicate the ordered treatment was completed. During a review of Resident 5's Order summary dated 6/28/2026, the Order summary indicated treatment for mid chest surgical wound to be done every day shift for wound management. During a review of Resident 5's Order summary dated 8/8/2026, the Order summary indicated treatment for right lower abdomen reopened surgical wound to be done every day shift for wound management. During a review of Resident 5's care plan titled the Resident has actual impairment to the skin integrity of the right lower abdomen related to reopened surgical wound date revised 8/18/2026, the care plan indicated a goal to minimize the risk for injury. The care plan indicated interventions to include treatment to right lower abdomen reopened surgical wound to be done every day shift for wound care management. During a review of Resident 5's care plan titled The resident has actual impairment to skin integrity of the mid chest related to surgical wound, dated 8/18/2026, the care plan indicated a goal to minimize injury. The care plan indicated interventions to include treatment and monitoring of mid chest surgical wound to be done everyday shift for wound care management. During a review of Resident's 5 care plan titled Risk for infection transmission related to presence of unidentified rash and potential communicable pathogen dated 2/26/2026, the care plan goal indicated that Resident 5's rash would have signs of healing. The care plan indicated interventions that includes skin care and treatment as ordered by MD with topical applications as prescribed. During a review of Resident 6's AR, the AR indicated the resident was admitted to the facility on [DATE] with a diagnosis of chronic ulcers of right heel, midfoot, and right and left lower leg. During a review of Resident 6's MDS dated [DATE], indicated the resident has severe cognitive (mental capacity) impairment and requires total dependance for most all activities of daily living (ADLs). During a review of resident 6's care plan titled The resident has diabetic ulcer of the Right heel related to Diabetes dated 6/14/2026, the care plan indicated the goal was to have complications related to ulcer minimized and interventions of Treatment to right heel ulcer During a review of Resident 6's care plan titled the resident has diabetic ulcer of Right lateral(outer) foot related to do Diabetes dated 6/14/2026, the care plan indicated a goal for the resident's risk for complications related to ulcer will be minimized. The care plan indicated interventions to include treatment of right lateral foot diabetic ulcer. During a review of Resident 6's care plan titled The resident has diabetic ulcer of the Right Plantar foot (bottom of foot near the toes) related to diabetes dated, 6/14/2026, the care plan indicated a goal for risk for complication to be minimized and intervention to include right plantar foot diabetic ulcer cleansed with normal saline, pat dry with betadine, then cover with dry dressing. During a review of Resident 6's TAR, the TAR indicated a Physician's order for Silvadene (antimicrobial medication used to treat infection in wounds) external cream to be applied to Right heel topically everyday shift. The treatment administration field for 8/18/2026 was left blank, with no documentation to indicate the ordered treatment was completed. During a review of Resident 6's TAR, the TAR indicated a physician' s order for treatment of Silvadene external cream to be applied to Right lower leg topically every day shift. The TAR administration field for 8/18/2026 was left blank, with no documentation to indicate the ordered treatment was completed. During a review of Resident 6's TAR, the TAR indicated a physician' s order for treatment of right anterior (front) of great toe ulcer to be cleansed with normal saline, pat dry, paint with betadine, then cover with dry dressing to be done everyday shift for wound management. The TAR administration field for 8/18/2026 was left blank, with no documentation to indicate the ordered treatment was completed. During a review of Resident 6's TAR, the TAR indicated a physician' s order for treatment of Right lateral (side) foot ulcer to cleansed with normal saline, pat dry, paint with betadine, then cover with dry dressing to be done everyday shift for wound management. The TAR administration field for 8/18/2026 was left blank, with no documentation to indicate the ordered treatment was completed. During a review of Resident 6's TAR, the TAR indicated a physician's order for right Medial 1st metatarsal (one of the 5 long bones in the middle of the foot) ulcer dressing to be changed every day shift for wound management. The TAR administration field for 8/18/2026 was left blank, with no documentation to indicate the order treatment was completed. During a review of Resident 6's TAR, the TAR indicated a physician's order for treatment of Right medial great toe ulcer to cleansed with normal saline, pat dry, paint with betadine, then cover with dry dressing to be done everyday shift for wound management. The TAR administration field for 8/18/2026 was left blank, with no documentation to indicate ordered treatment was completed. During a review of Resident 6's TAR, the TAR indicated a physician's order for treatment of right plantar foot ulcer dressing to be changed everyday shift for wound management. TAR administration field for 8/18/2026 was left blank, with no documentation to indicate ordered treatment was completed. During a review of Resident 6's TAR, the TAR indicates a physician's order for treatment of Right medial foot with normal saline, pat dry, apply Silvadene and cover with dry dressing to be done everyday shift for wound management. The TAR administration field for 8/18/2026 was left blank, with no documentation to indicate ordered treatment was completed. During a concurrent observation and interview on 8/19/2026 at 10:45 AM with Registered Nurse (RN)1, treatment carts 1 & 2 were observed. RN 1 stated the facility utilized two treatment carts and identified residents requiring treatments by reviewing the treatment administration records (TARs) for each cart. Concurrent review of the treatments carts/ TARs with RN1 indicated treatment cart 1 had 32 residents requiring wound care/ treatments and Treatment cart 2 had 29 resident requiring wound care/ treatments, for a total of 61 residents. RN1 confirmed the count and stated some residents require treatment twice daily. RN 1 stated the facility did not perform treatments in the evening or night shifts and the treatments were expected to be completed on the day shift.RN1 stated that two LVN treatment nurses were needed to complete the treatments for the 61 residents requiring wound treatment in the facility. RN 1 stated that one LVN had been performing the treatments by herself for about one week. On 8/19/2026, the assigned treatment nurse had called off, and RN1 stated he was informed prior to the shift that he would perform both RN supervisor and treatment nurse duties. During an interview on 8/19/2026 at 11:14 AM with Resident 2, Resident 2 stated he had noticed a shortage of treatment nurses at the facility and believed this because his scheduled wound treatment was missed on 8/17/2026. Resident 2 stated his wound treatment was ordered once daily. Resident 2 stated that when his treatment was not completed, he asked the medication LVN to change his dressing and was told the treatment nurse had already left for the day. Resident 2 stated the LVN did not change or offer to change the dressing. Resident 2 expressed concern regarding the missed treatment because he had recently had an amputation of one of his toes. During an interview on 8/19/2026 at 11:25 AM with Infection Preventionist (IP), IP stated the treatment nurse had quit approximately one week earlier. The IP stated he was not aware that residents had not been receiving their ordered treatments. IP could not state who covered the treatment nurse when the treatment nurse was not in the facility. During an interview on 8/19/2026 at 11:33 AM with Resident 3, Resident 3 stated it seemed the facility was short of treatment nurses because his ordered treatments to his heel and leg had not been provided the previous day (8/18/2026). Resident 3 stated no staff member came to perform the treatments. Resident 3 stated the treatment nurse provided treatment Resident 3's roommate and then left the facility without returning. Resident 3 stated he continued to ask facility staff for wound care treatment up until 11 PM, but no one came to provide treatment to Resident 3's heel and leg. Resident 3 stated he felt he was not receiving the care and treatment he needed. Resident 3 further stated he experienced pain and believed wounds were not improving because his treatments were not being provided as ordered. During a concurrent interview and record review on 8/19/2026 AT 11:50 AM with Licensed Vocational Nurse (LVN) 1, Resident 3's TAR was reviewed for 8/18/2026. The TAR indicated Resident 3's ordered treatments were overdue and remained pending at the time of review. During a concurrent interview and Record review on 8/19/2026 at 12 PM with the Director of Nursing (DON) , Resident 3's TAR dated 8/18/2026 was reviewed. The DON observed that the ordered treatments were displayed in red as overdue and had not been signed as completed. The DON stated that the absence of documentation / signature in the TAR of any resident indicated the treatment had not been provided. During an interview on 8/25/2026 at 1:20 PM with Resident 4 , Resident 4 stated he received wound care treatments he thought, every other day. Resident 4 stated he had noticed the facility appeared to be short of staff and may not have received all treatments for his wounds. During a concurrent interview and record review on 8/19/2026 at 1:30 PM , with RN 2 , Resident 5's TAR was reviewed. The TAR indicated the ordered treatment was administered on 8/17/2026 however, there was no documentation indicating the treatment was provided on 8/18/2026 . During an interview on 8/19/2026 at 1:41PM with Resident 5, Resident 5 stated he believed his treatment had been provided approximately once every two days rather than every day. During a concurrent interview and record review on 8/19/2026 at 1:41 RN 1 , Resident 6's TAR was reviewed. The TAR indicated the treatment was not documented as administered on 8/18/2026. Durning a concurrent interview and record review on 8/19/2026 at 1:51 PM with LVN 2 , Resident 6's TAR was reviewed. LVN 2 stated no wound care was provided for 8/18/2026. During an interview on 8/19/2026 at 1:57 PM with Resident 6, Resident 6 stated his dressing changes were ordered to be completed daily, however the staff does not always provide the dressing changes as ordered. Resident 6 stated even when he requested that staff change his wound dressing, the treatment was not always provided. Resident 6 further stated he believed staff did not like him and dressing were only changed when staff wanted to perform the treatment. During an interview on 8/19/2026 at 2:49PM with DON, DON stated he was aware the facility did not have sufficient staff to provide wound care treatments . The DON stated the facility had hired three additional treatment nurses, which would bring the total to four. The DON continued to state that when the treatment nurse called off on 8/19/2026, an RN Supervisor was reassigned to perform treatments, and another RN assumed the supervisory duties. The DON stated the Assistant Director of Nursing (ADON) was responsible for reviewing the TAR to ensure ordered treatments were completed, however the ADON was on vacation. The DON stated he did not believe it was possible for one treatment nurse to complete all of the residents' required treatments and confirmed the treatment nurse had been working alone. DON further stated the treatment nurse had been provided additional time to complete treatments by coming in early and leaving late, however, the DON could not provide documentation that the treatment nurse came in early or left later then scheduled. The DON stated the facility had difficulties retaining a treatment nurse. During a review of the facility's facility assessment (FA, an assessment tool to determine what resources, such as nurse staffing needs, are necessary to care for its residents competently during both day-to-day operations and emergencies), dated 1/15/2026, the FA indicated a staffing plan that is based on the facility's resident population and their needs for care and support. The FA also indicated that the staffing plan is to ensure that [the facility has] sufficient staff members to meet the needs of the residents at any given time. Further review of the FA indicated that the plan includes an evaluation of overall number of facility staff members needed to ensure a sufficient number of qualified staff are available to meet each resident's needs. During a review of the facility's policy and procedure titled, Sufficient Staffing revised on October 2017, indicated the facility will provide sufficient numbers of staff with the skills and competency necessary to provide care and services to all residents in accordance with resident care plans and the facility assessment.

Based on interview and record review, the facility failed to ensure that physician-ordered wound care treatments were provided, in accordance to the physician's orders, resident care plans and the facility's policy and procedure (P&P) for Quality of Care for 5 of 7 sampled residents (Resident 3, 4, 5, 6, and 7) who were reviewed for wound care. This deficient practice resulted in residents not receiving ordered wound treatments and had the potential for delayed wound healing, worsening wounds, infection, pain, and other complications. During a review of Resident 3's admission Record (AR), the AR indicated Resident 3 was admitted to the facility on [DATE] with a diagnosis to include cellulitis (bacterial infection of the deeper layers of the skin and tissues underneath it) of right lower limb. During a review of Resident 3's Minimum Data Set (MDS- comprehensive assessment and care screening tool) dated 5/19/2026, the MDS indicated resident 3 may have difficulties with memory or recall and requires maximal assistance (helper does more than half the effort) with activities that include toileting hygiene, showering, lower body dressing and putting on / taking off footwear. During a review of Resident 3's care plan titled The resident has diabetic ulcer of the right heel dated 7/6/2026, the care plan indicated interventions to include right heel diabetic ulcer treatment every day shift for wound care management and as needed for dislodged dressing. During a review of Resident 3's care plan titled Chronic Venous Hypertension with Ulcer Problem: impaired skin integrity dated 5/13/2026, the care plan indicated a goal to promote wound healing with intervention to perform wound care per orders and monitor for infection. During a review of Resident 3's care plan titled Cellulitis of Right Lower Limb dated 8/2/2026, the care plan indicated the goal was to have infection resolved without complications and interventions to include wound care per physician orders. During a review of Resident 3's Treatment Administration Record (TAR) for 8/12/2026, the TAR indicated physician ordered treatment date of 8/6/2026 for Santyl (used for removing dead tissue) Topical ointment to be applied to right anterior (front) lower leg topically everyday shift. The treatment administration field for 8/12/2026 was left blank, with no documentation indicated that treatment was administered to Resident 3. During a review of Resident 3'sTAR for 8/12/2026 and 8/18/2026, the TAR indicated physician ordered treatment date on 8/6/2026 for Santyl topical ointment to be applied to Right Heel topically everyday shift. The Treatment administration field for 8/12/2026 and 8/18/2026 was left blank, with no documentation indicated that treatment was administered to Resident 3. During a review of Resident 3's TAR for 8/12/2026, the TAR indicated physician ordered treatment date on 8/6/2026 for Santyl topical ointment to be applied to right posterior lower leg topically every day shift. The treatment administration field for 8/12/2026 was left blank, with no documentation indicated that treatment was administered to Resident 3. Durin a review of resident 4's AR, the AR indicated Resident 4 was admitted on [DATE], with a diagnosis of Chronic (persists a long time) venous hypertension (increased pressure within the veins) with ulcer (open sore) of left and right lower extremity. During a review of Resident 4's History and Physical (H&P) dated 4/19/2026, indicated the resident has ability to understand and make decisions. During a review of Resident 4'sMDS dated [DATE], the MDS indicated resident has moderate cognitive impairment(forgetful) and requires Maximal assistance with activities such as personal hygiene and dressing lower body. During a review of Resident 4's Order Summary Report the Report indicated treatment was ordered on 4/20/2026 to monitor testicular edema (a buildup of extra fluid in the skin and tissues of the scrotum) on right side every day shift. During a review of Resident 4's TAR for 8/18/2026 the TAR indicated physician ordered treatment date of 4/20/2026 to monitor testicular edema on right everyday shift. The treatment administration field for 8/18/2026 was left blank, with no documentation to indicate the ordered treatment was completed. During a review of Resident 4's care plan titled Right Testicular Edema/ Male Genital Disorder dated 8/12/2026, the care plan goal indicated a goal that scrotal edema will remain stable or improved. The Care plan intervention indicated to monitor swelling routinely, assess for pain and redness, report sudden size changes and encourage comfort positioning. During a review Resident 5's AR, the AR indicated Resident 5 was admitted on [DATE], with a diagnosis of infection following a surgical encounter and dehiscence of closure of surgical wound (separation or reopening of a closed surgical wound). During a review of Resident 5's H&P dated 6/29/2024, the H&P indicated Resident 5 does not have the capacity to understand and make decisions. During a review of Resident 5's MDS dated [DATE], the MDS indicated Resident 5 is cognitively intact (mental capacity) and is totally dependent on staff for lower body dressing and putting on and taking off footwear. During a review of Resident 5's TAR dated 8/18/2026, the TAR indicated a treatment order for hibiclens (antiseptic agent used to reduce or kill bacteria) topical solution to be applied to back rashes every day shift and an order for Mupirocin (antibiotic ) topical ointment to be applied to back everyday shift for rashes. The treatment administration field for 8/18/2026 for both treatments was left blank, with no documentation to indicate the ordered treatment was completed. During a review of Resident 5's TAR for 8/9/2026 , 8/12/2026 and 8/18/2026, the TAR indicated a treatment for mid chest surgical wound to be cleansed with normal saline, pat dry and to apply collagen powder and calcium alginate (a natural, seaweed-derived gelatinous substance primarily used in advanced medical wound dressings to absorb heavy drainage and stop bleeding) then cover with dry dressing every day shift for wound management . The treatment administration field for 8/9/2026, 8/12/2026, and 8/18/2026 was left blank, with no documentation to indicate the ordered treatment was completed. During a review of Resident 5's TAR for 8/9/2026, 8/12/2026, and 8/18/2026, the TAR indicated treatment for Right lower abdomen reopened surgical wound to be cleansed with normal saline, pat dry, apply calcium alginate then cover with dry dressing every day shift for wound management. The treatment administration field for 8/9/2026, 8/12/2026, and 8/18/2026 was left blank, with no documentation to indicate the ordered treatment was completed. During a review of Resident 5's Order summary dated 6/28/2026, the Order summary indicated treatment for mid chest surgical wound to be done everyday shift for wound management. During a review of Resident 5's Order summary dated 8/8/2026, the Order summary indicated treatment for right lower abdomen reopened surgical wound to be done every day shift for wound management. During a review of Resident 5's care plan titled the Resident has actual impairment to the skin integrity of the right lower abdomen related to reopened surgical wound revised 8/18/2026, the care plan indicated a goal to minimize the risk for injury. The care plan interventions indicated treatment to right lower abdomen reopened surgical wound to be done every day shift for wound care management. During a review of Resident 5's care plan titled The resident has actual impairment to skin integrity of the mid chest related to surgical wound dated 8/18/2026, the care plan indicated a goal to minimize injury. The care plan interventions indicated to include treatment and monitoring of mid chest surgical wound to be done everyday shift for wound care management. During a review of Resident's 5 care plan titled Risk for infection transmission related to presence of unidentified rash and potential communicable pathogen dated 2/26/2026, the care plan indicated a goal for Resident 5's rash to have rash signs of healing. The care plan interventions indicated care and treatment as ordered by the physician with topical applications as prescribed. During a review of Resident 6's AR, the AR indicated the resident was admitted to the facility on [DATE] with a diagnosis of chronic ulcers of right heel, midfoot, and right and left lower leg. During a review of Resident 6's MDS dated [DATE], the MDS indicated the resident has severe cognitive (mental capacity) impairment and requires total dependance for most all activities of daily living (ADLs). During a review of resident 6's care plan titled The resident has diabetic ulcer of the Right heel related to Diabetes dated 6/14/2026, the care plan indicated the goal was to have complications related to ulcer minimized. The care plan indicated interventions of treatment to right heel ulcer. During a review of Resident 6's care plan titled the resident has diabetic ulcer of Right lateral(outer) foot related to do Diabetes dated 6/14/2026, the care plan indicated with a goal of the resident's risk for complications related to ulcer will be minimized. The care plan interventions indicated treatment of right lateral foot diabetic ulcer, no frequency indicated. During a review of Resident 6's care plan titled The resident has diabetic ulcer of the Right Plantar foot (bottom of foot near the toes) related to diabetes dated, 6/14/2026, the care plan indicated a goal of risk for complication to be minimized. The care plan indicated intervention to include right plantar foot diabetic ulcer cleansed with normal saline, pat dry and pain t with betadine, then cover with dry dressing. During a review of Resident 6's care plan titled The resident has diabetic ulcer of the Right anterior great toe related to diabetes, the care plan indicated a goal of complications related to ulcer minimized. The care plan indicated interventions for treatment to the Right anterior great to diabetic ulcer. During a review of Resident 6's (TAR), the TAR indicated a Physician's order for Sivadene (antimicrobial medication used to treat infection in wounds) external cream to be applied to Right heel topically everyday shift. The treatment administration field for 8/18/2026 was left blank, with no documentation to indicate the ordered treatment was completed. During a review of Resident 6's (TAR, the TAR indicated a physician' s order for treatment of Sivadene external cream to be applied to Right lower leg topically every day shift. The TAR administration field for 8/18/2026 was left blank, with no documentation to indicate the ordered treatment was completed. During a review of Resident 6's TAR, the TAR indicated a physician' s order for treatment of right anterior (front) of great toe ulcer to be cleansed with normal saline, pat dry , paint with betadine, then cover with dry dressing to be done every day shift for wound management. The TAR administration field for 8/18/2026 was left blank, with no documentation to indicate the ordered treatment was completed. During a review of Resident 6's TAR, the TAR indicated a physician' s order for treatment of Right lateral (side) foot ulcer to cleansed with normal saline, pat dry, paint with betadine, then cover with dry dressing to be done everyday shift for wound management. The TAR administration field for 8/18/2026 was left blank, with no documentation to indicate the ordered treatment was completed. During a review of Resident 6's TAR, the TAR indicated a physician's order for right Medial 1st metatarsal (one of the 5 long bones in the middle of the foot) ulcer dressing to be changed everyday shift for wound management. The TAR administration field for 8/18/2026 was left blank, with no documentation to indicate the order treatment was completed. During a review of Resident 6's TAR, the TAR indicated a physician's order for treatment of Right medial great toe ulcer to cleansed with normal saline, pat dry, paint with betadine, then cover with dry dressing to be done everyday shift for wound management. The TAR administration field for 8/18/2026 was left blank, with no documentation to indicate ordered treatment was completed. During a review of Resident 6's TAR, the TAR indicated a physician's order for treatment of right plantar foot ulcer dressing to be changed everyday shift for wound management. TAR administration field for 8/18/2026 was left blank, with no documentation to indicate ordered treatment was completed. During a review of Resident 6's TAR, the Tar indicates a physician's order for treatment of Right medial foot with normal saline, pat dry, apply Silvadene and cover with dry dressing to be done everyday shift for wound management. The TAR administration field for 8/18/2026 was left blank, with no documentation to indicate ordered treatment was completed. During an interview on 8/19/2026 at 11:33AM with Resident 3, Resident 3 stated it seemed the facility was short of treatment nurses because his ordered treatments to his heel and leg had not been provided the previous day (8/18/2026). Resident 3 stated no staff member came to perform the treatments. Resident 3 stated the treatment nurse provided treatment to Resident 3's roommate, the resident to his left and then left the facility without returning. Resident 3 stated he continued asking for staff to perform Resident 3's wound treatment to Resident 3's heel and leg, until approximately 11PM, but stated no came. Resident 3 stated he felt he was not receiving the care and treatment he needed. Resident 3 further stated he experienced pain and believed wounds were not improving because his treatments were not being provided as ordered. During a concurrent interview and record review on 8/19/2026 AT 11:50 AM with Licensed Vocational Nurse (LVN) 1, Resident 3's (TAR was reviewed for 8/18/2026. The TAR indicated Resident 3's ordered treatments were overdue and remained pending at the time of review since the treatment was not documented on the TAR. LVN 1 was unable to verify that the ordered treatment had been provided to Resident 3. During a concurrent interview and Record review on 8/19/2026 at 12 PM with the Director of Nursing (DON), Resident 3's TAR dated 8/18/2026 was reviewed. The DON observed that the ordered treatments were displayed in red as overdue and had not been signed as completed. The DON stated that the absence of documentation / signature on the TAR of any resident indicated the treatment had not been provided. During an interview on 8/25/2026 at 1:20 PM with Resident 4, Resident 4 stated he received wound care treatments every other day. Resident 4 stated he had noticed the facility appeared to be short of staff who provided wound care treatment and may not have received all treatments for his wounds. During a concurrent interview and record review on 8/19/2026 at 1:30 PM, with RN2 , Resident 5's TAR was reviewed. The TAR indicated the ordered treatment was administered on 8/17/2026 however, there was no documentation indicating the treatment was provided on 8/18/2026. During an interview on 8/19/2026 at 1:41PM with Resident 5, Resident 5 stated he believed his treatment had been provided approximately once every two days rather than every day. Resident 5 further stated it was difficult to obtain assistance from nursing staff. During a concurrent interview and record review on 8/19/2026 at 1:41 RN 1, Resident 6's TAR was reviewed. Concurrent review of the TAR indicated the treatment was not documented as administered on 8/18/2026. Durning a concurrent interview and record review on 8/19/2026 at 1:51 PM with LVN 2, Resident 6's TAR was reviewed. LVN 2 stated no wound care was provided for 8/18/2026. During an interview on 8/19/2026 at 1:57 PM with Resident 6, Resident 6 stated his dressing changes were ordered to be completed daily, however the staff does not always provide the dressing changes as ordered. Resident 6 stated even when he requested that staff change his wound dressing, the treatment was not always provided. Resident 6 further stated he believed staff did not like him and dressing were only changed when staff wanted to perform the treatment. During an interview on 8/19/2026 at 2:49PM with DON, DON stated he was aware the facility did not have sufficient staff to provide wound care treatments. DON stated he did not believe it was possible for one treatment nurse to complete all the residents' required treatments and confirmed the treatment nurse had been working alone. DON further stated the treatment nurse had been provided additional time to complete treatments by coming in early and leaving late. When asked to provide payroll/ time records to substantiate the additional hours the DON stated he could not provide the records and could not verify that the treatment nurse had worked before or after her scheduled hours. The DON stated the facility had issues retaining a treatment nurse. further acknowledged that turnover of wound care treatment nurses had been an ongoing issue. During a review of the facility' s policy and procedure titled, Quality of Care revised February 2020, indicated that the facility was to provide care and services based on comprehensive assessments and individualized, person-centered care plans that reflected residents' needs. The policy indicated care was to be delivered in accordance with professional standards and regulatory requirements to prevent avoidable decline and promote optimal outcomes The policy further identified prevention and treatment of pressure injuries and avoidable decline, maintenance of skin integrity and comfort, and adequate, competent staffing as key standards of care. The policy indicated assessment, care plans interventions, and outcomes were to be documented timely and accurately in the medical record. 2. During a review of Resident 7's admission Record (AR), the AR indicated that the resident was originally admitted on [DATE], and readmitted on [DATE], with diagnoses that included Stage 4 pressure ulcer (the most severe type of bedsore, where a deep open wound goes all the way through the skin and damages muscle, tendons, or bone) of the right buttock, left buttock, and sacral region. During a review of Resident 7's History and Physical (H&P), dated 7/4/2026, the H&P indicated that the resident does not have the capacity to understand and make decisions. The H&P also included a plan that the resident's Stage 4 pressure ulcers of the right buttock, left buttock, and sacral region will receive wound treatment as ordered by the physician. During a review of Resident 7's Minimum Data Set (MDS, a resident assessment tool), dated 6/13/2026, the MDS indicated that the resident has severely impaired cognition (the ability to process thoughts and emotions). The MDS also indicated that the resident is dependent (the helper does all of the effort) on self-care activities such as eating, oral hygiene, toileting, bathing, and personal hygiene. The MDS also indicated that the resident is dependent on mobility tasks such as rolling in bed left to right, transferring from bed to chair, and changing positions from sitting to lying and sitting to standing. The MDS also indicated that the resident has two Stage 4 Pressure ulcers and one unstageable pressure ulcer (a pressure ulcer in which the true depth and stage (usually a Stage 3 or 4) cannot be measured because dead tissue that covers the base of the wound). During a review of Resident 7's physician's orders included the following wound treatment orders: a, Treatment: Left Inner Ischium Pressure Injury: Cleanse with Dakins (a liquid solution used to clean wounds and prevent or treat skin and tissue infections), pat dry, apply Dakins wet-to-dry dressing, then cover with silicone foam dressing (a type of medical bandage) two times a day for wound management, ordered on 8/2/2026. b. Treatment: Left Lateral leg [extending] to malleolus (bone in the foot on each side of ankle): cleanse with normal saline (a sterile solution of sodium chloride (salt) in water used to clean or irrigate wounds), pat dry, apply Santyl (a topical medication used to remove dead or damaged tissue from chronic skin ulcers) followed by collagen powder (a topical protein treatment applied directly to chronic, slow-healing, or irregular wounds to aid in tissue regeneration) and calcium alginate (a wound care dressing that is used to absorb heavy drainage and stop bleeding), then cover with dry dressing every day shift for wound management, ordered on 8/2/2026. c. Treatment: Left outer ischium pressure injury: Cleanse with Dakins, pat dry, apply Dakins wet-to-dry dressing, then cover with silicone foam dressing two times a day for wound management, ordered on 8/2/2026. d. Treatment Sacrum [extending] to right buttock pressure injury: Cleanse with Dakins, pat dry, apply Dakins wet-to-dry dressing, then cover with silicone foam dressing two times a day for wound management, ordered on 8/2/2026. During a review of Resident 7's care plan for the resident's wound of the left lateral leg extending to the malleolus, initiated on 6/15/2026, the care plan included interventions for staff to follow the facility's protocols for treatment of injury. The care plan also indicated for staff to perform wound treatment every day shift and as needed. During a review of Resident 7's care plan for the resident's Stage 4 pressure injury of the left inner ischium, initiated on 6/15/2026, the care plan indicated for staff to perform wound treatment to the resident's wound. During a review of Resident 7's care plan for the resident's Stage 4 pressure injury to the sacrum extending to the right buttock, initiated on 6/16/2026, the care plan included interventions for staff to follow facility protocols for treatment of injury. The care plan also indicated that wound treatment is to be performed every day shift and as needed. During a review of Resident 7's Treatment Administration Record (TAR) for the month of 8/2026, the TAR was blank and did not have entries to indicate that the resident's wound treatments were provided on 8/3/2026, 8/4/2026, 8/5/2026, 8/7/2026, 8/10/2026, 8/11/2026, and 8/12/2026. During a review of Resident 7's Interdisciplinary Team Note (IDT), dated 6/19/2026, the IDT indicated a plan for staff to continue wound care as ordered and to continue wound assessments and treatment recommendations. During a review of Resident 7's care plan for the resident's Stage 4 pressure injury of the left outer ischium, initiated on 7/27/2026, the care plan included an intervention for staff to administer treatments as ordered and monitor for effectiveness. During a concurrent interview and record review on 8/21/2026 at 2:47 PM with Registered Nurse (RN) 3, Resident 7's TAR for the month of 8/2026 and progress notes were reviewed. RN 3 stated that the TAR is blank on the dates 8/3/2026, 8/4/2026, 8/5/2026, 8/7/2026, 8/10/2026, 8/11/2026, and 8/12/2026. RN 3 stated that if the TAR is blank, that means that the treatment was not performed. RN 3 also stated that the progress notes do not indicate that the wound treatments were performed on those dates. RN 3 further stated that if wound treatments are not performed, the resident's health could become compromised, and the resident's wounds could get infected. During an interview on 8/21/2026 at 4:12 PM with the DON, the DON stated that it is important for staff to follow the plan of care of the resident, especially wound treatments. The DON stated that if the treatment nurses cannot perform the wound treatments of Resident 7, the Registered Nurses must perform the wound treatments. The DON stated that not performing the wound treatments could potentially worsen the wounds, such as the wounds getting infected. During a review of the facility's facility assessment (FA, an assessment tool to determine what resources, such as nurse staffing needs, are necessary to care for its residents competently during both day-to-day operations and emergencies), dated 1/15/2026, the FA indicated a staffing plan that is based on the facility's resident population and their needs for care and support. The FA also indicated that the staffing plan is to ensure that [the facility has] sufficient staff members to meet the needs of the residents at any given time. Further review of the FA indicated that the plan includes an evaluation of overall number of facility staff members needed to ensure a sufficient number of qualified staff are available to meet each resident's needs. During a review of the facility's policy and procedure (P&P) titled, Wound Care, revised 4/2026, the P&P indicated that the following should be recorded in the resident's medical record: [TRUNCATED]

Based on interview and record review, the facility failed to revise and/or update the care plan for one of one sampled resident (Resident 8), who was blind and deaf and required specific needs for communication. This deficient practice had the potential to result in Resident 8 to not receive appropriate interventions and treatment and/or services and negatively affect the resident's psychosocial wellbeing. Findings: During a review of Resident 8's admission Record (AR), the AR indicated the resident was admitted to facility on 12/29/2024 with diagnoses that included malignant neoplasm of prostate, chronic obstructive pulmonary disease (COPD), legal blindness, and deaf nonspeaking. During a review of Resident 8's History and Physical (H&P), dated 12/30/2024, the H&P indicated resident had the capacity to understand and make decisions. During a review of Resident 8's Minimum Data Set (MDS, a resident assessment tool) dated 8/11/2026, the MDS indicated Resident 8 had moderate difficulty (speaker has to increase volume and speak distinctly) with ability to hear. The MDS indicated Resident 8's ability to see in adequate light was severely impaired (no vision or sees only light, colors or shapes; eyes do not appear to follow objects). The MDS indicated Resident 8's cognition was intact. The MDS indicated Resident 8 required set up or clean-up assistance for eating. The MDS indicated Resident 8 required substantial/maximal assistance (helper does more than half the effort) for toileting hygiene. The MDS indicated Resident 8 was dependent (helper does all of the effort) with shower/bathing self, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. During a review of Resident 8's Communication care plan, the care plan did not indicate specific interventions on how to communicate and approach resident when providing care. During an interview on 8/21/2026 at 11:53 AM, the Director of Nursing (DON) stated there was no communication between Certified Nursing Assistants (CNA) 1 and 2 with Resident 8 and the CNAs did not explain to Resident 8 what they were doing. The DON stated staff were being in-serviced about how to communicate with disabled residents who are blind and deaf. The DON stated CNA 1 and 2 were suspended. The DON stated it was important for staff to know how to communicate with residents who were deaf or blind like Resident 8 since their care and communication can be misinterpreted by the resident. The DON stated CNA 1 and 2 should have introduced themselves to Resident 8 and explained what care they were providing. The DON stated Resident 8's care plan was updated to indicate specific interventions on how to communicate to Resident 8. During a concurrent interview and record review of Resident 8's care plans, the DON stated the communication and tactile services care plan was not specific since the care plan did not indicate staff to use the specific language services for Resident 8. The DON stated the care plan only indicated that staff had a generic in-service not specific to Resident 8's needs. The DON stated the care plans did not have specific needs for Resident 8. The DON stated the translating in-service should have been included in the care plan since that specific communication needs was required when communicating with Resident 8. A review of the facility's policy and procedure (P&P) titled Resident Participation- Assessment/Care Plans dated 11/2025 indicated the care planning process: facilitates the inclusion of the resident and/or representative; includes an assessment of the resident's strengths and needs; and incorporates the resident's personal and cultural preferences in establishing goals of care.

Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was assessed and provided pain relief in accordance with the facility Policy and Procedure (P&P) titled, Pain Management. This deficient practice had the potential to result in prolonged or worsening pain, unnecessary suffering, decreased mobility and functional ability, and a diminished quality of life. FINDINGS:During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to facility on 5/13/2026 , with a diagnosis of cellulitis ( bacterial infection of the deeper layers of the skin ) of Right lower limb, hemiplegia ( complete or nearly complete paralysis of one side of the body) and hemiparesis( weakness or partial loss of movement on one side of body) following cerebral infarction affecting right dominant side and Chronic venous hypertension with ulcer ( long term increased pressure in the veins of the leg that damage the skin and tissues and cause an open sore or area ). During a review of Resident 1's History and Physical (H&P) dated 7/2/2026, the H&P indicated Resident 1 had diabetic (chronic health condition where the body cannot properly process blood sugar [glucose] due to a lack of insulin or insulin resistance wound on lower right and left leg. The H&P indicated Resident 1 had fair mentation (mental activity). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 5/19/2026, the MDS indicated Resident 1's cognition was intact (the ability to think , understand, remember, communicate, and make decisions). The MDS indicated Resident 1 has functional limitation in range of motion of left and right lower legs requiring maximal assistance with most activities of daily living (ADLs' ) such as oral hygiene , toileting hygiene, shower/ bathe self, upper body dressing, lower body dressing, putting on taking off footwear and personal hygiene. The MDS indicated Resident 1 received as needed (PRN) pain medications. During a review of Resident 1's Medication Administration Record ( MAR) , dated 5/19/2026 the MAR indicated a documented pain level of 9 out of 10 on a numerical pain scale (tool used to measure pain intensity from 0 [no pain] to 10 [the worst pain imaginable] during the 11:00PM to 7:00AM shift. The facility's pain assessment order identified a pain level of 7-10 as severe pain . During a review of Resident 1's Order Summary Report, the Report indicated a physician's order dated 8/2/2026 for oxycodone (pain medication to treat moderate to severe pain) tablet 5 milligrams (mg- a unit of measurement) to be given every 6 hours PRN for severe pain . During a review of Resident 1's Care plan titled The Resident has pain related to bilateral lower leg cellulitis (bacterial skin infection that causes red, swollen, and painful skim) dated 5/13/2026, the care plan goal indicated Resident 1 would have an acceptable level of pain. The CP interventions indicated to administer pain medication as ordered and to monitor and document for probable cause of each pain episode. During a review of Resident 1's Care plan titled Resident has difficulty performing ADLs related to weakness and right- sided hemiparesis following a stroke, dated 5/25/2026, the Care Plan goal indicated Resident 1 would maintain or improve ability to perform ADLs with assistance as needed. The Care Plan interventions for Resident included assisting with bathing, dressing, grooming and to monitor and manage Resident 1's pain. During a review of Resident 1's Medication Administration Record (MAR), dated 8/6/2026, the MAR indicated oxycodone 5 mg, one tablet by mouth every six hours PRN for severe pain, was administered at 12:29 PM for a documented pain level of 8 out of 10. The MAR indicated the pain level summary was reassessed at 2:12 PM (one hour and 43 minutes) after Resident 1 was administered oxycodone 5mg, and Resident 1's pain level remained at 5. The MAR indicated no additional intervention were conducted to help alleviate Resident 1's pain. During an interview on 8/6/2026 at 10:16 AM with Resident 1, Resident 1 stated he experienced constant pain related to the wounds on his right and left lower legs, and right heel. Resident 1 stated his pain was at a 7/10. Resident 1 stated during dressing changes, Resident 1's pain remained at 7/10, and that Resident 1 always informed facility staff that he was in pain. Resident 1 stated the prescribed oxycodone did not adequately relieve his pain and that staff did not routinely assess his pain level or offer pain medication prior to dressing changes. During an interview on 8/6/2026 at 11:37 AM with Licensed Vocation Nurse (LVN)1, LVN 1 stated she had never asked Resident 1 if he was experiencing pain prior to or during dressing changes when performing Resident 1's wound treatment. LVN1 further stated Resident 1 had not complained of pain while she performed the wound treatment. During an observation on 8/6/2026 at 1:35 PM, LVN 1 was observed performing wound care treatment for Resident 1's. Prior to initiating the wound care treatment, LVN 1 did not assess Resident 1's pain level. During an interview on 8/6/2026 at 2:12 PM with LVN 2, LVN 2 stated Resident requested pain medication at 12:29 PM for a reported pain level of 8/10. and reported a pain level of 8. LVN 2 stated she administered oxycodone 5 mg to the resident. LVN 2 stated she did not reassess Resident 1's pain level following the administration of oxycodone 5 mg. LVN 2 stated that the resident' s pain level must be reassessed one hour after pain medication administration. LVN 2 stated that if the resident continued to experience pain upon reassessment, LVN 2 would offer Tylenol (medication used to temporarily reduce fever and relieve minor aches and pains) and if the intervention was ineffective, LVN 2 would notify the physician. LVN 2 further stated she had never notified the physician because Resident 1 did not report continued pain. LVN 2 stated that when she attempts to reassess Resident 1, he is usually sleeping, and she believed that because he was sleeping, he was not experiencing pain. During an interview on 8/6/2026 at 2:39 PM with Resident 1, Resident 1 stated he had informed LVN 2 numerous times that he continued to experience pain. Resident 1 stated staff have never reassessed his pain level to determine if the pain medication was effective and stated, I always have pain. During an interview on 8/6/2026, with Director of Nursing (DON), the DON stated residents who received pain medication were expected to be reassessed for effectiveness within 30 to 40 minutes following pain medication administration. The DON stated staff would be in- serviced regarding timely reassessment and proper pain management. The DON further stated wound - related pain was part of wound management and that pain must be assessed and addressed. The DON stated failure to adequately assess, reassess, and manage a resident's pain, resulting in continued pain, anxiety, and a diminished quality of life. During a review of the facility' s policy and procedure (P&P) titled, Pain Management dated 5/2023, the P&P indicated pain is subjective and is what the resident says it is, existing when and where the resident says it does. The facilities P&P indicated the purpose was to accurately assess and achieve pain control. The P&P further indicated all residents will be evaluated for pain by utilizing a pain evaluation tool in resident's electronic record, as applicable, to include the location, intensity rating, and resident's response to pain management interventions and their degree of effectiveness. During a review of the facility's policy and procedure (P&P) titled, Pain Assessment and Management dated 4/2025, indicated the purposes of the procedure was to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. The P&P indicates when opioids are used for pain management the resident is to be monitored for its effectiveness in managing the residents pain.

Based on observation, interview, and record review , the facility failed to ensure infection control practices were implemented for 1 of 3 sampled residents ( Resident 1), who required wound treatment in accordance with the facility's policies and procedures ( P&P) titled Enhanced Barrier Precautions and Wound Care. This deficient practice had the potential to result in cross contamination between wound sites, transmission of infectious organisms, delayed wound healing, and the development or worsening of infection.FINDINGS:During a review of Resident1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of Cellulitis (bacterial infection of the deeper layers of the skin ) of Right lower limb, hemiplegia (complete or nearly complete paralysis of one side of the body) and hemiparesis (weakness or partial loss of movement on one side of body) following cerebral infarction affecting right dominant side and Chronic venous hypertension with ulcer (long term increased pressure in the veins of the leg that damage the skin and tissues and cause an open sore or area ). During a review of Resident 1's History and Physical (H&P) dated 7/2/2026, the H&P indicated Resident 1 had diabetic (chronic health condition where the body cannot properly process blood sugar [glucose] due to a lack of insulin or insulin resistance wound on lower right and left leg. The H&P indicated Resident 1 had fair mentation (mental activity) . During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 5/19/2026, the MDS indicated Resident 1's cognition was intact ( the ability to think , understand, remember, communicate, and make decisions). The MDS indicated Resident 1 has functional limitation in range of motion of left and right lower legs requiring maximal assistance with most activities of daily living ( ADLs' ) such as oral hygiene , toileting hygiene, shower/ bathe self, upper body dressing, lower body dressing, putting on taking off footwear and personal hygiene. During a review of Resident 1's Care Plan for Infection Control, risk for transmission of Multi- drug Resistant Organism ( MDRO bacteria that resist standard antibiotics [medicines that fight bacterial infections by killing bacteria or stopping them from growing]), related to Methicillin - Resistant Staphylococcus aureus (MRSA- bacteria that cannot be killed by standard antibiotics) bloodstream infection as evidenced by positive cultures dated 5/14/2026, the care plan goal indicated Resident 1 will remain free from secondary healthcare- associated infections, staff will demonstrate compliance with enhanced barrier precautions (EBP -infection control guidelines used in nursing homes and long-term care facilities to stop the spread of dangerous germs called multidrug-resistant organisms (MDROs), including gown and glove use during high contact care activities. The Care Plan indicated intervention to implement EBP immediately, utilizing gowns and gloves for high- contact resident care activities such as dressing, bathing, and device management and maintaining rigorous hand hygiene and environmental cleaning protocols. During a review of Resident 1's Order Summary Report, the Report indicated an order dated 8/5/2026 to initiate and implement EBP and that staff must don gown and gloves prior to all high- contact resident care activities to mitigate the transmission risk of communicable and infectious Diseases. (Diabetic ulcers/ cellulitis). During a review of Resident 1's Order Summary Report, the Report indicated an order dated 8/5/2026 for Resident 1's Right heel diabetic ulcer to cleanse with normal saline and pat dry. The order indicated to apply Medi- honey (topical product used to manage wounds and burns), then Calcium Alginate (a soft, absorbent, non-woven medical pad or rope made from natural polysaccharides derived from brown seaweed. When it touches wound fluid, it trades calcium ions for sodium ions and turns into a moist gel, which helps control heavy bleeding and absorbs large amounts of drainage) and cover with abdominal pad and wrap with Kerlix (woven cotton gauze bandage rolls featuring a crinkle-weave pattern) and secure with tape. The order indicated to perform the treatment every day shift for wound care management. During a review of Resident 1's Order summary Report, the Report indicated an order dated 8/6/2026 for Resident 1's right anterior lower leg wound to apply Santyl ointment ( removes dead tissue and promotes wound healing) topically ( directly on to the skin) every day shift, cleanse with normal saline, pat dry, mix then apply Neosporin ( antibiotic) Santyl ointment and cover with dry dressing every day. During a review of Resident 1's Order summary Report, the Report indicated an order dated 8/6/2026 for Resident 1's Right heel wound to be cleansed with normal saline, pat dry, and apply Neosporin with Santyl and cover with dry dressing every day. During a review of Resident 1's Order summary Report, the Report indicated an order dated 8/6/2026 for Resident 1's right posterior lower leg wound to cleanse with normal saline, pat dry, mix and apply Neosporin with Santyl and cover with dry dressing every day with an order date of 8/6/2026. During an observation on 8/6/2026 at 1:35PM, a wound treatment observation was conducted with Licensed Vocational Nurse (LVN)1 in Resident 1's Room. LVN 1 was observed initiating wound care without performing hand hygiene. LVN 1 applied gloves but did not wash or sanitize hands prior to donning the gloves. LVN 1 did not don a gown prior to providing wound care treatment to Resident 1. LVN 1 placed Resident 1's leg on top of resident 1' clean pillow, used to support lower leg extremity without using a protective barrier underneath Resident 1's leg. LVN 1 removed her gloves and exited the resident's room without performing hand hygiene, entering hallway and then proceeded to reach into the clean linen cart to obtain clean linen. LVN 1 then returned to Resident 1;'s room without performing hand sanitizing prior to donning gloves, no gown worn. During the same concurrent observation on 8/6/2026 at 1:35 PM, LVN1 was observed using sterile tongue depressor ( flat , thin wooden stick) to obtain ointment from small plastic medication cup. The tongue depressor made contact with Resident 1's wound. LVN 1 then placed the same contaminated tongue depressor back into the container of ointment and removed additional ointment for use to use on another wound site for Resident 1. During an interview on 8/6/2026 at 1:37 PM with LVN 1, LVN 1stated she should have performed hand hygiene and applied appropriate personal protective equipment, including gloves and gown, prior to providing the wound treatment wounds care treatment to Resident 1. LVN 1 stated she should not have placed the contaminated tongue depressor back into the cup of ointment. LVN1 stated failure to follow infection control practices placed Resident 1 at risk for infection. During an interview on 8/6/2026 at 2:50PM with Director of Nursing (DON) stated that Enhanced Barrier Precautions require the use of appropriate protective equipment, including gloves and a gown. The DON stated that hand hygiene should be performed, and infection control policies and procedures should be followed. The DON further stated that failure to follow appropriate infection control practices could result in cross- contamination and the spread of infection to other residents. During a review of the facility's policy and procedure titled Enhanced Barrier Precautions revised in December 2023, indicated, enhanced barrier precautions ( EBPs) are utilized to prevent the spread of multi- drug-resistant organisms ( MDROs) to residents . Policy indicated enhanced barrier precautions apply when a resident has a wound regardless of suspected or confirmed infection or colonization status. Further indicating EBP's employ targeted gown and glove use in addition to standard preauction during high contact resident care activities when contact precautions do not otherwise apply. Gloves and gown are applied prior to preforming the high contact resident care activity . Examples of high - contact resident care activities requiring the use of gown and gloves from EBPs include dressing, bathing/ showering, providing hygiene or grooming as well as wound care ( any skin opening requiring a dressing). During a review of the facility's policy and procedure titled Wound Care revised on April 2026, indicated the purpose of this procedure is to provide guidelines for the care of wounds to promote healing. The following are Equipment and supplies necessary when performing this procedure: Personal Protective equipment ( e.g., gowns , gloves, masks). Steps in the procedure are to include placement of disposable cloth next to resident ( under the wound) to serve as a barrier to protect the bed linen and other body sites. A no touch technique should be implemented when using sterile tongue blades and applicators to remove ointments and cream from their containers.

Based on interviews and records review, the facility failed to ensure a safe and appropriate discharge for one of two sampled residents (Resident 1), who left for an out-on-pass (OOP- temporary leave an admitted patient has official, temporary permission from their doctor to leave a hospital or care facility for a short, set amount of time before returning to finish treatment) on 7/27/2026 by failing to: Ensure Resident 1 signed out of the facility onto the out on pass log on 7/27/2026 in accordance with the facility's Policy and Procedure (P&P) titled, Signing Residents Out. Inform Resident 1 the clinical risks for discontinuing care at the facility in accordance with the facility's P&P titled, Discharging a Resident Against Medical Advice. Document the reason for the discontinuation of care for Resident 1 in accordance with the facility's P&P titled, Discharging a Resident Against Medical Advice. Provide information or arrangements regarding post discharge plan of care in accordance with the facility's P&P titled, Discharging a Resident Against Medical Advice. These deficient practices resulted in a facility initiated discharge against medical advice (AMA) of Resident 1. After leaving for an OOP on 7/27/2026 at 10:30 PM and returning on 7/28/2026 at 2 PM (16 hours later), Resident 1 was left to stay at FM 1's home. These actions placed Resident 1 at risk for an unsafe transition of care, unrecognized changes in medical condition, interruption of necessary treatment, and inadequate continuity of care following discharge. Findings:During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis stable burst fracture of 4th lumbar vertebra (break or crack in the 4th bone of the lower back), multiple fractures of the ribs, right side (more than one right side of chest had been broken or cracked) and psychoactive substance abuse (the harmful or excessive use of any chemical substance-such as drugs or alcohol-that alters brain function). During a review of Resident 1's History and Physical (H&P) dated 5/21/2026, the H&P indicated that Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Care Plan for Impaired Physical Mobility, dated 5/21/2026, the Care Plan indicated interventions to assist with transfers and activities of daily living (ADLs). During a review of Resident 1's Care Plan for Risk for Falls related to impaired mobility, pain, and medication effects, dated 5/21/2026, the Care Plan indicated interventions to assist with all transfers. During a review of Resident 1's Care Plan for Acute Pain related to Multiple Traumatic Fractures, dated 5/21/2026, the Care Plan indicated interventions to administer analgesics (pain medication) as ordered and to monitor for opioid (pain medication) side effects such as sedation, constipation, and respiratory depression. During a review of Resident 1's Care Plan for Resident is dependent on staff for meeting emotional, intellectual, physical and social needs related to physical limitations, dated 5/21/26, the Care Plan indicated interventions to ensure that adaptive equipment that the resident needs is provided and is present and functional. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 5/26/2026, the MDS indicated that Resident 1 had an intact cognition (thinking). The MDS further indicated used a wheelchair for mobility, required substantial/maximal assistance for shower/bathing self and partial/moderate assistance for upper/lower body dressing and toileting hygiene. The MDS further indicated that Resident 1 had a hip fracture and other fractures. During a review of Resident 1's current Order Summary Report for all active physician's orders, the Report indicated a physician's order, dated 5/28/2026, authorizing Resident 1 to leave the facility on an OOP with a family or a companion for up to four hours. During a review of Resident 1's Care Plan for Discharge to Board and Care of Assisted Living, revised on 6/10/2026, the Care Plan interventions indicated Resident 1 would be provided with written instructions as required to ensure care continuity post-discharge. During a review of Resident 1's Care Plan for Pain related to multiple fractures upon admission to the facility, dated 7/8/2026, the Care plan interventions indicated administer analgesia as ordered, evaluate effectiveness of pain interventions, and to monitor and document side effects of pain medication. During a review of Resident 1's Order Summary Report for all active physician's orders, the Report indicated a physician's order dated 7/27/26, indicated that Resident 1 may go OOP for emergency of his daughter on 7/27/2026 (May come back mid night or he will notify time of back). During a review of Resident 1's Order Summary Report for all active physician's orders, the Report indicated a physician's order that for Morphine Sulfate Extended Release (pain medication) oral tablet 15 milligram (mg - unit of measurement) 1 tablet by mouth two times a day for pain management hold if respiratory rate of 12 breaths per minute (bpm - unit of measurement). During a review of Resident 1's Order Summary Report for all active physician's orders, the Report indicated a physician's order for oxycodone hydrochloride (pain medication) 1 tablet by mouth 6 hours as needed for moderate to severe pain hold if respiratory rate of 12 bpm, hold if confused. During a review of Resident 1's Nursing Progress Notes dated 7/27/2026 at 10:26 PM, the Notes indicated that Resident 1 requested an emergency OOP to tend to Resident 1's FM 1 and was approved by the medical doctor (MD). The Note indicated that Resident 1 had stated he was unsure when he would return, that his friend would provide transportation, and that he would notify the facility regarding his return. The note indicated that Resident 1 left the facility with his friend at approximately 10:10 PM on 7/27/2026. During a review of Resident 1's Nursing Progress Notes dated 7/28/2026 at 6:29 AM, the Notes indicated that Resident 1 had not returned to the facility from his emergency OOP and staff attempted to contact Resident 1 using the telephone number on file but received no answer. The Note indicated no additional information was available and Resident 1's status was endorsed to the oncoming shift. During a review of Resident 1's Nursing Progress Notes dated 7/28/2026 at 10:46 AM, the Notes indicated that staff attempted to contact Resident 1 but was unsuccessful. The Notes indicated that the facility left a voicemail for Resident 1 reminding Resident 1 that the OOP was limited to four hours only, and to contact the facility immediately. During a review of Resident 1's Nursing Progress Note dated 7/28/2026 at 1:57 PM, the Notes indicated that Resident 1 remained out on OOP beyond the authorized four-hour limit despite multiple unsuccessful attempts by staff to contact him. The note indicated that the MD was notified and issued an order to discharge Resident 1 Against Medical Advice (AMA - when a resident chooses to leave the facility or stop treatment before the doctor says it is safe). The Note indicated that FM 1 was notified of the AMA discharge and informed that Resident 1 had exceeded the authorized OOP time and Resident 1 had not responded to the facility's telephone calls. During a review of Resident 1's Interdisciplinary Team Review note (IDT - group of health professionals who work together) dated 7/28/26 at 4:30 PM, the Note indicated that Resident 1 was presented with an AMA but the resident refused to sign the form because the resident did not want to be discharged from the facility. During a review of Resident 1's IDT Note dated 7/28/26 at 4:35 PM, the Note indicated that the IDT met with Resident 1 upon his return to the facility from OOP and informed Resident 1 that he had exceeded the facility's four-hour out-on-pass limit. The Note indicated that staff had made multiple unsuccessful attempts to contact Resident 1, after which the MD was notified and ordered an AMA discharge. The Note indicated that Resident 1 was informed of the risks and benefits of leaving AMA, verbalized understanding, and staff assisted Resident 1 with packing his belongings and arranging Uber (a ride-hailing app used to book private car rides) transportation to a location of Resident 1's choice. The Note indicated that Resident 1 was alert and oriented, verbally responsive, in no acute distress, and departed Without a signed AMA form . During a review of Resident 1's Resident Out-on-Pass Log dated 6/2026 to 7/2026, the Log indicated that Resident 1 had not signed out of the facility on 7/27/2026 prior to leaving on an emergency OOP and returning to the facility from the emergency OOP on 7/28/2026. During a review of Resident 1's Telephone Orders (TO) dated 7/28/2026 at 2PM, the Order indicated a physician's order to discharge Resident 1 Against Medical Advice (AMA). The TO indicated the order was received and confirmed by the Assistant Director of Nursing (ADON). During a review of Resident 1's Record review of the Release of Responsibility - Discharge Against Medical Advice (AMA) form dated 7/28/2026, the Form indicated that Resident 1 was informed of the risks and consequences of leaving the facility AMA. The form indicated that it was not signed by Resident 1 and included documentation indicating, Resident refused to sign. The form was completed with the signatures of two facility witnesses documenting the resident's refusal. During an interview on 7/29/2026 at 9:30 AM with the Social Services Director (SSD), SSD stated Resident 1 was discharged from the facility on 7/28/2026 AMA. The SSD stated that the AMA discharge was initiated after Resident 1 exceeded his physician-approved OOP time limit of 4 hours and did not respond to multiple telephone calls placed to Resident 1 by facility staff. During an interview on 7/29/2026 at 9:57 AM with Registered Nurse (RN 1), RN 1 stated that Resident 1 was OOP at approximately 10 PM on 7/27/2026 and was expected to return to the facility at approximately 2 AM on 7/28/26. RN 1 stated that Resident 1 failed to return to the facility within 4 hours within the authorized timeframe and was subsequently discharged AMA by the facility for violating the facility's out-on-pass policy. During a telephone interview on 7/29/2026 at 10:25 AM with Resident 1, Resident 1 stated that he had OOP privileges and had consistently complied with the facility's OOP policy until 7/27/2026, when a family emergency involving Resident 1's FM 1 delayed his return to the facility. Resident 1 stated he had previously informed facility staff that his cellular phone only worked when connected to Wi-Fi and had provided an alternate contact number for a friend if staff were unable to reach him. Resident 1 stated he left the facility at approximately 10 PM on 7/27/2026 and had overslept, resulting in his failure to notify the facility that he would be returning later than authorized. Resident 1 stated he did not receive any telephone calls, voicemail messages, or any other communications from the facility, nor was his alternate contact notified to his knowledge. Resident 1 stated that upon returning to the facility at approximately 2 PM (16 hours later) on 7/28/2026, staff informed him he had been discharged from the facility AMA for exceeding the authorized OOP time limit of 4 hours. Resident 1 stated he was not notified of the discharge before arriving at the facility and refused to sign the AMA form because he did not agree with the discharge. Resident 1 stated staff informed him he would need to go to the hospital for evaluation before he could be readmitted , which Resident 1 declined. Resident 1 stated the facility arranged transportation to a friend's residence, and Resident 1 left the facility without any discharge paperwork or medications. Resident 1 stated that he was not receiving home health services or any medical follow-up after leaving the facility. Resident 1 stated that he had not been receiving home health services, nursing follow-up, or any other medical monitoring after the facility discharged Resident 1 on 7/28/2026. During an interview on 7/29/2026 at 11:38 AM with the ADON, ADON stated Resident 1 left the faciity on 7/27/2026 for a family emergency and failed to return within the authorized timeframe. ADON stated that after multiple unsuccessful attempts to contact Resident 1, the attending physician was notified and issued an order to discharge Resident 1 AMA. ADON stated Resident 1 had not been notified of the AMA discharge prior to returning to the facility on 7/28/2026. ADON stated when Resident 1 returned to the facility at 2 PM on 7/28/2026, it was only then that Resident 1 was informed he had been discharged AMA for not returning to the facility within 4 hours. ADON stated an IDT meeting was conducted, during which Resident 1 was advised to go to the hospital for medical evaluation before the facility would consider readmission. ADON stated that Resident 1 declined to go to the general acute care hospital (GACH) for evaluation, refused to sign the AMA form, and departed the facility at approximately 4 PM after the facility arranged transportation to a friend's residence. ADON stated that no nursing or physical assessment was performed, no vital signs were obtained, no discharge instructions or discharge documentation were provided, and no medications were issued because Resident 1 was discharged AMA. ADON stated that the facility did not provide Resident 1 with a proposed notice of discharge or any other discharge-related documentation prior to informing Resident 1 that he was discharged AMA from the facility. ADON stated that no discharge notice was issued because the facility had designated Resident 1's discharge as AMA. ADON stated Resident 1 was alert and oriented, and left the facility with his personal belongings, wheelchair, and walker. DON stated upon Resident 1's return to the facility on 7/28/2026, a nursing and comprehensive physical assessment should have been conducted before the discharge decision was finalized to evaluate Resident 1 after an extensive leave away from the facility. ADON stated the assessment would have evaluated Resident 1's overall condition after being away from the facility beyond the authorized out-on-pass timeframe and could identify any changes in Resident 1's medical status. During an interview on 7/29/2026 at 12:45 PM with FM 1, FM 1 stated Resident 1 had provided an alternate contact number for a friend and that the facility also had FM 1's telephone number as an emergency contact. FM 1 stated the facility had not contacted FM 1 regarding Resident 1 or informing FM 1 about Resident 1 being discharged AMA from the facility. FM 1 stated Resident 1 was upset that he was discharged AMA without prior notification. During an interview on 7/29/2026 at 1:20 PM with Licensed Vocation Nurse (LVN 1), LVN 1 stated that she had reported to work at 6:45 AM on 7/28/2026 and received shift report that Resident 1 had not returned from his OOP after leaving the facility on 7/27/26 at approximately 10:30 PM. LVN 1 stated she was informed that Resident 1's cellular phone only functioned with Wi-Fi and that he had provided an alternate contact number for his friend. LVN 1 stated Resident 1's FM 1's telephone number was listed as the primary emergency contact. LVN 1 stated she attempted to contact Resident 1 by telephone and left two voicemail messages, and she also called Resident 1's friend's telephone number multiple times but was unable to leave a voicemail. LVN 1 stated Resident 1 returned to the facility at approximately 2 PM on 7/28/2026. LVN 1 stated no nursing or physical assessment was conducted on Resident 1 because she believed the ADON would complete the assessment. LVN 1 stated she understood that Resident 1's AMA discharge had already been initiated upon his return to the facility on 7/28/2026. LVN 1 stated that a comprehensive nursing assessment would have identified any changes in his medical status or immediate healthcare needs prior to his AMA discharge. During a concurrent interview and record review on 7/29/2026 at 1:36 PM with LVN 1, Resident 1's Out-on-Pass Log dated 6/2026 to 7/2026 was reviewed. LVN 1 stated that Resident 1 had not signed out of the facility on 7/27/2026 prior to leaving on an emergency OOP. LVN 1 stated that the log further indicated that Resident 1 had not signed back into the facility upon his return on 7/28/2026. LVN 1 stated it was the responsibility of the charge nurse to have Resident 1 sign out on 7/27/2026 and sign back in on 7/28/2026. During an interview on 7/29/2026 at 2:21PM with the Director of Nursing (DON), DON stated that upon Resident 1's return to the facility on 7/28/2026 a 2 PM, Resident 1 was informed that he had violated the facility's OOP policy, an IDT meeting was conducted, and the AMA discharge for Resident 1 was finalized. DON stated Resident 1 departed alert and oriented with his personal belongings, wheelchair, and walker, and no medications or discharge paperwork were provided because he was discharged AMA. DON stated Resident 1 had previously used his OOP privileges without exceeding the authorized four-hour limit and that this was his first OOP violation. DON stated the facility did not follow the AMA discharge policy by failing to identify, address, or attempt to resolve the circumstances that led to the extended absence before proceeding with the discharge. DON stated he acknowledged that Resident 1 should have received a nursing and physical assessment upon his return to the facility after being out for 16 hours, and that efforts should have been made to resolve the situation prior to finalizing the AMA discharge. During a review of the facility P&P titled Signing Residents Out revised 8/2006, indicated that each resident leaving the premises (excluding transfers/discharges) must be signed out. The P&P indicated that residents leaving the facility on a physician-approved pass must return within the timeframe specified by the physician and failure to return as ordered may be considered noncompliance with physician orders and the residents plan of care. The P&P indicated that if a resident does not return within the approved timeframe and remain absent for more than four (4) hours beyond the physician-authorized return time, the resident may be subject to voluntary discharge or discharge against medical advice (AMA) by the attending physician, as appropriate. The P&P indicated that residents must be signed in upon return to the facility. During a review of the facility P&P titled Discharging a Resident Against Medical Advise revised 9/2025, indicated that prior to discharge, the following information is clearly documented in the resident's medical record: The reason, in the resident's (or representative's) words, for requesting the discontinuation of care and/or discharge; Facility staff, provider, and physician attempts to address or correct factors that have led to the request for discharge (e.g., dissatisfaction with care, financial concerns, dependent care, etc.); All information provided to the resident or representative regarding the clinical risks of discontinuing care at the facility, and why it is in the best interest of the resident to stay at the facility and complete the plan of care. The P&P indicated that the physician or provider's assessment of the resident's decision-making capacity; the resident or representative's informed consent for discharge; and any information provided by the resident or representative regarding the setting and care-giving arrangements made for the resident after discharge. The P&P indicated that if a resident or representative requests to be discharged to a setting that does not appear to meet the resident's post-discharge needs, or appears unsafe, the staff and physician will discuss with the resident and/or representative (and document) the implications and/or risks of being discharged to a location not equipped to meet the resident's needs and attempt to ascertain why the resident or representative is choosing that location: discuss with the resident and/or representative (and document) other, more suitable locations equipped to meet the needs of the resident; document if, despite being offered other options that could meet the resident's needs, the resident and/or representative refused the more appropriate settings; and determine if a referral to Adult Protective Services or other state entity charged with investigating abuse and neglect is necessary. The referral should be made at the time of discharge and documented.

Based on interviews and record reviews, the facility failed to ensure a facility does not discharge a resident in an unsafe manner, to a location that does not meet the resident's needs, does not provide needed support and resources, and does not meet the resident's preferences for one of three sampled residents (Resident 1) on 5/14/2026, after Resident 1 was discharged from General Acute Care Hospital (GACH) 1 with an order to discharge to a Skilled Nursing Facility (SNF) level of care. The facility did not follow required processes for a safe and appropriate discharge by failing to: 1. Ensure effective discharge planning to support a safe and appropriate transition to a lower level of care. On 5/14/2026, SNF 1 arranged a discharge of Resident 1 to a Board and Care (B&C) facility, an hour after being readmitted back to SNF 1 from GACH 1, without securing necessary medications, oxygen equipment, or continuity of care, despite Resident 1's need for continuous oxygen therapy and BiPAP use at night. 2. Provide advance notice to Resident 1's responsible party (Family Member 1) regarding the resident's discharge to a B&C on 5/14/2026, in accordance with the facility's Discharge Policy. 3. Supply written discharge instructions to the B&C outlining Resident 1's care needs, medication regimen, medical equipment requirements, and follow up services, consistent with facility's Discharge Policy and standard of practice for safe transitions of care. As a result, Resident 1 remained at the B&C from 5/14-5/15/2026 without essential medications or oxygen support. The B&C was not equipped to meet Resident 1's chronic oxygen needs, leading to continued decline, including generalized weakness and poor oral intake. Resident 1 required rehospitalization and was transferred back to GACH 1 for stabilization and placement to an appropriate level of care, from 5/15/2026 and was later discharged on 5/21/2026 to another skilled nursing facility (SNF 2). Findings: During a review of Resident 1's SNF 1 admission Record (AR), the AR indicated Family Member 1 (FM1) to be the resident's responsible party. The AR indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with a diagnoses that included, acute( suddenly and severe) and chronic (a condition that lasts a long time) respiratory failure( a condition that results in low levels of oxygen) with hypoxia (not enough oxygen available to function properly resulting in shortness of breath, confusion, and fatigue), obstructive sleep apnea (a disorder of the upper airway becoming blocked during sleep, causing pauses in breathing and decreased oxygen levels) , and dependence on supplemental oxygen (additional oxygen provided in order to maintain adequate blood oxygen levels). During a review of Resident 1's SNF 1 History and physical (H&P) dated 3/18/2025, the H&P indicated Resident 1 has the capacity to understand and make decisions. During a review of Resident 1's SNF 1 care plan titled Episodes of frequent obstructed breathing during sleep requiring use of BIPAP respiratory therapy dated 3/10/2025, with a goal of adequate air delivered through the use of BIPAP machine. The care plan interventions included to assess for shortness of breath and cyanosis and to notify medical doctor, elevate head of Bed, and to monitor sleeping pattern. During a review of Resident 1's SNF 1 Order summary Report, a physician order dated 1/22/2026 indicated an order for BIPAP (Bilevel positive Air way pressure) machine (breathing device that helps a person breath by delivering pressurized air through a mask worn over the nose or mouth) to be placed at 9 PM or prior to sleep every night and off at 6 AM. During a review of Resident 1's SNF 1 Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 3/2/2026, the MDS indicated Resident 1 had moderate cognitive impairment (may have difficulty with short term memory, need repetition and require assistance with decision making for more complex issues) requiring maximal assistance (helper does more than half the effort) for tasks such as toileting, showering, dressing, and personal hygiene. During a review of Resident 1's SNF 1 Order summary Report, an order dated 3/14/2026 indicated Resident 1 was receiving continuous oxygen at 2 to 5 liters per minute by nasal cannula (two small prongs placed into the nostrils that deliver oxygen to help oxygen levels) and to titrate (adjust the amount of oxygen) oxygen to achieve a Saturation of 92 % (a prescriber parameter with normal range being 95-100 % for a normal health adult) or higher. During a review of Resident 1's SNF 1 Psychosocial/ Discharge Planning Note dated 3/17/2026, 3/17/2026, a late entry authored by the Social Services Director (SSD) indicated the discharge planner sent a text message containing a notification of LCD (last covered date) from Resident 1's health insurance provider. The note indicated the LCD was not until 8/31/2026 . The note further indicated that several placement agencies had contacted the family regarding tours and placement options. The note indicated family stated they were not interested and did not have time for tour at this time. During a review of Resident 1's Physician Order dated 4/4/2026 at 12:04 PM, the order indicated an order to transfer Resident 1 to GACH 1 due to severe abdominal distention with past medical history of intestinal obstructions, for further evaluation and treatment. Another review of the GACH 1 record titled Discharge dated 5/8/2026, the record indicated Resident 1's planned discharge disposition was to be discharged back to [SNF 1]. During a review of GACH 1 records titled Discharge Planning dated 5/7/2026, the record indicated for Resident 1 to have the same BIPAP settings of 20/7 rate of 14 and FIO2 of 50% and titrate FI02 to keep oxygen saturation to 95%, as needed at night starting 8 PM onwards during sleep, for discharge. During a review of GACH 1 Discharge record dated 5/14/2026 timed at 3:25 pm, the GACH Discharge Record indicated Resident 1's Discharge Disposition: Skilled Nursing Facility and to follow up with PCP [Primary Care Physician] in 1-2 weeks. During a review of a documentation entered in Resident 1's SNF 1 record titled Psychosocial/Social Services Note dated 5/14/2026, timed at 3:02 PM created by the Discharge planner (DP), the record indicated the SSD received a call from RN 1, regarding resident's family (FM 1) wanting to speak with the SSD regarding Resident 1. The SSD scheduled an IDT with family to discuss matters about Resident 1 the next day on 5/15/2026 at 10:00 AM. During a review of Resident 1's SNF 1 Interdisciplinary Team Review dated 5/15/2026 timed at 11:11AM authored by the SSD, indicated the IDT met with FM1 and FM2 to discuss resident's current placement and options. Resident's family goal is to take mom home after she is stable. Attendees present: Administrator, SSD, Discharge planner, FM1, and FM2. During a review of Resident 1's SNF 1 Physician Order dated 5/14/2026 timed at 5:06 pm, MD 1, Resident 1's attending physician at the facility, ordered to discharge Resident 1 to a Board & Care facility. During a review of Resident 1s SNF 1 Progress notes, dated 5/14/2026, The note indicated MD 1 ordered to send Resident 1's medications to the B&C facility. During a review of Resident 1's SNF 1 Physician's Orders dated 5/15/2026 at 5:30 PM, it was noted that an order was entered a day after Resident 1 left the facility (on 5/14/2026). The order stated, Re-admit then discharge to Board & Care by MD 1. Further review of Resident 1's SNF 1 records showed no documented evidence of Resident 1's status upon readmission to the facility on 5/14/2026. In addition, Resident 1's records did not indicate the resident's condition, including what follow up care and services were needed, upon discharge to a lower level of care (Board and Care) later that same day, 5/14/2026. During a review of GACH 1 record titled EDMD General, Adult dated 5/15/2026 timed at 2:01 PM, the GACH 1 record indicated a General History and Physical (HPI) indicating the resident was recently discharged from GACH 1 to [SNF 1] less than 24 hours ago on 5/14/2026 and returned to GACH 1 ED from a B&C facility via ambulance with failed outpatient/facility management and persistent decline including complaints of generalized weakness and poor oral intake. The GACH 1 record indicated despite absence of clear focal infectious process, [Resident 1] remained significantly debilitated with chronic oxygen requirement. Resident 1 was readmitted to GACH 1 again to be monitored for advanced debility, persistent weakness, poor oral intake, chronic oxygen requirement and failed discharge disposition. During a review of the GACH 1 discharge record titled Physician Discharge Summary Note, documented on 5/30/2026, it was noted that GACH 1 had readmitted Resident 1 on 5/15/2026 and discharged the resident to another Skilled Nursing Facility (SNF 2) on 5/21/2026. The record indicated the reason for admission was Placement and further noted that Resident 1 had been discharged twice and subsequently readmitted within the past week due to ongoing placement issues. The GACH 1 record documented Resident 1's past medical history, including intestinal obstruction, Ogilvie syndrome, COPD, sleep apnea, and morbid obesity. Resident 1 had been discharged back to SNF 1 on 5/14/2026 after stabilization but was rerouted to a Board and Care (B&C) facility on the same day. The B&C facility then sent the resident back to GACH 1 on 5/15/2026 because it was not equipped to meet the resident's care needs. Further review of the GACH 1 record indicated that Resident 1 was readmitted due to chronic hypercapnic respiratory failure and a urinary tract infection. Resident 1 received BiPAP nightly and as needed and was started on antibiotics, with other comorbidities managed accordingly. During a review of SNF 2's record titled admission summary dated [DATE] timed at 2:58 pm, the record indicated Resident 1 was admitted to SNF 2 on 5/21/2026. The record indicated Resident 1 was on continuous oxygen at 3 LPM via nasal cannula. During a telephone interview with SNF 1's Registered Nurse (RN) 1 on 5/20/2026 at 12:24 PM, RN 1 stated she received instruction from the facility's Social Services Director (SSD) to readmit Resident 1 and transfer to the B&C since transportation was already set up by the facility. RN 1 stated Resident 1 arrived at the facility on 5/14/2026 at around 5:30 PM and was at the facility for about an hour. RN 1 stated when a resident arrives from GACH 1, whoever the admitting nurse is should review the discharge medication list for medication reconciliation, discharge summary and instructions and H&P. RN 1 stated Resident 1 arrived with the discharge documentation from GACH 1, but she did not review any of the GACH 1 documentation. During the same interview, RN 1 stated she checked on Resident 1 when she arrived [at SNF 1], checked her vital signs and did not document her findings in the [SNF 1] resident's records. RN 1 stated she attempted to conduct a skin and body assessment, but Resident 1 refused. RN 1 stated she did not document any of her encounters with Resident 1 while she was in the facility [SNF 1] for that one hour. RN 1 stated there should be an assessment and she should have documented before Resident 1 was transferred, but because of instruction received from the SSD of readmitting Resident 1 and [the] pick up for the patient [Resident 1] [was] in 1 hour, I did not do it. RN 1 [stated] the purpose of an assessment was to check if there were any skin issues, wounds, or any other issues. RN 1 stated she did not document anything. RN 1 stated if there were any abnormalities on assessment something could happen with resident and whoever was receiving the resident would report us. During an interview on 7/10/2026 at 8:04 AM with Family Member (FM)1, FM 1 stated Resident 1 had been hospitalized in GACH 1 and was discharged on 5/14/2026 with a plan to be readmitted back to [SNF 1]. FM 1 stated the GACH 1 notified her that Resident 1 was being transported by ambulance to SNF 1 for readmission. FM 1 stated the ambulance arrived at SNF 1 on 5/14/2026 in the afternoon (unable to recall time), however SNF 1 refused to readmit the resident back. FM 1 stated she received a telephone call later that afternoon from a male employee at a Board and Care (B&C) facility, informing her that Resident 1 had arrived without medications, oxygen, or her BiPAP machine, which she required nightly for breathing. FM 1 further stated the B&C employee informed her that the facility had been told Resident 1 had no family. FM 1 stated she was not made aware by SNF 1 that resident 1 had been discharged to a B&C on 5/14/2026. FM 1 stated that Resident 1 had been oxygen dependent for approximately 20 years and typically used 4 liters of oxygen via a portable tank. During an interview on 7/10/2026 at 8:04 AM, FM 1 stated she contacted FM 2, who immediately went to the B&C facility on 5/14/2026 at approximately 9:30 PM. FM 1 reported that the B&C administrator informed FM 2 that Resident 1 could not be readmitted to SNF 1. FM 1 stated Resident 1 remained at the B&C for about one day, during which the B&C provided oxygen but did not have Resident 1's medications or BiPAP machine. FM 2 then transported Resident 1 to the General Hospital, where Resident 1 was readmitted for five days before being discharged to another B&C facility. FM 1 stated she believed the facility discharged Resident 1 due to medical coverage issues; however, she reported she was never provided documentation indicating a lack of insurance benefits. During an interview on 7/10/2026 at 10:55 AM with SNF 1's Discharge planner, stated discharge planning had been initiated prior to Resident1's transfer to the acute care hospital. The Discharge Planner stated Resident 1 no longer required skilled nursing services [level of care] and the discharge plan was for placement in a B&C facility. The Discharge Planner stated the family was aware they were looking a B&C facility who would accept Resident 1's benefits and oxygen needs, but FM 1 was not in agreement to send Resident 1 at a B&C. During a concurrent interview and record review on 7/10/2026 At 11:31 AM with SNF 1's Administrator (ADMIN), Resident 1's medical records was reviewed. SNF 1 Admin stated he could not find documentation for Resident 1's readmission or discharge status, including discharge needs on 5/14/2026. SNF 1 Admin stated because no readmission documentation was available in Resident 1's records, he could not determine how long Resident 1 remained in the facility before being discharged to the B&C on 5/14/2026 or whether the family been notified of Resident 1's return and same - day discharge from SNF 1. During another interview on 7/10/2026 at 12:00PM with the SNF 1 Discharge Planner, she stated Resident 1 had been hospitalized from [DATE] through 5/14/2026, exceeding 30 days. SNF 1 Discharge Planner stated the facility [SNF 1] believed it was no longer obligated to hold Resident 1's bed after seven days. While no documentation could be provided of Resident 1's DC plan and reevaluation to be discharged to an appropriate location, the DC Planner stated the facility had informed the hospital that no bed was available when a readmission was requested. Discharge Planner further stated the resident returned to the facility by ambulance on 5/14/2026 at an unknown time, however, the receiving RN did not document the resident's arrival. As a result, the facility could not determine whether the resident arrived on oxygen or whether the resident' s CPAP machine accompanied the transfer During a concurrent interview and record review on 7/10/2026 at 12 PM with SNF 1's Discharge Planner, Resident 1's SNF 1 Progress Notes dated 5/14/2026 were reviewed. The Progress Notes indicated that MD 1 had ordered that Resident 1's medications be sent to the B&C facility upon discharge. During the interview, the Discharge Planner stated that no medications were sent with Resident 1 at the time of discharge to the B&C on 5/14/2026. During an interview on 7/10/2026 at 12:30 PM with the SNF 1's Assistant DON (ADON), the ADON stated that upon arrival of Resident 1 to SNF 1, RN 1 activated the Admit/ Discharge /Transfer (ADT) function in the electronic medical record, making Resident 1 active in the electronic system for 5/14/2026, however, no admission assessment, nursing notes, monitoring, arrival documentation, or discharge documentation were completed for Resident 1 on 5/14/2026. The ADON confirmed the licensed nurse should have completed these records upon the resident's arrival and acknowledged no discharge documentation could be located as well. During an interview on 7/10/2026 at 12:45 PM, SNF 1 SSD stated that Resident 1 returned to the facility on 5/14/2026 after a hospitalization of approximately 30 days. SS reported the resident had been accepted to a Board and Care (B&C) facility prior to hospitalization, and the resident's belongings-including the wheelchair and BiPAP machine-were placed in storage during the hospital stay. SS acknowledged she was not on duty when the resident was transferred; however, upon returning to work on 5/15/2026, she found Resident 1's BiPAP machine still in her office, indicating it had not been sent with the resident during the transfer. During an interview on 7/10/2026 at 1:40 PM with the SNF 1 SSD, the SSD stated she was unsure why Resident 1's responsible party was not notified at the time of Resident 1's discharge to the B&C on 5/14/2026. The SSD stated SNF 1's usual practice is to notify the responsible party whenever a resident is transferred or discharged from the facility. During an interview on 7/10/2026 at 2:00 PM with SNF 1 ADON, the ADON stated she could not confirm whether the resident's family was notified upon the resident's return to the facility because there was no documentation indicating RN1 notified the responsible party. ADON stated, Every part of [Resident 1's] [readmission] to discharge was wrong. The ADON further stated the resident left without her medications or BIPAP machine. The ADON stated she did not know who gave the order for Resident 1 to transfer without necessary medical equipment and medications During a concurrent interview and record review on 7/10/2026 at 2:15 PM with the SNF 1 Discharge Planner, Resident 1's Physicians Orders for month of May 2026 was reviewed. The Physicians Orders indicated no order for oxygen concentrator to be provided to the resident at the board - and - care facility had been placed prior to Resident 1's discharge to the B&C on 5/14/2026. The Discharge Planner stated it is important that residents are transferred with all prescribed respiratory equipment to prevent respiratory compromise. During an interview on 7/10/2026 at 2:45 PM with SNF 1 MD 1, MD 1 stated he was familiar with Resident 1 and that the facility normally notifies him before discharging a resident to a lower level of care like a B&C. MD 1 stated he would not have expected Resident 1 to discharge from the facility without his knowledge. MD 1 stated he believed Resident 1 no longer required skilled nursing services level of care and was appropriate for discharge to a B&C facility. MD 1 however stated SNF 1 was responsible for ensuring all necessary discharge arrangements were completed before Resident 1's discharge, including obtaining and sending the residents' prescribed medications, oxygen, oxygen concentrator, bipap machine, and any other necessary medical equipment and supplies. MD 1 stated he was not aware that Resident 1 had been discharged without prescribed medications and necessary medical equipment and that the resident's family had not been notified. MD 1 stated he provided the discharge order based on the assumption that SNF 1 had completed all required discharge planning, including ensuring Resident 1's necessary medical equipment and medications. During an interview on 7/10/2026 at 3:30 PM with Discharge Planner, stated the family had been planning to transfer the resident to a lower level of care prior to the resident's transfer to the acute care hospital however, no transfer date had been established because the family had not yet agreed to a specific B&C facility. She stated that after the resident returned from GACH 1, Resident 1 was discharged directly to the B&C facility on 5/14/2026. SNF 1 Discharge Planner acknowledged the discharge occurred without reevaluation of resident's status after GACH 1 discharge and without notifying the resident' s family. During an interview on 7/21/2026 at 11:54 AM with the B & C Administrator (Admin), the B&C Admin stated, that on 5/14/2026 she received a telephone call from a placement agent seeking immediate placement for a resident [Resident 1]. B&C Admin stated they had an available bed and agreed to accept Resident 1 the same day. B&C Admin stated the resident arrived by ambulance approximately two hours later without medications, transfer documentation, medical equipment, or other paperwork. The B&C Admin stated the placement agent advised that all documentation would be provided the following day and he had no reason not to believe him. B&C Admin stated because Resident 1 arrived without medications, she contacted the Residents' family (FM 1) through the resident, who reported she was unaware Resident 1 had been discharged to the B&C. The B&C Admin stated the FM2 arrived at the B&C on 5/15/2026 to see Resident 1 and then arranged for transfer to GACH1 the next day around 11:00AM in afternoon because the B&C could not care for Resident 1's oxygen needs and need for medications. During a review of the facility's undated policy and procedure titled admission Policy, it was noted that the policy requires all admission documentation to be completed, signed, and maintained in the resident's medical record. The policy states that physician admission orders and clinical information must be obtained before or upon admission, medication reconciliation and nursing assessments must be completed upon admission, and that transfers to a higher level of care must be managed in accordance with applicable transfer and discharge regulations. The policy further requires that a written discharge summary be completed and included in the medical record, and that the resident and/or responsible party receive written discharge instructions and contact information to ensure coordination between hospitals and providers for continuity of care. The policy identifies the Administrator, Director of Nursing, Social Services, and Attending Physician as responsible for implementation. During a review of the facility's Policy and Procedure (P&P) Titled Discharge Policy undated, the policy indicated that all resident discharges would be safe, planned, and coordinated to promote continuity of care. The P&P further requires the facility to involve the resident and/ or responsible party in discharge planning, obtain physician discharge orders, complete medication reconciliation, coordinate necessary medical equipment and services, provide written discharge instructions, coordinate with receiving providers to ensure continuity of care, and complete a written discharge summary in the resident' s medical record. The P&P also required all discharges to comply with applicable federal and California regulation regarding residents' rights, transfer, discharge notice requirements, and documentation. During a review of the facility's Policy and Procedure (P&P) titled Transfer or Discharge dated 4/2025, indicated once admitted to the facility, residents have the right to remain in the facility. Transfers and discharges must meet specific criteria and require resident/ representative notification, orientation, and documentation in the medical record. The policy indicated documentation of the basis for the transfer or discharge, notification to the resident and /or legal representative, the date and time of transfer, receiving location, transportation, discharge summary, and physician documentation supporting the transfer when the resident's needs could no longer be met. The policy further required communication with the receiving provider, assistance with discharge planning, and notification of the resident' s appeal rights.

Based on observation, interview, and record review the facility failed to provide physical therapy, (a healthcare specialty focused on restoring movement, reducing pain, and improving overall function) five (5) times a week in accordance with the physician's order for one of two (2) sampled residents (Resident 4). This deficient practice had the potential to place Resident 4 at risk for decline in functional mobility. Findings: During a review of Resident 4's admission Record (AR), the AR indicated Resident 4 was originally admitted to the facility on [DATE] with diagnoses that included repeated falls, cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain), and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 4's Minimum Data Set (MDS - resident assessment tool), dated 3/17/2026, the MDS indicated Resident 4's cognitive (the ability to process thoughts) ability for daily decision making was moderately impaired. The MDS indicated that Resident 4 needed substantial/maximal assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.) with lower body dressing. Resident 4 needed partial/moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort.) with putting on/taking off footwear, upper body dressing, toileting hygiene, rolling left and right, sitting to lying, lying to sitting on the side of the bed, sitting to stand, and chair/bed-to-chair transfer. During a review of Resident 4's Care Plan Resident Has Impaired Physical Mobility dated 4/6/2026, the Care Plan indicated Resident 4 has risks for falls with injury, further loss of mobility and independence, increased need for assistance with Activities of Daily Living (Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The care plan interventions were to continue ordered rehab services for strengthening, gait training, and neuromuscular (hands-on-training to help the brain and muscles communicate better, and therapeutic activities (exercises that mimic daily movements) re-education. During a review of Resident 4's Order Summary Report dated 5/7/2026, the Order Summary Report indicated a physician order for skilled physical therapy every day 5 times a week for 4 weeks for therapeutic exercises, gait training (therapy designed to improve how to walk and stand), neuromuscular re-education. During a review of Resident 4's Physical Therapy Treatment Encounter Note (s), the Physical Therapy Treatment Encounter Notes indicated Resident 4 received an evaluation for physical therapy on 5/7/2026, and physical therapy treatments on 5/8/2026, 5/11/2026, 5/14/2026, and 5/20/2026. During a review of Resident 4's History and Physical (H&P) dated 5/25/2026, the H&P indicated that Resident 4 was admitted to the facility for skilled physical therapy services with the goal to improve balance, prevent falls, increase functional activity tolerance, increase coordination, and promote safety awareness. H&P also indicated that Resident 4 has a high risk of developing contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion), pressure ulcers (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) poor healing or fall if not receiving adequate therapy and that discharge planning was pending therapy progress. During an interview on 6/1/2026 at 1:14 PM, the Director of Rehabilitation (DOR) stated that Resident 4 has not been receiving physical therapy as ordered by the physician and Resident 4's physician has not been notified of lack of therapy treatments. The DOR stated they do not have adequate Physical Therapist coverage and are actively hiring. During an interview on 6/1/2026 at 4:15 PM, Resident 4 stated that he has not been receiving therapy as he knows he should. Resident 4 stated that he has only received physical therapy a few times and does not understand why he is not receiving it more frequently. Resident 4 stated that his personal goal is to return home, and his physician advised that physical therapy is necessary for him to regain the ability to care for himself safely and independently. During an interview on 6/1/2026 at 4:50PM, the Director of Nurses (DON) stated that the facility must inform the physician when there is an order that cannot be carried out. The DON added it is the facility's responsibility to ensure timely communication with physicians to prevent decline and maintain the well-being of the residents. During an interview on 6/1/2026 at 4:20 PM with Family Member 2 (FM 2), FM 2 stated that Resident 4 has been informing her that he is not receiving physical therapy and Resident 4 would like to go home. FM 2 stated the main purpose of Resident 4's stay at the facility is to receive physical therapy. During a review of the facility's undated Facility Assessment, the Facility Assessment indicated that therapy services such as physical therapy is needed to meet the needs of the resident population. The Facility Assessment indicated the necessity of having qualified staff members available to deliver these services and ensure residents receive appropriate care. During a review of the facility 's policy and procedure (P&P) titled, Functional Impairment - Clinical Protocol, dated 3/2018, the P&P indicated that the facility staff and physician will collaborate to identify rehabilitative or restorative care plan to help improve function and quality of life and meet a resident/patient's goals and needs to attain desired outcomes such as discharge to the community. During a review of the facility's policy and procedure (P&P) titled, Guidelines for Notifying Physicians of Clinical Problems dated 2/2014, indicated that any change in physical condition or functional status that is not accompanied by debilitation or more than minimal distress.

Based on interview and record review the facility failed to ensure informed consent (the process in which a healthcare professional explains the risks, benefits, and alternatives of a procedure to a person, ensuring they fully understand it before agreeing to participate was obtained prior to the use of psychotropic medications for one of two sampled residents (Resident 2) in accordance with the facility's policy and procedure (P&P) titled Informed Consent for Psychotropic Drugs. This deficient practice had the potential to violate resident' rights to be informed prior to administering medications without their knowledge or approval. This also placed the resident at risk for unnecessary chemical restraint (the use of medication to intentionally slow down, sedate, or control a person's movements and behavior) that limit their ability to participate in care decisions.Findings: During a review of Resident 2's admission Record (AR), it indicated, Resident 2 was originally admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), mood disorder (a mental health condition that affects emotional state and it causes extreme mood swings), mental disorder (a medical condition characterized by significant changes in a person's thinking, mood, or behavior), and anxiety (a mental health condition characterized by excessive, persistent and uncontrollable fear or worry). During a review of Resident 2's History and Physical (H&P) dated 4/1/2026 it indicated that Resident 2 had the ability to understand and make basic decisions, need some help with more complicated healthcare related decisions. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 4/6/2026, indicated Resident 2 cognition (the ability to process thoughts) was severely impaired. During a review of Review of Resident 2's Physician Order Report dated 3/30 2026 to 5/29/2026 indicated to give Resident 2 the following: a. valproic acid (a prescribed medication used to stabilize severe mood swings in bipolar disorder [sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs]) oral capsule 250 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) give 3 capsule by mouth four times a day for recurrent behavior fluctuations from calm to manic behavior and vice versa as evidence by sudden outburst anger with screaming and yelling dated 3/30/2026. b. Seroquel (is a medication that treats schizophrenia (a mental illness that is characterized by disturbances in thought) and bipolar disorder) oral tablet 100 mg give 3 tablets by mouth at bedtime for sudden outbursts of anger dated 3/31/2026. c. Ativan (is a medication used to treat anxiety disorders or anxiety) oral tablet 1mg give one tablet by mouth every 12 hours as needed for anxiety for 14 days manifested by outburst of anger as evidence by disorganized behavior with attempt to strike out when receiving care dated 4/30/2026. During a review of Resident 2's Psychotherapeutic Drug Informed Consent Form dated 3/31/2026, indicated for the informed consent for Seroquel, valproic acid, (Ativan) lorazepam (Resident 2's cognition was severely impaired)was not signed by the physician. The consent for Ativan indicated for the dose of 0.5 mg and it did not have the consent for 1 mg that was ordered on 4/30/2026. During a concurrent interview and record review of Resident 2's Psychotherapeutic Drug Informed Consent Form on 5/30/2026 at 3:40 PM Social Services Director (SSD) stated, Resident 2's cognition status varied from time to time and the resident was assessed to have impaired cognition and therefore the resident cannot sign the inform consent. SSD understands that the Interdisciplinary team (IDT - a coordinated group of experts from several different fields who work together) should have intervene with decision making since Resident 2 did not have the capacity to make decision for self and there was no designated family or resident representative to make the decision on behalf of the resident. SSD stated the facility only had three consents for Resident 2 and none for Resident 1's Ativan 1 mg. During a review of the facility's P&P Informed Consent for Psychotropic Drugs undated, it indicated, inform consent must be obtained for all psychotropic medications prior to initiation or a dose increase. The policy indicated for residents that lack capacity to make decisions and are without a representative follow state-specific procedures such as ethics committee (a group of people from different backgrounds who review rules and tough choices to make sure things are done fairly and safely), court appointment.

Based on observation, interview, and record review, the facility failed to ensure a safe and comfortable environment for one of two sampled residents (Resident 3) as indicated on the facility policy by failing to provide resident with a comfortable and safe bed. This deficient practice resulted in Resident 3 experiencing discomfort which could negatively affect Resident 3's overall well-being and quality of life. Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] with diagnoses that included pneumothorax (collapse lung), thoracic -1,2 vertebra (back bone, first two bones of the mid back, located at the base of the neck fracture [break in a bone]) fracture, multiple rib fractures of the right side 1, 4 to 11, right shoulder scapula (shoulder blade) fracture, 4,5- lumbar vertebra fracture (lower back bone fracture), laceration of the liver, right acetabulum (large cup-shape socket on the side of the pelvis) fracture, right pubis fracture (break in one of the bones that makes the front of the pelvis), difficulty in walking, multiple facial bone fractures, and left acetabulum left pubis fracture with bladder injury. During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 5/26/2026, the MDS indicated Resident 3 had intact cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. Resident 3 required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) in shower/bathe self. Resident 3 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with personal hygiene, putting on/taking off footwear, lower body dressing, upper body dressing, and toileting hygiene. During an observation and interview on 5/30/2026 at 11:40 AM in Resident 3's bedroom, Resident 3 stated that the bed was not comfortable, especially at night when his pain worsens. Resident 3 stated that the right corner of the bed had a metal piece used for supporting the corner of the mattress, but the left side was missing the left corner metal piece causing the mattress to tilt to the left side. Resident 3 further stated this misalignment caused him discomfort when lying in bed. Resident 3 stated that he had told facility staff how uncomfortable the bed was, but nothing was resolved. During a concurrent observation and interview on 5/30/2026 at 1:24 PM with Maintenance (MAINT 1), MAINT 1 assessed Resident 3's bed. MAINT stated the right metal corner on Resident 3's bed was missing the left side causing the mattress to tilt to the side. MAINT 1 stated that Resident 3 had told him about the mattress issue and had told Resident 3 that MAINT 1 was going to order another mattress that might take up to 2 weeks to receive. During a review of Resident 3's Care Plan titled, Acute Pain Related to Multiple Traumatic Fractures, dated 5/21/2026, the Care Plan indicated that Resident 3 was at risk for sleep disturbance. The pain goal was 3/10 during rest and activity. The care plan interventions were to assess pain every shift, administer analgesics as ordered and reassess effectiveness, implement non-pharmacological interventions such as positioning, relaxation, environment adjustment. During a review of the facility's Policy and Procedure (P&P) titled, Pain Assessment and Management, dated 4/2025, the P&P indicated to implement pain management strategies considering the resident's medical condition, current medication regimen and cause of the pain, course of the illness, and treatment goals. During a review of the facility's undated P&P titled, Preventive Maintenance of Equipment Policy, the P&P indicated that the facility would ensure all facility equipment is maintained in safe working condition to support resident care, safety, and regulatory compliance.

Based on observation, interview and record review the facility failed to administer continuous oxygen (O2) therapy (a treatment that provides you with supplemental, or extra, oxygen. The administration of O2 at concentrations greater than that in ambient air [20.9%] with the intent of treating or preventing the symptoms and manifestations of hypoxia [decreased perfusion of oxygen to the tissues] and respiratory therapy [services that are provided by a qualified professional such as respiratory therapists or respiratory nurse] for the assessment, treatment, and monitoring of residents with deficiencies or abnormalities of pulmonary function) as ordered by the physician for one of four sampled residents (Resident 5). This failure had the potential to put Resident 5 at risk of breathing difficulty including respiratory arrest (completely stop breathing) due to the lack of oxygen. Findings: During a record review of Resident 5's admission Record, the admission Record indicated Resident 5 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and chronic respiratory failure (a condition where there is not enough oxygen or too much carbon dioxide [natural waste odorless gas that humans breathe out]). During a record review of Resident 5's Minimum Data Set (MDS - a resident assessment tool) dated 3/26/2026, it indicated Resident 5's cognition (the ability to process thoughts) was intact. The MDS indicated Resident 5 had been on oxygen therapy in the last seven days lasting at least 15 minutes. During a review of Resident 5's Order Summary Report dated 5/30/2026, it indicated a physician order to administer continuous O2 at 2 to 5 liters per minute (LPM) via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) and titrate (adjust setting) O2 to maintain saturation (measure the percentage of oxygen-carrying hemoglobin in your blood) of more than 92%. During a review of Resident 5's Care Plan titled Resident Has Ineffective airway exchange and Respiratory Diagnosis/history of Pulmonary Edema dated 11/21/2025, the care plans indicated the goal that Resident 5 will have no respiratory distress and will maintain saturation above 92%. The care plan indicated intervention to provide supplemental O2 delivery Resident 5 on 2 LPM via nasal cannula. During an observation in Resident 5's room on 5/31/2026 at 5:23 PM, Resident 5 was observed with a nasal cannula connected to an empty portable oxygen cylinder (small metal tank that holds extra oxygen). Resident 5 complained of not getting enough oxygen. Resident 5's oxygen saturation was checked by Respiratory Therapist (RT) and it was noted to be 80%. During an interview on 5/31/2026 with Resident 5, Resident 5 stated he called for staff assistance because he noticed he was not getting enough oxygen and was having difficulty breathing. During an interview on 5/31/2026 with RT, RT stated the staff did not notify RT that Resident 5 was back in bed and that RT was responsible to reconnect Resident 5 to the oxygen concentrator (a medical device/ machine that draws in ambient air, removes nitrogen, and delivers concentrated oxygen up to 95% pure). During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration dated 10/2010, it indicated while residents are receiving oxygen therapy the resident should be assess for the following signs or symptoms: restlessness, confusion, difficulty breathing, or slow rate of breathing including vital signs. The P&P indicated verify that there is a physician's order for this procedure review the physician orders or facility protocol for oxygen administration

Based on interview and record review the facility failed to ensure one of four sampled residents (Resident 4) who was assessed as a high risk for pressure injury (a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result pressure in combination with shear) received services to protect skin integrity (state of being intact, healthy, and free from damage), promote healing, and prevent development and worsening of pressure injury by failing to ensure toileting hygiene was done after Resident 4 had a bowel movement and not wait for one hour in accordance with Resident 4's care plan to keep skin clean and dry. This deficient practice had the potential to result in a delay in promoting healing of a pressure ulcer. Findings: During a review of Resident 4's admission Record (AR), it indicated Resident 4 was originally admitted to the facility on [DATE] with diagnoses that included pressure ulcer of right buttock, cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain), and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 4's Care Plan, titled Pressure Injury/Ulcer dated 3/12/2026, it indicated to keep skin clean and dry. During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool) dated 3/17/2026, the MDS it indicated, Resident 4 needed substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with lower body dressing and partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with putting on/taking off footwear, upper body dressing, toileting hygiene. The MDS also indicated Resident 4 needed supervision with oral and personal hygiene. It indicated Resident 4 is at high risk of developing pressure ulcers/injuries and was admitted to the facility with a stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) During a review of Resident 4's Care Plan, titled Resident is at Increased Risk for Recurrent Infection Due to Pressure Injury dated 4/6/2026, it indicated due to chronic illness and reduced mobility Resident 4 is at risk of infection with intervention to ensure timely wound care and hygiene. During a review of Resident 4's Wound Assessment dated 5/1/2026, it indicated right ischium/gluteal fold stage 4 pressure ulcer with a measurement of 4.0 centimeters in length (cm - unit of length used to measure) and 0.5 cm in width and 0.2 cm in depth with light serosanguinous (fluid or discharge that contains both blood and fluid). During an interview 6/1/2026 at 4: 20 PM with Resident 4, Resident 4 stated that when he has had episodes of bowel incontinence, he has used the call light (call system used in the healthcare facility for residents to alert staff when the resident needed help) to ask for assistance and has been left in bed soiled for long periods of time (resident cannot recall a specific date) and it is usually at night time. During a concurrent interview and record review on 6/1/2026 at 1:42 PM with Director of Staff Development (DSD), Resident 4's Nursing Progress Notes 5/27/2026 was reviewed. DSD stated according to the nursing progress notes that on 5/27/2026 at 10:00 AM Resident 4 had an episode of diarrhea (stool is loose, watery, and happens more often than usual). DSD stated that the Certified Nurse Assistant (CNA) assigned to Resident 4 provided toileting hygiene one hour after the bowel incontinence episode because per the CNA's task documentation on 5/27/2026 Resident 4 did not get toileting care until 11:05 AM. DSD stated staff are instructed to provide incontinent care as soon as possible to the residents to ensure residents are kept clean and dry and in order to prevent skin complications, including a decline in wound healing. During a review of the facility's P&P Call Light System Policy undated, it indicated, in order for residents to have a reliable method to request assistance, promote timely staff response the facility will maintain a call light system to allow residents to request assistance and communicate their needs safely and effectively. The P&P also stated that it is the facility's expectation that staff should respond promptly to all call light activations. During a review of the facility's P&P Pressure Wound Documentation, Consultant Review, and Care Plan Update Policy undated, it indicated, weekly Interdisciplinary (IDT - a coordinated group of experts from several different fields who work together) should be completed for the resident by the IDT on a weekly basis to monitor for progression and healing status of wound, treatment effectiveness, nutritional and clinical risk factors, consultant and physician recommendations, need for additional interventions or services, and appropriateness of current care plans.

Based on interview and record review the facility failed to prevent a physical abuse (a type of abuse that uses physical force) one of two sampled resident (Resident 1) when: The facility did not follow physician order to send Resident 2 to the General Acute Community Hospital emergency room for psychiatric evaluation on 4/30/2026. Certified Nurse Assistant (CNA 1) left Resident 1 alone with Resident 2 (Resident 1's roommate) after Resident 2 had attempted to hit Resident 1 on 5/28/2026. CNA 1 did not separate Resident 2 from Resident 1 when Resident 2 was actively hitting Resident 1 with the water pitcher on 5/28/2026. The facility failed to address and accommodate Family 1 (FM 1- Resident 1's family) verbalized to the Interdisciplinary team (IDT - a coordinated group of experts from several different fields who work together) and to Social Services concerns of Resident 1's safety with the roommate (Resident 2) and had requested a room change since 5/25/2026. These deficient practices resulted in Resident 2 hitting Resident 1 with a water pitcher which may cause serious injury and psychosocial harm to Resident 1. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted Resident 1 on 5/22/2026, with diagnoses that included compression fracture (break in a vertebra [spine bone]) of thoracic (T-upper middle back) 7 & T8 Vertebra, wedge compression fracture (two bones have cracked and collapse) of T11 & T12 vertebra, difficulty walking, and muscle weakness. During a review of Resident 1's History and Physical (H&P) dated 5/23/2026, it indicated Resident 1 had the ability to understand and make healthcare decisions. During a review of Resident 1's Care Plan dated 5/25/2026, it indicated Resident 1was at risk of injury, fractures, decreased mobility and that resident would remain free from falls and injury with interventions to report changes in condition promptly. During a review of Resident 1's IDT dated 5/28/2026 at 4:00PM, it indicated the altercation between Resident 1 and Resident 2 occurred in Resident 1 and 2's room. The IDT note also indicated Resident 1 had a pain level of 7/10 with decreased range of motion. During a review of Resident 1's Progress Notes (psychosocial notes) dated 5/28/2026 at 5:38 PM, it indicated Resident 1 complained that Resident 1 was hit on the right shoulder and right leg by roommate Resident 2 with the water pitcher. During a review of Resident 2's admission Record, it indicated that Resident 2 was originally admitted to the facility on [DATE], with diagnoses that included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), mood disorder (a mental health condition that affects emotional state and it causes extreme mood swings), mental disorder (a medical condition characterized by significant changes in a person's thinking, mood, or behavior), and anxiety (a mental health condition characterized by excessive, persistent and uncontrollable fear or worry). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 4/6/2026, it indicated Resident 2 had active diagnoses of anxiety disorder, bipolar disorder, schizophrenia disorder, morbid obesity, and severe cognitive impairment (ability to think and reason). During a review of Resident 2's Order Summary Report it indicated a medication order dated 3/30/2026 valproic acid (prescribed medication to stabilize extreme mood swings)750 mg four times a day for mood disorder manifested by recurrent behavior of fluctuations from calm to manic (mental state of an extreme highs or depressive lows) behavior with sudden outburst anger with screaming and yelling. During a review of Resident 2's Multidisciplinary Care Conference dated 3/31/2026 it indicated, Resident 2 was recently in a psychiatric hospitalization (a temporary stay in a specialized hospital or hospital unit that provides care for mental illness) after setting the resident's room on fire and reporting suicidal ideation (suicidal thoughts or ideas centered around death) while expressing distress about the care received at the previous facility. During a review of Resident 2's Order Summary Report it indicated, Resident 2 had medication order dated 3/31/2026 for Seroquel (prescribed medication that is an antipsychotic to treat schizophrenia and bipolar disorder) 300 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) at bedtime for schizoaffective disorder manifested by sudden outburst of anger. During a review of Resident 2's Nursing Progress Notes dated 4/29/2026 at 2:08 PM it indicated that Resident 2's Medical Doctor (MD 1) was notified of Resident 2 yelling in the hallway. During a review of Resident 2's Care Plan titled Impaired Emotional Regulation dated 4/29/2026, it indicated Resident 2 had sudden outbursts of anger, yelling and inability to control emotional responses related to Resident 2's psychiatric disorders. It also indicated interventions were to remove Resident 2 from stimulating environment and escort to quiet, safe area, and to provide one to one staff supervision (one staff designated to monitor or supervise the resident) during the episode. During a review of Resident 2's Nursing Progress Notes dated 4/30/2026 at 9:33 AM it indicated that MD1and Psychiatric Nurse Practitioner (PNP 1) gave order to send Resident 2 to GACH emergency room for further evaluation and management of behavioral outburst. During a review of Resident 2's Psychosocial/Social Services Note dated 4/30/2026 at 10:21 AM indicated that while in the dining room Resident 2 threw a food plate at the Administrator (ADMIN) and was using profanity. During a review of Resident 2's Nursing Progress Notes dated 4/30/2026 at 10:52 PM Resident 2 struck a CNA (not indicated who) on the chest while CNA was providing care to the resident. During an interview on 5/30/2026 at 4:01 PM with Assistant Director of Nurses (ADON) stated that there was no documentation in Resident 2's chart that Resident 2's MD 1 was made aware that Resident 2 was not transferred to the GACH emergency room (ER) as ordered on 4/29/2026. ADON also stated Resident 2 was not transferred to the GACH ER due to insurance issues. During an interview on 6/01/2026 at 10:40 AM, MD 1 stated since Resident 2 was not transferred to GACH due to insurance issued, the facility should have continued to make arrangement for the 5150 (psychiatric hospitalization). During an interview on 6/1/2026 at 10:53 AM with CNA 1, CNA 1 stated on 5/28/2026 approximately 3:10 PM soon after CNA 1 left Resident 1 and 2's room, CNA 1 heard screaming when he returned to the room, he saw the water pitcher on the floor and Resident 2 was trying to hit Resident 1. CNA 1 stated CNA 1 told Resident 2 to calm down, and CNA 1 left the room to get Resident 1 another pitcher of water. CNA 1 filled the water pitcher with ice water and placed it on Resident 2's overside table and left the room. CNA 1 stated about 2 minutes later he heard screaming and returned to the room to find Resident 2 hitting Resident 1 with the water pitcher on the right shoulder and that Resident 2 was complaining that Resident 1 had thrown water at her (Resident 1). CNA 1 stated Resident 1 was wet but does not remember Resident 2 being wet. CNA 1 stated he did not report it to the charge nurse because Resident 2 was calm and cooperative and did not see the need to report it. During an interview on 6/1/2026 at 12:05 PM with Licensed Vocational Nurse (LVN 1), stated that CNA 1 came running to her and told her, They (Resident 1 and 2) are fighting in Room A LVN 1 stated, LVN 1 told CNA 1 do not leave the Residents 1 and 2 alone in the room while having an altercation. LVN 1 stated it was the end of her shift and did not do an investigation or gather more information because it was time for LVN 1 to go home. During an interview on 6/1/2026 at 1:53 PM with FM1, FM 1 stated that FM 1 was not in the facility when the altercation between Resident 1 and 2 occurred. FM 1 stated FM 1 immediately drove to the facility after learning about the altercation between Residents 1 and 2 on 5/28/2026. FM 1 stated when she arrived at the facility there were FM 1 saw when Resident 1 was taken out of the room while Resident 2 was still yelling at Resident 1. FM 1 stated Resident 1 has been enduring loud noises such as yelling, singing, loud television sound, stated that Resident 1 would gesture Resident 2 to lower the television, but it would only get louder. FM 1 also stated, FM 1 requested the facility during one of the IDT meetings (unable to recall when) and social services multiple times verbalizing FM 1's concerns with Resident 2 and asked them to move Resident 1 out to another room since 5/25/2026 but stated nothing happened until 5/28/2026 the day of the incident. During an interview on 6/1/2026 at 4:50 PM with the Director of Nurses (DON), the DON stated that CNA 1 should have stayed in the room with the resident and immediately separated both Resident 1 and 2 on 5/28/2026. The DON stated when there is a verbal or physical altercation this episode should have been reported immediately to the charge nurse, physician, and the DON stated that CNA 1 observed that Resident 2 was calm and cooperative, and CNA 1 thought everything was okay. During an interview on 6/1/2026 at 5:12 PM with the Administrator (ADMIN), ADMIN stated, when there is any type of verbal or physical altercation between the residents the policy should have been followed even when Resident 2 showed no signs of aggression. During a review of the facility's policy and procedure (P&P) Abuse Prevention, Reporting, Investigation, and Response Policy undated, it indicated, the facility is committed to providing a safe environment free from abuse and that all the residents have the right to be treated with dignity, respect, and protection from harm. The facility's policy indicated, part of their prevention of abuse is that staff would be educated to recognize signs and symptoms of abuse and that immediate measures will be implemented to protect residents from further harm. The policy indicated the facility would maintain an environment that promotes resident safety, dignity, and respect.

Based on interview and record review, the facility failed to assess and monitor in accordance to the facility's policy and procedures and professional standard of practice for one of three sampled residents (Resident 1) who was readmitted to the facility and transferred to a Board & Care (B&C) by failing to: Ensure Registered Nurse (RN) 1 assessed and monitored Resident 1's condition by checking the blood pressure (BP), heart rate (HR), respiratory rate (RR), oxygen saturation level, and pain level and documented in Resident 1's clinical record when resident was readmitted to facility and transferred to a B&C.Ensure RN 1 conducted a full head to toe assessment when Resident 1 was readmitted to facility and transferred to a B&C.Ensure RN 1 notified Resident 1's responsible party to inform them of Resident 1's readmission to facility and transfer to B&C. These deficient practices increased the risk of Resident 1 not being accurately assessed for any changes of condition upon readmission and transfer.Findings:During a review of Resident 1's admission Record (AR), the AR indicated the resident was readmitted on [DATE] with diagnoses that included acute and chronic respiratory failure with hypercapnia, unspecified inflammatory spondylopathy (lumbar region,), and acute respiratory failure with hypoxia. During a review of Resident 1's History and Physical Assessment (H&P), dated 3/12/2026, the H&P indicated the resident was alert and oriented to person (know who they are), place (know where they are), and time (has a general sense of time, e.g. the correct day, month, or year). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 3/2/2026, the MDS indicated the resident had moderately impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). During a review of Resident 1's Order Summary Report, the report indicated the following physician orders:On 5/14/2026, an order to re-admit Resident 1 to the facility and then to discharge Resident 1 to a B&C.On 5/14/2026, an order to discharge Resident 1 from the facility to a B&C. During a review of Resident 1's electronic medical chart, the chart did not indicate an admission assessment, vital signs, nursing progress notes, discharge/transfer summary were documented/completed during the duration of Resident 1's stay at the facility. During an interview with the Director of Nursing (DON) on 5/20/2026 at 11:39 AM, the DON stated during the process of admission, the nurse who is admitting the resident should conduct and document an assessment of the resident. The DON stated the nurse should review the discharge papers from the General Acute Care Hospital (GACH) which includes discharge medications and discharge instructions and appointments. The DON stated the nurse would notify the resident's Physician when the resident arrives to the facility and reconcile the medications and orders from the GACH with the resident's Physician to input into the electronic medical record. The DON stated after review of GACH discharge papers with the Physician the nurse would ask if they wanted to include any additional orders. During the same interview on 5/20/2026 at 11:40 AM with the DON, the DON stated when a resident is transferred or discharged from the facility, there must be a Physician's order for where the resident's destination would be. The DON stated the nurse should communicate and endorse to the staff of the receiving facility that Resident 1 would be transferred to. The DON stated the nurse should complete a discharge summary, assessment, notification of transfer/discharge to the ombudsman, Physician, and resident's responsible party. The DON stated the purpose of conducting and documenting assessments on admission, transfer and discharge was to check if resident was stable for transfer and make sure resident had no issues. The DON stated he was not sure what time Resident 1 arrived at facility on 5/14/2026 and when Resident 1 transferred to the B&C. The DON stated he could not recall how long resident was in the facility on 5/14/2026 for readmission. During a telephone interview on 5/20/2026 at 12:08 PM, Discharge Planner (DP) stated on 5/14/2026 stated there were no open female beds at the facility at the time. DP stated Resident 1's family was provided referrals to several places to accommodate resident's needs. DP stated based on Resident 1's clinical information, they were able to find a B&C that accepted Resident 1. DP stated Resident 1's family was upset because they wanted resident to stay at the facility, but there were no female beds available. DP stated Resident 1 was out of the facility for 30 days and usually when the resident is out of the facility for more than 30 days it was considered a discharge from the facility. During a telephone interview with RN 1 on 5/20/2026 at 12:24 PM, RN 1 stated she received instruction from the Social Services Director (SSD) to readmit Resident 1 and transfer to B&C since transportation was already set up by the facility. RN 1 stated Resident 1 arrived at the facility on 5/14/2026 at around 5:30 PM and was at facility for about an hour. RN 1 stated when a resident arrives from GACH, whoever the admitting nurse is should review the discharge medication list for medication reconciliation, discharge summary and instructions and H&P. RN 1 stated Resident 1 arrived with the discharge documentation from the GACH, but she did not review any of the documentation. RN 1 stated she checked on Resident 1 when she arrived, checked her vital signs and did not document her findings. RN 1 stated she attempted to conduct a skin and body assessment, but Resident 1 refused. RN 1 stated she did not document any of her encounters with Resident 1 while she was in the facility for that one hour. RN 1 stated there should be an assessment and she should have documented before Resident 1 was transferred, but because of instruction from the SSD of readmitting the patient and pick up for the patient in 1 hour, I did not do it. RN 1 the purpose of an assessment was to check if there were any skin issues, wounds, or any other issues. RN 1 stated she did not document anything. RN 1 stated if there were any abnormalities on assessment something could happen with resident and whoever was receiving the resident would report us. During an interview with the DON on 5/20/2026 at 12:43 PM, the DON stated the expectation of the licensed nurses was to conduct and document assessments for admissions, transfers, and discharges. The DON stated RN 1 should have taken instruction from himself and not the SSD. The DON stated because Resident 1 was readmitted , RN 1 should have done the complete admission and discharge process. A review of the facility's policy and procedure (P&P) titled Transfer or Discharge Documentation, dated 12/2016 indicated when a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider. The P&P indicated when a resident is transferred or discharged from the facility, the following information will be documented in the medical record:The basis for the transfer or discharge;If the resident is being transferred or discharged because his or her needs cannot be met at the facility, documentation will include:the specific resident needs that cannot be met;this facility's attempt to meet those needs; andthe receiving facility's service(s) that are available to meet those needs.2. That an appropriate notice was provided to the resident and/or legal representative;3. The date and time of the transfer or discharge;4. The new location of the resident;5. The mode of transportation;6. A summary of the resident's overall medical, physical, and mental condition;7. Disposition of personal effects;8. Disposition of medications;9. Others as appropriate or as necessary; and10. The signature of the person recording the data in the medical record.

Based on observations, interview, and record review, the facility failed to ensure physician's order for rehabilitation (Rehab- therapy given to restore an individual back to their highest possible level of physical, mental, and psychosocial well-being) physical therapy (PT- helps improve strength, flexibility and mobility) was implemented or one for three sampled residents (Resident 4), who had impaired functional mobility in the lower extremities. This deficient practice had the potential for Resident 4 to have a decline in strength and mobility.Findings: During a review of Resident 4's admission Record (AR), the AR indicated that Resident 4 was originally admitted to the facility on [DATE] and recently readmitted on [DATE] with diagnoses with displaced intertrochanteric fracture of left femur (a type of broken bone between the bumpy parts at the top of the left thigh bone), chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of right hip. During a review of Resident 4's Minimum Data Set (MDS- resident assessment tool) dated 2/10/2026, the MDS indicated that Resident 4 had impairment in functional limitation in range of motion (ROM- the extent of movement of a joint) in one side of lower extremities. The MDS also indicated that Resident 4 required substantial/maximal assistance (Helper does MORE THAN HALF the effort) on sit to stand, sit to lying, and chair/bed-to-chair transfer. During a review of Resident 4's Order Summary Report (OSR) dated 3/6/2026, the OSR indicated an order to provided PT, occupational therapy (OT), and speech therapy (ST) evaluation and treatment. During a review of Resident 4's Care Plans (CP) titled The resident is at risk for falls: Found on floor on 3/11/2026, the CP indicated interventions for which included PT to evaluate and treat as ordered. During a review of Resident 4's CP titled Unsafe [NAME] Use / Improper Body Alignment dated 3/12/2026, the CP included interventions to refer to PT for gait training, posture correction, and strength exercises. During a review of Resident 4's Rehab Post Fall Screen (RPFS) dated 3/12/2026, the RPFS indicated that Resident had a fall on 3/6/2026 and factors included LE (lower extremities) weakness. The RPFS Screen Result also indicated that Resident 4 was currently on Rehab services. During a concurrent observation and an interview on 4/30/2026 at 9:15AM with Resident 4, Resident 4 stated that he was upset and frustrated because he was weak and could not walk by himself with a walker like he used to prior to the fall on 3/6/2026. Resident 4 stated he has not had therapy for training his legs for ambulation since after he came back from the hospital in March 2026. During a concurrent interview and a record review on 4/30/2026 at 9:40 AM with the MDS nurse (MDSN), Resident 4's OSR was reviewed. MDSN stated there were OT clarification orders for treatment for Resident 4. MDSN stated Resident 4's OT was discharged on 3/24/2026. MDSN stated she did not see any other order for PT except for the admission order that indicated to provide PT, OT and ST. During a concurrent interview and a record review on 4/30/2026 at 11:55 AM with the occupational therapist assistant (OTA 1), Resident 4's Rehab documentations were reviewed. OTA 1 stated that she could not find Resident 4's PT Eval record that was dated after Resident 4's readmission on [DATE]. OTA 1 stated she did not document in Resident 4's medical record that she had informed the previous Director of Rehab (DOR) that Resident 1 was not seen by a PT. During a concurrent interview and a record review on 4/30/2026 at 12:20 PM with the Registered Nurse Supervisor (RNS), Resident 4's OSR was reviewed. The RNS stated she could not find documentation indicating that Resident 4 had PT. The RNS further stated that she was supposed to review Resident 4's Care Plans and confirm the resident's needs and ensure that Resident 4 received PT. During an interview on 4/30/2026 at 1:49PM with the Director of Nursing (DON), DON stated that after RNS entered the rehab order the nursing staff must follow up on the order. DON stated that the nursing staff were supposed to identify resident's needs and communicate with the rehab department when Residents did not receive their ordered therapy. DON stated according to the policy the facility was supposed to ensure residents receive services and/or equipment to help the residents improve or maintain their functional mobility. During a review of the facility's Policy and Procedures (P&P) Resident Mobility and Range of Motion revised in 7/2017, the P&P indicated that residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. The P&P also indicates that the care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion. During a review of the facility's P&P Specialized Rehabilitative Services undated, the P&P indicated that the facility will provide rehabilitative services to residents as indicated by the MDS.

Based on observation, interview, and record review, the facility failed to dispose garbage and refuse properly when: a. One (1) of four (4) dumpsters (a movable waste container designed to be brought and taken away by special collection vehicle, or to a bin that a specially designed garbage truck lifts) was not completely closed and was overflowing with trash when not actively in use. b. The garbage container by the preparation area was not completely covered when not actively being used in the kitchen. These failures had potential to attract birds, flies, insects, pests and potentially spread infection to 124 of 124 facility residents. Findings: a. During a concurrent observation and interview on 4/7/2026 at 9:22 AM, of the dumpster area with the Dietary Supervisor (DS), observed 1 of 4 dumpsters was overflowing with trash. The DS stated 1 dumpster was not completely closed with overflowing trash when not actively use. The DS stated 3 of the dumpsters were not full and staff could have thrown the trash there instead to prevent overflowing. The DS stated the dumpster must be closed completely when not in use to prevent flies in the facility for infection prevention. During an interview on 4/7/2026 at 3:19 PM with the Maintenance Supervisor (MS), the MS stated the dumpster should not be overflowing with trash and should always be close to prevent flies, pests (animals that cause damage and spread disease such as cockroaches, rats and mice) that could lay eggs. The MS stated flies carry diseases that could contaminate food resulting in residents getting sick as a potential outcome. During a review of the facility's Policies and Procedures (P&P) titled, Food-Related Garbage and Refuse Disposal, dated 10/2017, the P&P indicated, 7. Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 5-501.116 Cleaning Receptacles. Proper storage and disposal of garbage and refused are necessary to minimize the development of odors, prevent such waste from becoming an attractant and harborage of breeding places for insects and rodents, and prevent the soiling of food preparation and food service areas. Improperly handled garbage creates nuisance conditions, makes housekeeping difficult, and may be possible source of contamination of food, equipment, and utensils. Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. Proper equipment and supplies must be made available to accomplish thorough and proper cleaning of garbage storage areas and receptacles so that unsanitary conditions can be eliminated. b. During an observation on 4/7/2026 at 9:36 AM, a trash can in the food preparation area was not completely closed when it was not actively being used. During an interview on 4/7/2026 at 9:38 AM, with the DS, the DS stated the lid of the trash can by the preparation area was not closed and the dietary staff were not using it. The DS stated it was important to keep the lid of the trash close to prevent bugs and flies. The DS stated pest droppings could contaminate food, and flies bring diseases that is why it is important to prevent flies going to the kitchen. During a review of the facility's P&P titled Food-Related Garbage and Refuse Disposal, dated 10/2017, the P&P indicated, 2. All garbage and refuse container are provided with tight-fitting lids or covers and must be kept covered when stored or not in continuous use. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 5-501.113 Covering Receptacles and waste handling units for refuse, recyclables, and returnable shall be kept covered: (A) Inside food establishment if the receptacles and units: (1) Contain food residue and are not in continuous use; or (2) After they are filled; and 174 (B) With tight-fitting lids or doors if kept outside the food establishment.

Based on interview and record review, the facility failed to complete the Advance Directive Acknowledgment Form (a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity) with signature to indicate whether an advance directive has been executed, for three of three sampled residents (Resident 7, 9, and 87). This failure had the potential to result in a lack of clarity regarding the residents' healthcare wishes and may impact on the facility's ability to honor those wishes. Findings: 1. During a review of Resident 7's admission Record, the record indicated Resident 7 was admitted to the facility on [DATE] with diagnosis that included metabolic encephalopathy (a condition that can affect cognition, attention, and mental status) and type 2 diabetes mellitus (a chronic condition that requires ongoing monitoring of blood sugar and routine medical). During a review of Resident 7's Minimum Data Set (MDS- a resident assessment and care planning tool), dated 3/23/2026, indicated the resident's functional and cognitive (thought process) was intact. During a review of Residents 7's Advance Directive Acknowledgement Form, dated 12/23/2025, the field was blank and did not indicate whether the resident had or had not executed an Advance Directive. 2. During a review of Resident 9's admission Record, the record indicated Resident 9 was admitted to the facility on [DATE] with diagnosis that included metabolic encephalopathy (a condition that can affect cognition, attention, and mental status). During a review of Resident 9's Minimum Data Set (MDS), dated [DATE], indicated the resident's functional and cognitive (thought process) was intact. During a review of Residents 9's Advance Directive Acknowledgement Form, dated 1/22/2026, the field was blank and did not indicate whether the resident had or had not executed an Advance Directive. 3. During a review of Resident 87's admission Record, the record indicated Resident 87 was admitted to the facility on [DATE] with diagnosis that included metabolic encephalopathy. During a review of Resident 87's Minimum Data Set (MDS), dated [DATE], the MDS indicated Resident 87 was moderately cognitively impaired. During a review of Residents 87's Advance Directive Acknowledgement Form, dated 12/18/2025, the field was blank and did not indicate whether the resident had or had not executed an Advance Directive. During an interview on 4/8/26 at 9:40 a.m. with Social Services Designee (SSD) 1, SSD 1 stated the Advance Directive Acknowledgment Forms for Resident 7,9 and 87 were incomplete. During an interview on 4/9/26 at 2:25 p.m. with SSD 1, SSD 1 stated if the residents do not have an Advance Directive, their care may not be aligned with their wishes and there is a risk of providing unwanted care. During a review of the facility's policy and procedure (P&P) titled, Advance Directives, dated 3/10/2023, the P&P indicated, The facility shall ask residents whether they have executed any Advance Directives.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: Kitchen equipment and utensils were not free from dirt, dust and food debris. Reach-in freezer bottom shelves by the walk-in refrigerator had dirt and cardboard boxes debris. Reach-in freezer bottom shelves by the ice machine had dirt, dust and cardboard boxes debris. Dry storage floor had dirt and trash accumulation in the corner. Kitchen utensils drawer and pots and pans storage area had food debris. Pots and pans storage area had dirt and food debris. 2. Reach-in freezer temperature was at 15 degrees Fahrenheit ( F, a scale of temperature) on 4/6/2026, and 7 F on 4/7/2026 and blank on 4/3/2026 in the afternoon shift. Two trays of sandwiches were not labeled and dated. Two dented (a hallow, dip, or depression on a surface, caused by blow, impact or pressure) cans were stored with non-dented cans. Dietary Aide 2 (DA 2) did not cover his beard completely while preparing puree dessert. Staff did not perform hand hygiene properly when: Dietary Aide 1 (DA 1) touched the towel dispenser knob after washing his hands then proceeded to prepare desserts. [NAME] 1 touched the towel dispenser knob after washing his hand and touched the scoops. [NAME] 1 touched the lid of the trash then proceeded to prepare food. Dietary Aide 3 (DA 3) did not wash his hands or did not change his gloves when touching soiled dishes and putting away clean and washed dishes. Soiled towel was on top of the preparation area while [NAME] was cooking. Coffee scoop was not washed after every use.Blue bin was cracked, with coffee residue and debris touching the lips of disposable cups used for resident's coffee. Sixty (60) of 65 resident's trays were cracked and chipped.Cook 1 was chewing gum during lunch trayline (an area where foods were assembled from the steamtable [kitchen appliance that keeps food warm at a safe temperature for serving] to resident's plates). DA 1 was wearing a nose ring. Pans were stacked wet in the pan storage area. Residents' refrigerator in the activity room had dirt accumulation. The attached freezer had no thermometer and had ice buildup. These failures had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 124 of 127 medically compromised residents who received food and ice from the kitchen. Findings: 1a. During concurrent observation and interview on 4/6/2026 at 8:54 AM, of the reach-in freezer near the walk-in refrigerator with the Dietary Supervisor (DS), the reach-in freezer bottom shelves had dirt debris. The DS stated there was ice and dirt debris at the bottom of the shelves, and it is not okay because of cross-contamination. The DS stated the reach-in freezer cleaning had to be done daily so that germs would not be transferred to food and residents would not get sick from foodborne illness. b. During a concurrent observation and interview on 4/6/2026 at 9:17 AM in the kitchen with the DS, dirt debris was on the bottom of the reach-in freezer. The DS stated the reach-in freezer should be cleaned every day and he did not think the staff cleaned it last night (4/5/2026) because there was dirt debris. The DS stated it was important to maintain the reach-in freezer cleanliness to prevent cross-contamination. During a review of the facility's policies and procedures (P&P) titled Policy: Refrigerator and Freezer Sanitation and Cleanliness (Dietary Services), undated, the P&P indicated, The facility shall maintain all dietary refrigerators and freezers in a clean, sanitary, and proper functioning condition to ensure safe food storage and prevent contamination, in compliance with the CMS food safety standards and California Title 22 regulations. To prevent foodborne illness, ensure food safety, and maintain compliance with infection control and dietary service regulations. Refrigerators and freezers cleaning include: shelves, walls, gaskets, handles, and door surfaces, removal of debris, spills and expired items. c. During an observation on 4/6/2026 at 9:33 AM in the dry storage area, a pile of trash and dirt was on the floor in the corner back. During an interview on 4/6/2026 at 9:38 AM with the DS, the DS stated they deep clean the dry storage room every Wednesday to prevent rodents (small, furry animals such as mice and rats). The DS stated the dirt and trash accumulation on the floor was not okay as it could attract pest (animals that cause damage and spread disease such as cockroaches, rats and mice) and pest dropping could get into the containers and get to the food causing cross-contamination. During a review of the facility's P&P titled Policy: Dry Food Storage (Dietary Services), undated, the P&P indicated, Dry storage areas are cleaned weekly and as needed. Cleaning includes: shelves, floors, corners, and containers, removal of spills, crumbs and debris. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated,4-602.13 Nonfood-Contact Surfaces. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. d. During an observation on 4/7/2026 at 9:39 AM of the kitchen utensils drawer, food debris was in the drawer. During an interview on 4/7/2026 at 9:42 AM with the DS, the DS stated the kitchen utensils drawer was dirty and it had food debris. The DS stated the kitchen staff needed to clean the drawer daily and after each service. During a review of the facility's P&P titled Dietary Services Policy, undated, the P&P indicated, To ensure the dietary services kitchen is maintained in a clean, sanitary, and safe condition at all times in order to prevent food contamination, maintain food quality, and comply with health and safety standards. All equipment, utensils, and food contact surfaces shall be cleaned and sanitized before and after use. e. During a concurrent observation and interview on 4/7/2026 at 9:42 AM with the DS in the kitchen, food debris was in the pot and pans storage area. The DS stated the pots and pans area were not cleaned last night (4/6/2026) because it had food debris and it was not okay because of cross-contamination. During a review of the facility's P&P titled Dietary Services-Kitchen Overall Cleanliness, undated, the P&P indicated, All food preparation, service, and storage areas shall be maintained in a sanitary condition. During a review of Food Code 2022, the Food Code 2022 indicated, 4-601.11 (E) Except when dry cleaning methods are used as specified under S 4-603.11, surfaces of utensils and equipment contacting food that is not time/temperature control for safety food shall be cleaned: (1) At any time when contamination may have occurred; (2) At least every 24 hours for iced tea dispensers and consumer self-service utensils such as tongs, scoops, or ladles; (3) Before restocking consumer self-service equipment and utensils such as condiment dispensers and display containers; and (4) In equipment such as ice bins and beverage dispensing nozzles and enclosed components of equipment such as ice makers, cooking oil storage tanks and distribution lines, beverage and syrup dispensing lines or tubes, coffee bean grinders, and water vending equipment: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specification, at a frequency necessary to preclude accumulation of soil or mold. 2. During an observation on 4/6/2026 at 8:48 AM in the kitchen, no temperature was recorded in the facility's Reach-in Freezer Log for 4/3/2026. During an observation on 4/6/2026 at 9:02 AM, the inside thermometer of the reach-in freezer was at 15 F while the temperature recorded on the log dated 4/5/2026 was 7 F. There was no corrective action indicated on the log. During an interview on 4/6/2026 at 9:07 AM, with the DS, the DS stated they check the freezer temperature three (3) times a day and the freezer should be maintained at 0 F to -10 F to prevent food from defrosting in the freezer. The DS stated the food needed to stay frozen in the freezer to prevent residents from getting sick with foodborne illness. The DS stated if the freezer temperatures were outside the temperature ranges of 0 F to -10 F, the dietary staff should take the food out from freezer and throw it away. During a concurrent interview and record review on 4/6/2026 at 9:10 AM with the DS, the facility log titled, Reach-in Freezer Log, dated April 2026, was reviewed. The log indicated 7 F on 4/5/2026 at 6:55 AM and there was no recorded temperature on 4/3/2026 for the evening shift. The log did not indicate any corrective action. The DS stated the temperature on 4/5/2026 is -7 F and the staff forgot to put a negative sign. The DS stated there was no temperature recorded on 4/3/2026 and it's the responsibility of the PM cook. The DS further stated it is important to monitor temperature to ensure food is staying frozen in the freezer for food safety. During a review of the facility's P&P titled, Policy: Temperature Maintenance-Refrigerators and Freezers (Dietary Services), undated, the P&P indicated, The facility shall ensure that all refrigerators and freezers used for food storage are maintained at safe temperatures, monitored routinely, and documented.Freezers must be maintained at 0 F or below. Logs include date and time, temperature reading, staff initials and signature. Logs are reviewed by supervisor/designee routinely. If temperature is outside the acceptable range: Recheck temperature immediately Adjust thermostat or ensure door is properly closed Notify dietary supervisor/maintenance Assess food for safety and discard if compromised Document corrective action taken. 3. During an observation on 4/6/2026 at 9:19 AM in the walk-in refrigerator, two trays of sandwiches were not labeled and dated. During an interview on 4/6/2026 at 9:25 AM with the DS, the DS stated all food should be labeled and dated upon opening and during delivery. The DS stated the process of labeling and dating included using a date gun indicating received date, prepared date and if it was prepared sandwiches, the whole tray had to be labeled with the sandwich name and three (3) days shelf life (the length of time for which an item remains usable for consumption). The DS stated he prepared the sandwiches last Friday (4/3/2026) and he did not label them. The DS stated he was new and trying to learn the position. The DS stated it was important to label and date the food so they would know when the food item would expire for the staff not to give residents bad food. The DS stated residents could get food poisoning as a potential outcome. During a review of the facility's P&P titled Food Labeling and Dating (Dietary Services), undated, the P&P indicated, All food items stored in the facility shall be properly labeled and dated to ensure safe consumption, prevent contamination, and comply with CMS and California Title 22 regulations. All items must be clearly labeled with: name of food item, date received or prepared, date opened (if applicable), use-by or discard date (if applicable). During a review of Food Code 2022,dated 1/18/2023, the Food Code 2022 indicated, 3-501.17 Commercially processed food, open and hold cold, (B) except specified in (E) - (G) of this section, refrigerated, ready-to-eat time/temperature control for food safety food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacture's use-by- date if the manufacturer determined the use-by date based on food safety. 4. During an observation on 4/6/2026 at 9:33 AM in the dry storage room, there was a designated area for dented cans storage. During a concurrent observation and interview on 4/6/2026 at 9:42 AM with the DS in the dry food storage area, two dented cans were stored with non-dented cans. The DS stated there is a designated dented can area with label by the corner for the staff to use. The DS stated the dented cans are picked up by the vendor every Wednesday. The two dented cans should not be stored with non-dented cans because if consumed, residents could get food poisoning from botulism (a rare and serious illness caused by toxin produced by bacteria of improperly canned food) as the air could spoil the food and grow mold. During a review of the facility's P&P titled, Policy: Dented Cans and Damaged Food Containers (Dietary Services), undated, the P&P indicated, The facility shall ensure that all canned and packed food items are inspected upon receipt and prior to use, and that any dented, swollen, leaking, or damaged cans are immediately removed from service.To prevent foodborne illness and contamination by ensuring that compromised food containers are not used or served to residents. Damaged cans must be removed from food storage area and dented cans are segregated in the designated storage area. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-101.11 Safe Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under 3-601.12, honestly presented. 3-201.11 Compliance with Food Law. A primary line of defense ensuring that food meets the requirements of S3-101.11 is to obtain food from approved sources, the implications of which are discussed below. However, it is also critical to monitor food products to ensure that, after harvesting, processing, they do not fail victim to conditions that endanger their safety, make them adulterated, or compromise their honest presentation. The regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard. 5. During an observation on 4/6/2026 at 11:05 AM in the food preparation area, DA 2 did not completely cover his beard. During a concurrent observation and interview on 4/6/2026 at 11:14 AM in the food preparation area, DA 2 was preparing fruit and dessert while wearing his beard guard halfway to his chin and did not cover all of his facial hair. The DS stated the policy is for the staff to cover all facial hair with a beard guard so it would not go in the food to prevent cross-contamination. During a review of the facility's P&P titled, Policy: Hair Restraints-Dietary/Kitchen Staff, undated, the P&P indicated, All dietary staff shall wear appropriate hair restraints to prevent contamination of food Purpose: To minimize the risk of hair and other contaminants entering food, ensuring safe food handling and infection control. All staff must wear effective hair restraints, including beard guards for facial hair. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated 2-402 Hair Restraints. 2-402.11 Effectiveness (A) except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, and linens, and unwrapped single-service and single use article. 6a. During an observation on 4/6/2026 at 11:06 AM by the sink area, DA 2 washed his hands, touched the towel dispenser knob for some paper towel, wiped his hands, then proceeded to put on gloves and touched clean residents' small plates. During an interview on 4/6/2026 at 11:19 AM with the DS, the DS stated staff should not touch the knob of the towel dispenser after washing their hands because it could contaminate their hands. The DS stated DA 1 should have washed his hands again before going back to work. b. During an observation on 4/6/2026 at 11:31 AM by the sink area, [NAME] 1 washed his hands, touched the paper towel knob dispenser, dried his hands with the paper towel, and proceeded to cook. During an interview on 4/6/2026 at 12:11 PM with the DS, the DS stated [NAME] 1 should wash his hands again after touching the towel dispenser knob before cooking the residents' food to prevent cross-contamination. c. During an observation on 4/6/2026 at 12:07 PM in the kitchen, [NAME] 1 used his hands to lift the cover of the garbage can, then proceeded to touch the tongs and other kitchen utensils without washing his hands. During an interview on 4/6/2026 at 12:11 PM with the DS, the DS stated [NAME] 1 touched the lid of the garbage container so he should have washed hands before proceeding to work to prevent the spread of infection to the residents. d. During an observation on 4/7/2026 at 8:58 AM in the dishwashing area, DA 3 loaded soiled domes in the rack then touched the clean trays. After that, DA 3 went to the two (2)-compartment sink to rinse his gloves, then touched the clean pans and put them away in the storage area. During an interview on 4/7/2026 at 9:03 AM with the DS, the DS stated DA 3 needed to change his gloves when moving from touching the dirty dishes to putting away clean dishes for infection control precaution. The DS stated the dishes that DA 3 washed needed to be rewashed because they were contaminated by his dirty hands. During a review of the facility's P&P titled, Policy: Hand Hygiene-Dietary/Kitchen Services, undated, All dietary staff shall perform proper hand hygiene to prevent contamination and foodborne illness.When to wash hands: starting work handling food or clean equipment donning gloves handling garbage or cleaning chemicals removing gloves contact with contaminated surfaces. The P&P further indicated Proper handwashing techniques included: wet hands with warm water apply soap and lather thoroughly scrub all surfaces for at least 20 seconds rinse thoroughly dry hands with disposable paper towel use towel to turn off faucet. During a review of the facility's P&P titled, Ware Washing, undated, the P&P indicated, 8. If the same person is loading and unloading the racks, hands must be washed and a clean apron worn before unloading the clean dishes. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLESP and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; (B) After using the toilet room; (C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in S 2-403.11(B); (D) Except as specified in S 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using TOBACCO PRODUCTS, eating, or drinking; (E) After handling soiled EQUIPMENT or UTENSILS; (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; (H) Before donning gloves to initiate a task that involves working with FOOD; and (I) After engaging in other activities that contaminate the hands. 7. During an observation on 4/6/2026 at 11:13 AM in the food preparation area, a soiled towel was by the food preparation sink. During an interview on 4/6/2026 at 11:17 AM with the DS, the DS stated towels were used for wiping area down and staff should be putting them inside the red sanitizing bucket to prevent cross-contamination of food. During a review of the facility's P&P titled, Policy: Red and [NAME] Bucket System and Soiled Towel Management (Dietary Services), undated, the P&P indicated, The facility shall utilize a color-coded bucket system (red and green) to ensure proper sanitation of contact surfaces and safe handling of clean and soiled towels, preventing cross-contamination. [NAME] buckets are designated for soiled or contaminated cloths only. During a review of the facility's P&P titled, Policy: Prevention of Cross-Contamination (Dietary/Kitchen Services), undated, the P&P indicated, The facility shall implement strict practices to prevent cross-contamination during food storage, preparation, and service, ensuring safe food handling. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-307.11 Miscellaneous Sources of Contamination. Food shall be protected from contamination that may result from a factor or source not specified under subparts 3-391 - 3-306. 8. During an observation on 4/6/2026 at 11:32 AM in the coffee machine area, the coffee scoop had coffee debris and buildup on the handle and the scoop head. During an observation on 4/6/2026 at 11:39 AM in the coffee preparation area, a kitchen staff made a new batch of coffee using the coffee maker, then placed the scoop he had used to measure the coffee grounds in a blue container without washing it. During an interview on 4/6/2026 at 11:43 AM with the DS, the DS stated the coffee scoop needed to be washed after each use and not every other shift to prevent cross-contamination. During a review of the facility's P&P titled, Policy: Prevention of Cross-Contamination (Dietary/Kitchen Services), undated, the P&P indicated, clean and sanitize all surfaces between tasks. All equipment is cleaned and sanitized after each use. No reuse of contaminated utensils without proper cleaning. During a review of Food Code 2022, dated 1/18/2022, the Food Code 2022 indicated, 4-601.11 (A) Equipment Food Contact Surfaces and utensils shall be cleaned: (1) Except as specified in (B) of this section, before use with a different type of raw animal food such as beef, fish, lamb, pork or poultry; (2) Each time there is a change from working with raw foods to working with ready-to-eat food; (3) Between uses with raw fruits and vegetables and with time/temperature control for safety food. (4) Before using or storing a food temperature measuring device, and (5) At the time during the operation when contamination may have occurred. 9. During a concurrent observation and interview on 4/6/2026 at 11:43 AM in the coffee preparation area, a blue plastic coffee scoop container had cracks, dirt and coffee debris was touching the lip of the container. The DS stated the scoop container needed to be replaced and washed to prevent cross-contamination. During a review of the facility's P&P titled, Ware Washing, undated, the P&P indicated, Utensils, dishes, beverage containers, pots and pans, flatware used for the preparation, service, or storage of food will be cleaned and sanitized after each use. 10. During an observation on 4/6/2026 at 11:51 AM in the kitchen, 60 of 65 residents' food trays inside the food carts had cracks and chips. During an interview on 4/6/2026 at 11:54 AM with the DS, the DS stated the residents' trays had chips and cracks and they could not clean them properly. The DS stated bacteria could grow in the cracks and chips of the trays and bacteria could go to residents' meals. The DS stated, residents could get sick of foodborne illness as a potential outcome. During a review of the facility's P&P titled, Ware Washing, undated, the P&P indicated utensils are inspected for cleanliness and damage (cracks, chips, rust) and shall be removed from the service immediately. During a review of Food Code 2022, dated 1/18/2023 the Food Code 2022 indicated, 4-202.11 Food-Contact Surfaces. (A) Multiuse Food-contact surfaces shall be (1) Smooth (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. (3) Free of sharp internal angles, corners, and crevices, (4) Finished to have smooth welds and joints. 11. During an observation on 4/6/2026 at 12:03 PM in the trayline area, [NAME] 1 was chewing gum while setting up the residents' food. During a concurrent observation and interview on 4/6/2026 at 12:08 PM in the lunch trayline area with the DS, [NAME] 1 was chewing gum. The DS stated [NAME] 1 was chewing gum when he is not allowed to because there should be no eating on the line. The DS stated staff are not allowed to eat in the kitchen to prevent contamination and maintain sanitary conditions because saliva can go to the residents' food. During a review of the facility's P&P titled, Policy: Eating and Drinking in the Kitchen (Dietary Services), undated, the P&P indicated, Eating, drinking and personal food consumption are prohibited in the kitchen and food preparation area. No chewing gums, tobacco, or similar substances. During a review of Food Code 22, dated 1/18/2023, the Food Code 22 indicated, 2-401.11 Eating, Drinking, or Using Tobacco Products. (A) Except as specified in (B) section, an employee shall eat, drink, or use any form of tobacco products only in designated areas where the contamination of exposed food, clean equipment, utensils, and linens; unwrapped single-service and single-use articles; or items needing protection cannot result. 12. During an observation on 4/6/2026 at 1:08 PM in the kitchen, DA 1 was wearing a nose ring. During an interview on 4/7/2026 at 9:11 AM with the DS, the DS stated kitchen staff are not allowed to wear jewelry in the kitchen except wedding bands. The DS stated the staff are not allowed to wear hoops earrings, necklaces, nose rings because it could fall into the foods. The DS stated it was his assistant (DA 1) who wore a nose ring yesterday (4/6/2026) and he told DA 1 to remove it. During a review of the facility's P&P titled, Policy: Jewelry Restrictions- Dietary/Kitchen Staff, undated, the P&P indicated, Dietary staff shall limit or avoid wearing jewelry while working in the food preparation and service areas to prevent contamination.The following are not permitted in food preparation areas: rings with stones and intricate settings, bracelet including medical alert bracelets unless secured. 13. During an observation on 4/7/2026 at 9:38 AM in the kitchen, pans were not completely air dried when water droplets were visible on the stacked pans in the pots and pans storage area. During an interview on 4/7/2026 at 9:45 AM with the DS, the DS stated the pans were not air dried from breakfast and they should not be stacked wet because they could grow mildew (a type of surface fungus or mild that thrives in warm, moist, and poorly ventilated environments, often appearing as white, grey, or yellow powdery patches). The DS stated pans growing mildew could cause cross-contamination of food and residents could get sick. During a review of the facility's P&P titled Ware Washing, undated, the P&P indicated, (7) Allow clean dishes to air dry completely before storing. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-901.11 Equipment and Utensils, air-drying required. After cleaning and sanitizing equipment and utensils: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface sanitizing solutions), before contact with food and; (B) May not be cloth dried except that utensils that have been air-dried may be polished with cloths that are maintained clean and dry. 14. During a concurrent observation and interview on 4/7/2026 at 2:29 PM with the DS in the activity room, the freezer compartment of the refrigerator had ice buildup, the refrigerator gasket had dirt debris and buildup, and there was no internal thermometer present. The DS stated the refrigerator in the activity room might be the refrigerator used for residents' food storage coming from the outside source. The DS stated they monitor the temperature of compliance and if there were any spoiled food. The DS stated there should not be any ice buildup in the freezer and no dirt and dust accumulation on the gasket because it could cause cross-contamination. During an interview on 4/7/2026 at 2:45 PM, with the Administrator (ADM), the ADM stated they do not have a refrigerator for residents outside food and the refrigerator in the activities room is used for resident's related activities. During a review of the facility's P&P titled, Temperature Maintenance-Refrigerators and Freezers (Dietary Services), undated, the P&P indicated, Each unit has a functional thermometer (internal or external). Refrigerators and freezers are clean and in good working condition, not overstocked (allowing proper air circulation). free from excessive frost and ice buildup.

Based on staff interview and record review, the facility failed to provide sufficient nursing staff to meet the resident needs for five (5) of five (5) sampled residents (Resident 10, 43, 44, 46, 104) in accordance with the facility's policy and procedure titled Staffing, Sufficient and Competent Nursing. On 4/4/2026, during 11PM-7AM shift, only two (2) out of seven (7) scheduled Certified Nursing Assistants (CNAs) reported to work and were responsible for providing care for all of the residents in the facility while five (5) other CNAs were no call/no show (when an employee misses a scheduled work shift without notifying their employer). This deficient practice resulted in the residents' dissatisfaction and getting upset due to delays in assistance with activities of daily living (ADLs). All five residents reported waiting for at least one (1) hour and fifteen (15) minutes up to two (2) hours for care. This deficient practice had a potential to increase the risk of skin break down (damage to the skin due to prolong pressure or excessive moisture), skin irritation and the development of skin rashes on Resident 46 and Resident 104 when they had to wait at least 1.5 hours in soiled brief before receiving care. Findings: 1. During a review of Resident 10's admission Record (AR), the AR indicated the resident was readmitted to the facility on [DATE] with a diagnosis that included type 2 diabetes mellitus (DM, a condition when the body does not use sugar properly, causing high blood sugar levels), chronic obstructive pulmonary disease (COPD, long term lung condition that makes it hard to breathe) and endocarditis (infection of the inner lining of the heart). During a review of Resident 10's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 3/5/2026, Resident 10's cognition (thinking) was intact and required moderate assistance (helper does less than half the effort) with ADL's such as oral hygiene, toileting hygiene, shower/bathe and dressing. 2. During a review of Resident 43's AR, the AR indicated the resident was readmitted to the facility on [DATE] with a diagnosis that included cirrhosis of the liver (permanent damage to the liver) and insomnia (inability to fall or stay asleep). During a review of Resident 43's History and Physical (H&P) signed and dated 7/16/2025, indicated that Resident 43 had the capacity (a person's ability to think or make decisions changes over time) to understand and make decisions. During a review of Resident 43's MDS, dated [DATE], Resident 43's cognition was intact and required supervision with ADLs care. 3. During a review of Resident 44's AR, the AR indicated the resident was readmitted to the facility on [DATE] with diagnosis that included COPD and type 2 DM. During a review of Resident 44's H&P, signed and dated 6/13/2025, indicated that Resident 44 had the capacity to understand and make decisions. During a review of Resident 44's MDS, dated [DATE], Resident 44's cognition was intact and required substantial/maximal assistance with ADLs care. 4. During a review of Resident 46's AR, the AR indicated the resident was readmitted to the facility on [DATE] with diagnosis that included hemiplegia (paralysis [loss of the ability to move] that affects one side of the body), hemiparesis (weakness that affects one side of the body) affecting the right dominant side and type 2 DM. During a review of Resident 46's H&P, signed and dated 8/25/2025, indicated that Resident 46 had the capacity to understand and make decisions. During a review of Resident 46's MDS, dated [DATE], Resident 46's cognition was intact and required substantial/maximal assistance with ADLs care. 5. During a review of Resident 106's AR, the AR indicated the resident was readmitted to the facility on [DATE] with diagnosis that included hemiplegia & hemiparesis affecting the left dominant side and hypertension (high blood pressure). During a review of Resident 106's H&P, signed and dated 9/2/2025, indicated that Resident 106 had fluctuating capacity to understand and make decisions. During a review of Resident 106's MDS, dated [DATE], Resident 106's cognition was moderately impaired and required substantial/maximal assistance with ADLs care. During a review of the Facility Census, dated 4/4/2026, indicated that the facility census was 127. During a review of the Nursing Staffing Assignment and Sign-In Sheet for 11PM-7AM shift, dated 4/4/2026, indicated that two (2) CNAs (CNA 2, CNA 7) signed in and five (5) CNAs did not sign in. During an interview on 4/6/2026 at 11:08 AM with Resident 10, Resident 10 stated on Saturday 4/4/2026, there were only two CNAs working, which contributed to delays in care. During an interview on 4/7/2026 at 10:20 AM with CNA 3, CNA 3 stated that on 4/4/2026 the Director of Staff Development (DSD) had only scheduled two CNAs to work 11PM-7AM shift. CNA 3 further stated that she witnessed a resident who wandered throughout the facility and required frequent observation during her shift. CNA 3 reported that she had previously informed the DSD that she was unavailable to work Saturdays; however, her name remained on the schedule. During an interview on 4/7/2026 at 10:45 AM with CNA 2, CNA 2 stated that she worked 11PM-7AM shift on 4/4/2026. CNA 2 reported that seven (7) CNAs were originally scheduled; however, five (5) CNAs did not report to work. CNA 2 stated that the facility did not attempt to call in or obtain additional staff to cover the shortage. CNA 2 further stated that she notified the DSD on 4/5/2026 regarding concerns about the staffing on 4/4/2026. During an interview on 4/7/2026 at 11:00 AM with Resident 43, Resident 43 stated that on 4/4/2026 during 11PM-7AM shift, there were only two (2) CNAs available to care for all residents in the facility. Resident 43 reported waiting approximately one (1) hour and fifteen (15) minutes for assistance with ADLs care and expressed being upset due to the delay in care. During an interview on 4/7/2026 at 2:30 PM with Resident 44, Resident 44 stated that on 4/4/2026 during 11PM-7AM shift, there were only two (2) CNAs available to care for all residents. Resident 44 reported waiting approximately two (2) hours for assistance with ADLs care and expressed dissatisfaction with the delay in care. During an interview on 4/7/2026 at 2:39 PM with Resident 46, Resident 46 stated that on 4/4/2026 during 11PM-7AM shift, Resident 46 observed only two (2) CNAs assisting all residents. Resident 46 reported waiting approximately one and a half (1.5) hours in a soiled brief before receiving assistance. During an interview on 4/7/2026 at 2:45 PM with Resident 104, Resident 104 stated that on 4/4/2026 during 11PM-7AM shift, there were only two (2) CNAs providing care for all residents. Resident 104 reported that a CNA informed him that care would be delayed due to short staffing. Resident 104 stated that he waited approximately two (2) hours to be changed and reported that his brief was saturated with urine at the time of care. Resident 104 expressed being very upset due to the delay in care. During an interview on 4/8/2026 at 11:36 AM with the DSD, the DSD stated that on 4/4/2026, seven (7) CNAs were scheduled for the 11PM-7AM shift; however, five (5) CNAs were no call/no show. The DSD stated she was not notified in advance that the CNAs would not report to work. The DSD stated that the Assistant Director of Nursing (ADON) contacted her at approximately 12:02 AM on 4/5/2026; however, the DSD did not respond until 6:56 AM when she awoke and subsequently went to the facility to assess the situation. The DSD stated that there was a binder at the nursing station containing CNA names and contact information; however, she was unsure if the 11PM-7AM shift Registered Nurse (RN) had attempted to contact the absent CNAs. The DSD stated if she had been notified timely, she would have reported to the facility to assist. The DSD acknowledged that the facility did not have sufficient CNA staff on 4/4/2026 for 11PM-7AM shift to meet resident care needs, which resulted in delayed ADLs care, inadequate supervision for wander residents, and increased potential for resident harm, including injury. During an interview 04/08/2026 at 12:00 PM with the ADON, the ADON stated that on 4/4/2026 at approximately 11:40 PM, the RN supervisor notified her that five (5) CNAs had not reported to work, leaving only two CNAs to provide care for all of the facility residents. The ADON stated she sent a text message to the DSD at approximately 12:00 AM to notify her of the staffing shortage. The ADON further stated that attempts were made to contact the absent CNAs; however, they did not respond. The ADON acknowledged that due to insufficient staffing, resident care including assistance with ADLs was delayed. The ADON further stated that inadequate staffing increased the risk for adverse outcomes, including falls, injuries, and skin breakdown. During a review of the facility's Policy and Procedures (P&P) titled, Staffing, Sufficient and Competent Nursing, dated 2021, indicated that the facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. The P&P indicated that licensed nurses and certified nursing assistants are available 24 hours a day, seven (7) days a week to provide competent resident care services including: assuring resident safety; attaining or maintaining the highest practicable physical, mental, and psychosocial well-being of each resident. During a review of the facility's P&P titled, Safety and Supervision of Residents, revised 4/2017, indicated that resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The P&P indicated that resident supervision is a core component of the systems approach to safety.

Based on observation, interview, and record review, the facility failed to prepare food in a form designed to meet individual needs when pureed (a smooth, thick liquid or paste made by mashing, blending, or straining cooked food) cream of rice was flat on the plate and did not hold its shape. These failures had the potential to result in difficulty in swallowing, decrease in food and nutrient intake to 15 of 15 residents on puree diet (food that are soft and pudding like consistency), resulting in unintended (not planned) weight loss and choking (when food gets stuck in your airway, blocking the flow of air to your lungs). Findings: During a review of the facility's cook spreadsheet (a sheet containing the kind and amount of food each diet would receive) titled, Winter 2026, dated 4/6/2026, the spreadsheet indicated residents on puree diet/International Dysphagia Initiative ([IDDSI] a framework for categorizing food textures and drink thickness) Level 4 (foods that are soft and pudding like consistency) would include the following foods on the tray: Pureed pork chop 1/2 cup (c, household measurement) Herbed cream of rice 4 ounces (oz, a unit of measurement) Puree mixed vegetables 1/2 c Puree bread with margarine 1 each Puree peach cobbler 1/2 c During an observation on 4/6/2026 at 12:32 PM, of the tray line (an area where foods were assembled form the steamtable [kitchen appliance that keeps food warm at a safe temperature for serving] to resident's plates) with the Registered Dietitian 2 (RD 2), an herbed cream of rice served on puree diet was flat on the plate. In a concurrent interview, RD 2 stated they were going to fix and replace it as the cream of rice was flat on the plate. During an observation on 4/6/2026 at 12:46 PM, RD 2 was preparing the puree herbed cream of rice, observed RD 2 added slurry and mixing it with a whisk. During an observation on 4/6/2026 at 12:54 PM, of the herbed cream of rice, served on the plate was flat and touching other food items. During an interview on 4/6/2026 at 1PM with Registered Dietitian 1 (RD 1), RD 1 stated they made puree bread as a substitute for herbed cream of rice as it was too watery, and puree bread was safer to serve. During an interview on 4/7/2026 at 10:07 AM, with the Dietary Supervisor (DS), the DS stated the puree cream of rice yesterday had too much water. The DS stated [NAME] 1 did not follow the recipe for preparing puree food yesterday. The DS stated puree food was supposed to be thick and not sticky but yesterday, and the herbed cream of rice was too sticky, it was spreading out on the plate and did not hold its shape on the plate. The DS stated residents could choke, would not get their nutritional needs as they would not eat it resulting in weight loss as a potential outcome of puree food not in their right consistency. During an interview on 4/7/2026 at 3:08 PM with RD 1, RD 1 stated the puree herbed rice did not hold its shape on the plate yesterday. RD 1 stated when he spoke to [NAME] 1 and [NAME] 1 put the cream of rice in the blender instead of mixing it. RD 1 stated [NAME] 1 did not follow instruction indicated in the recipe. RD 1 stated residents with dysphagia (difficulty swallowing) could have choking hazards, aspiration (accidental breathing in of food and liquid into the airway and lungs) causing threat to resident's health as potential outcomes of inappropriate food textures. During a review of the facility's policies and procedures (P&P) titled Diet Manual (Dietary Services), undated, the P&P indicated, the facility shall maintain and utilize a current, standardized diet manual approved by a Registered Dietitian (RD) to guide therapeutic diets, ensuring nutritional adequacy, safety, and compliance. Purpose: to provide a reference for therapeutic diets, texture modifications, and nutritional standards that support resident health, physician orders, and interdisciplinary care planning. During a review of the facility's diet manual (a manual containing different diets descriptions, foods allowed and avoided and sample menus the facility have) titled IDDSI Level 4: Regular Pureed Diet, undated, the diet manual indicated, The facility shall provide IDDSI Level 4 (Pureed) diets that meets standardized texture requirements to ensure safe swallowing, adequate nutrition, and resident dignity.Definition: IDDSI level 4 foods are extremely thick, smooth and lump free, does not require chewing, hold shape on a spoon and fall off easily when titled. The Diet Manual further indicated, IDDSI level 4 food must be moist and cohesive and avoid over thinning (must not be liquid). During a review of the facility's P&P titled, Standardized Recipe, undated, the P&P indicated, The facility shall utilize standardized recipes for all menu items to ensure consistency, nutritional adequacy, food safety, and quality. Dietary staff must follow recipes exactly as written. Recipes must be used for all meals, including therapeutic diets. During a review of the facility's standardized recipe titled Herbed Cream of Rice, dated 2026, the recipe indicated, Method: Measure water into heavy stockpot. Bring to boil. Stir the dry cereal into boiling salted water.Cook for 1 minute.Cover and remove from heat. Stir in the margarine, spices and seasonings. Let stand for 2-3 minutes.Serve with a 4 oz ladle per portion. CCP: All IDDSI texture modifications need to pass their established testing methods that at the tart and every 15 minutes for duration of service. During a review of the IDDSI guideline website titled IDDSI, dated 7/2019, the IDSSI guideline indicated, Level 4 Pureed is usually eaten with spoon, falls off spoon in a single spoonful when tilted and continues to hold shape on the plate, no lumps, not sticky, and liquid must not separate from solid. Can be piped, layered or molded because it retains its shape but should not require chewing if presented in this form. Food testing method: Spoon tilt test and fork drip test.

Based on interviews and record reviews, the facility failed to ensure one of two residents (Resident 1) was free from physical restraint (any device attached or adjacent to the body that cannot be easily removed and restricts freedom of movement) when Certified Nursing Assistant 1 (CNA 1) tied the resident with a bed sheet to the waist and around the wheelchair on 4/11/24. According to CNA 1, she tied down the resident down in the wheelchair with a bed sheet to prevent the resident from getting up while she was attending to another resident (Resident 2) This deficient practice resulted in Resident 1's rights being violated, and held against her will. As a result of being tied down, Resident 1 expressed verbalization of feeling hopeless, humiliated, upset, cried, verbalized being treated like a kid, scared of CNA 1, and felt that day like a nightmare. Resident 1 verbalized that she felt helpless and overpowered . and that CNA 1 took her freedom away. On 4/16/2024 at 5:12 PM, while onsite at the facility, the California Department of Public Health (CDPH) identified an Immediate Jeopardy situation (IJ, a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) regarding the inappropriate use of physical restraint. The survey team notified the Director of Nursing (DON) and the Administrator (ADM) of an IJ situation due to the facility's failure to ensure Resident 1 was free from physical restraints imposed for discipline or staff convenience when CNA 1 tied Resident 1 to the wheelchair with a bedsheet, to restrict Resident 1's freedom of movement after finding Resident 1 playing with water in the toilet bowl and prevent the resident from falling, on 4/11/2024 during the 3 PM to 11 PM shift. On 4/17/2024 at 6:01 PM, the IJ was removed while onsite at the facility, in the presence of the ADM and the DON, after the facility submitted an acceptable IJ Removal Plan (a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation) and the surveyor verified/confirmed onsite the facility's implementation of the IJ Removal Plan and the IJ situation was no longer present. The IJ Removal Plan dated 4/16/2024, included the following: 1. CNA 1 was suspended from employment on 4/12/2024 and upon facility's investigation CNA 1 was terminated from the facility on 4/16/2024. 2. Resident 1 was assessed by the DON on 4/12/2024. There are no visible injuries noted on Resident 1. 3. Resident 1 was monitored by the DON initially and the Licensed Vocational Nurses (LVNs) every shift for 72 hours for negative psychosocial impact starting 4/12/2024. 4. Social Services Director (SSD 1) conducted an evaluation of Resident 1 for emotional distress on 4/12/2024, 4/15/2024 and 4/16/2024 and will continue daily visits for two weeks. Licensed nurses monitored Resident 1 every shift on 4/13/24 and 4 14/2024 to ensure the resident's psychosocial well-being. The facility's Interdisciplinary Team (IDT; team of professionals with a common goal) met with Resident 1 on 4/12/2024. 5. Resident 1 was seen by the primary care physician on 4/15/2024 and recommended Psychology (the scientific study of the human mind and its functions, especially those affecting behavior) and Psychiatry (the branch of medicine concerned with the study, diagnosis, and treatment of mental illness) consult. 6. Resident 1 was referred to and seen by the psychologist on 4/16/2024 via telehealth (facetime) in the resident's room and will be visited weekly. The Psychologist will follow up with a resident in-person visit on 4/18/2024, to continue to monitor and notify, will be seen via telehealth (facetime) as needed. 7. Resident 1 was referred to and seen by the psychiatrist on 4/16/2024 via telehealth (facetime) in the resident's room with recommendation to monitor for any changes and continue current medication regimen. 8. Residents who were assigned to CNA 1 were interviewed by the Assistant DON on 4/15/2024. There are no other residents identified to be affected by the same deficient practice. 9. Immediate in-service was provided to facility staff; CNA, Licensed Vocational Nurses, Registered Nurse (RN) Supervisor, Rehabilitation Department staff, housekeeping staff, Activity staff, Maintenance staff, Kitchen staff and laundry staff that started on 4/15/2024 and will continue until 100 % achieved (estimated completion: 4/17/2024) regarding the following: - Resident's rights to be free from physical restraint. - Policy and Procedure on the use of restraint - Policy and Procedure on Identifying Involuntary Seclusion and Unauthorized Restraint - Abuse Reporting (Timely reporting of abuse-2-hour reporting) - Any staff that has not undergone the above training will not be put in the facility's schedule. - The Director of Staff Development (DSD) rechecked professional licenses and certificate for current staff such as CNAs, Licensed staff and therapists on 4/17/2024 for any disciplinary action related to abuse. Any staff member with disciplinary action against their professional license will be subject for investigation by the ADM. 10. Department Managers will conduct room rounds in the morning for safety and observation of any physical restraints and will conduct interview with current residents who are alert and interviewable, for five days a week starting 4/17/2024. LVNs and RN supervisors will monitor residents every shift to ensure restraints are not being used. 11. During weekends, the Administrator/DON will assign room rounds to RN Supervisors and Manager of the day (MOD) regarding the inappropriate use of physical restraints. 12. For non-interviewable residents, LVNs and RN supervisors will monitor residents every shift to ensure physical restraints are not being used in the facility. 13. Any negative findings during room rounds and monitoring will be reported immediately to the ADM/DON and will conduct investigation appropriately and report to appropriate agencies (local police, ombudsman, CDPH licensing). 14. The Department Manager as part of room rounds will conduct safety and observation of any physical restraints and will conduct interview with current residents who are alert and interviewable five days a week in the morning. 15. Any findings of the use of physical restraints during daily rounds will be reported to CEO/Quality Assurance and Performance Improvement (QAPI) Committee for additional recommendations. 16. The QAPI Committee should evaluate weekly the implementation of the plan of correction (room rounds, daily safety observation of the residents), monitor for effectiveness and revise plan as necessary for continuous improvement until the resolution is achieved. Findings: A review of Resident 1's Admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included pneumonia (infection of one or two lungs), anxiety (feeling of fear, dread, and uneasiness), depression (mood disorder that causes a persistent feeling of sadness) and bipolar disorder (mental illness that causes unusual shifts in mood from extreme happiness to extreme sadness and vice-versa) A review of Resident 1's History and Physical dated 3/22/2024, indicated the resident did not have the capacity to make decisions. A review of Resident 1's Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool) with assessment reference date of 3/28/2024, indicated the resident had severe cognitive (thought process) impairment. The MDS indicated Resident 1 was independent (able to complete task by themselves) in walking, with the use of a walker. The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort) on tasks such as lower body dressing, bathing, and toileting, moderate assistance (helper does less than half the effort) on tasks such as upper body dressing, and supervision on tasks such as sit to stand and bed mobility. The MDS indicated Resident 1 did not have physical restraints used during the MDS assessment reference date. A review of Resident 1's Fall Risk Evaluation, dated 3/22/2024, indicated Resident 1 was assessed at high risk for falls. The Fall Risk Evaluation indicated Resident 1 had no falls for the past 90 days. A review of Resident 1's care plan dated 3/23/2024, indicated the resident was high risk for falls related to confusion, balance problems, and cognitive impairment. The care plan interventions included anticipating/meeting the resident's needs, providing the resident with a safe environment, and reevaluating the use of adaptive equipment and devices to ensure the appropriateness on the use of least restrictive device or restraints. A review Resident 1's Progress Notes New, dated 4/12/24, timed at 9:30 AM, indicated a Nursing Progress Note authored by the DON, that the DON received a report from the Director of Rehabilitation (DOR) regarding an alleged incident of abuse; Resident [1] was tied with white single sheet around the waist in the wheelchair on 4/11/2024 during 3 to 11 shift . The progress notes indicated CNA 1 admitted tying Resident 1 in the wheelchair to prevent the resident from falling while CNA 1 was attending to other residents. The progress notes indicated the DON reached out to Speech Therapist (ST) 1 who saw Resident 1 in the resident's room on 4/11/2024. The progress notes indicated Resident 1 informed ST 1 that there was a sheet around Resident 1's waist and ST 1 immediately informed the charge nurse (LVN 1). The progress notes indicated Resident 1 was slightly upset/frustrated about the incident . and stated that someone tied her with a bed sheet around her waist in the wheelchair . A review of a facility record titled Care Plan Conference Summary dated 4/12/2024, authored by SSD 1, indicated that Resident 1 stated that the evening shift CNA tied her with a bedsheet around her waist while sitting in the wheelchair. The record indicated Resident 1 stated that she could not get up and became frustrated and informed ST 1 that she was tied to the wheelchair. A review of Resident 1's Psychosocial/Social Note, dated 4/16/2024, and timed at 6:36 PM, authored by SSD 1, indicated Resident 1 stated the incident made her feel helpless, and was asking for help when two people walked by. The Psychosocial/Social Note indicated Resident 1 felt overpowered by the CNA who seemed not seeing her even though she was there. During an interview on 4/12/2024 at 2:42 PM, Resident 1 stated she remembered being tied up yesterday (4/11/2024) with a staff that works at the facility. Resident 1 stated when the new nurse (CNA 1) came in the nurse tied Resident 1 using a bed sheet around the waist to the wheelchair for hours. Resident 1 stated she kept screaming while she was tied up. Resident 1 stated while she was screaming She heard two people walking by and nothing happened. Resident 1 stated being tied up upset her that she cried, felt humiliated, and being tied up made her feel like a person that got caught in a nightmare. Resident 1 further stated that being tied up made her feel like a kid who had no control and that her life was over because someone had the power to make her a bad person. Resident 1 stated she could not remove the bedsheet. Resident 1 stated she would feel scared if she ever sees CNA 1 again. Resident 1 stated CNA1 took her freedom away. During an interview on 4/12/2024 at 4:22 PM with CNA 1, CNA 1 stated she was assigned to Resident 1 and Resident 2 in the same room, on 4/11/2024 for the 3 PM to 11 PM shift. CNA 1 stated when she was doing her initial rounds for her assigned residents when Resident 2 asked for assistance go to the bathroom. CNA 1 stated she was helping Resident 2 in the bathroom when Resident 1 started getting up from the bed. CNA 1 stated she did not call other staff for help because when she looked outside of Resident 1's room, there was no other staff available in the hallway. CNA 1 stated she put Resident 1 in the wheelchair and tied her to the wheelchair using a bed sheet. CNA 1 stated she tied Resident 1 to prevent the resident from falling because Resident 1 kept trying to get up. CNA 1 stated she started her initial rounds within 30 minutes of her arrival into the facility during the 3 PM to 11 PM shift. CNA 1 stated she finished the evening shift and had Resident 1 in her assignment throughout the shift, on 4/11/2024. CNA 1 stated that she informed LVN 2 on 4/11/2024, that she tied Resident 1 to the wheelchair. During an interview on 4/12/2024 at 4:36 PM with ST 1, ST 1 stated he went to Resident 1's room at around 5:45 PM to 6 PM and when he opened the door, he heard a resident yelling for help. ST 1 stated when Resident 1 saw ST 1, Resident 1 called ST 1 by his first name, asking for help to get her out. ST 1 stated he walked closer to Resident 1's bedside and he saw that Resident 1 was sitting on a wheelchair with a bed sheet wrapped around the waist and the wheelchair. ST 1 stated Resident 1 had a bedside table in front of her. ST 1 stated that during that same time, CNA 1 was inside the room, feeding another resident (Resident 3). ST 1 stated he reported what he saw to LVN 1 and the DOR. During an interview on 4/12/2024 at 4:13 PM with the DOR, the DOR stated she received a text message from ST 1 on 4/11/2024 at around 6 PM, stating that a resident was tied to the wheelchair. The DOR stated the text message also indicated that ST 1 informed a nurse about the incident. During an interview on 4/12/2024 at 5:33 PM with LVN 1, LVN 1 stated ST 1 reported to her that there was something blocking Resident 1. LVN 1 stated she started to walk towards Resident 1's room, but as she got closer to the room, she saw the resident walking outside of the room with LVN 2 and CNA 1. LVN 1 further stated she did not approach the resident or staff. During an interview on 4/12/2024 at 6 PM with LVN 2, LVN 2 stated CNA 1 did not inform him on 4/11/2024 that she tied Resident 1 to the wheelchair. LVN 2 stated he was not aware that CNA 1 tied Resident 1 with a bedsheet to the wheelchair on 4/11/2024. During an interview on 4/16/2024 at 3:19 PM, with Resident 2 (Resident 1's roommate) and Resident 2's family member (Family 1), Family 1 stated she talked to Resident 2 on 4/11/2024, on the phone but there was a lot of noise during that time, and she could not make sense of what Resident 2 was telling her. Family 1 stated so she told Resident 2 to stop talking about it. Family 1 stated that when she was at the facility, she had seen Resident 1 attempts to get up from bed frequently. During the interview, Resident 2 stated she was in the room with Resident 1, on the evening of 4/11/2024 but did not see Resident 1 being tied up in the wheelchair. However, Resident 2 stated that she heard Resident 1 screaming for help and swearing at the nurse (CNA 1) that evening. Resident 2 stated Resident 1 was screaming for a long time. A review of Resident 2's Admission Record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses that included weakness, hypertension (consistent high blood pressure), and lack of coordination. A review of Resident 2's MDS dated [DATE], indicated Resident 2 has intact cognition. The MDS indicated Resident 2 has adequate (no difficulty) hearing without the use of a hearing aid. On 4/16/2024 at 6:14 PM, during another interview with Resident 1, in the presence of SSD 1, five days after Resident 1 was tied up in the wheelchair on 4/11/2024, Resident 1 stated she remembered being tied to the wheelchair with a bedsheet by a staff. Resident 1 stated her trauma does not go away. Resident 1 stated that she cried and was upset. Resident 1 stated she remembered calling for help because she heard two people passing by and they did not stop. During an interview on 4/12/2024 at 8:24 PM, with the DON, the DON stated CNA 1 tied Resident 1 to the wheelchair with the bed sheet and it was a form of physical restraint. The DON stated other non-restrictive alternatives must be unsuccessful before physical restraints may be used and there must be a physician's order, proper monitoring, consent, and evaluation prior to the use of restraints. The DON stated Resident 1 could suffer from emotional trauma and physical injuries affecting the resident's quality of life with the improper use of restraints. During an interview on 4/15/24 at 3:10 PM, with the ADM, the ADM stated the improper use of restraints on Resident 1 with or without consent, could be classified as a form of physical, emotional, and psychological abuse. The ADM stated there was no reason for CNA 1 to tie down Resident 1. A review of the facility's policy and procedure titled, Identifying Involuntary Seclusion and Unauthorized Restraint, revised in September 2022, indicated Risk of falling is not considered a medical symptom or self-injurious behavior that warrants the use of restraints. The policy and procedure indicated Restraints that are used as a last resort to protect the safety of the resident and others must be accompanied by an order from the practitioner and documentation reflecting the circumstances that led up to the decision to restrain the resident. A review of the facility's policy and procedure titled Resident Rights, (undated), indicated it is the resident's right to be free from corporal punishment or involuntary seclusion, and physical restraints.

Based on observation, interview and record review, the facility failed to ensure two (2) of two (2) sampled residents (Residents 285 and 131), who had food intolerances (food sensitivity and inability to digest a certain food) and food allergies (a serious and potentially life-threatening medical condition to substances that are usually not harmful) were assessed for food restrictions, including food allergies and served with food substitutions (replaced food with allergens with food without allergens) as indicated in the facility ' s policies and procedures titled, Food Allergies and Intolerances, and Nutrition Assessment, by failing to: 1. Ensure Cook 1 did not serve fish and fish containing products to Resident 285 and Resident 131, who were allergic to fish on [DATE]. Cook 1 served seashell tuna bake [tuna casserole, made with pasta and canned tuna (a type of fish)] on [DATE] for dinner to Resident 285 and Resident 131. 2. Ensure Resident 285 and 131 ' s Primary Care Provider (PCP) 1 was aware that Residents 285 and 131 were allergic to fish, and Resident 285 was intolerant to milk. 3. Ensure Resident 285 ' s food allergies/intolerance were indicated in Resident 285 ' s physician ' s orders and Resident 131 ' s food allergies were indicated in Resident 131 ' s physician ' s orders. 4. Ensure the Dietary Services Supervisor (DSS) did not serve a High Protein Nutrient (HPN) [contains 2% milk and sugar] milk supplement from the facility ' s kitchen, on [DATE], [DATE], and [DATE] to Resident 285, who was intolerant (unable to fully digest) to milk. 5. Ensure the Registered Dietitian (RD) conducted a resident interview with Resident 285 and did not rely on the information entered by the Admitting Licensed Nurse (ALN) to complete Resident 285 ' s Nutrition Assessment and documented NKFA (No Known Food Allergies) in Resident 285 ' s nutrition assessment. 6. Ensure the DSS conducted a thorough verification during Resident 285 ' s interview for Resident 285 ' s food allergies and preferences when Resident 285 informed the DSS not to give Resident 285 fish or milk. 7. Ensure the DSS maintained a record of Resident 285 ' s allergy to fish in Resident 285 ' s tray card (a card on each meal tray that indicated food allergies/preferences) after Resident 285 reported fish allergy to Cook 1 on [DATE]. These deficient practices had the potential for Resident 285 and Resident 131 to experience severe allergic reaction to fish, which could cause a life-threatening condition such as severe tachycardia (increased heart rate), anaphylaxis (severe allergic reaction including closure of airways), cardiac arrest (sudden loss of heart function, breathing and consciousness), and or death. On [DATE] at 3:45 PM, while onsite at the facility, the California Department of Public Health (CDPH) identified an Immediate Jeopardy situation (IJ, a situation in which the provider ' s noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) regarding food and nutrition services. The survey team notified the Director of Nursing (DON), the Administrator (ADM) and the Registered Dietitian (RD) of the IJ situation due to Resident 285 and Resident 131, who reported food allergies to fish were served with seashell tuna bake on [DATE]; and Resident 285 who was lactose intolerant (unable to fully digest the sugar [lactose] in milk) was served with HPN on [DATE], [DATE], and [DATE]. On [DATE] at 6:13 PM, the IJ was removed in the presence of the ADM, and the DON after the facility submitted an acceptable IJ Removal Plan (a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation) and the surveyor verified/confirmed onsite the facility ' s implementation of the IJ Removal Plan and the IJ situation was no longer present. The IJ Removal Plan dated [DATE], included the following: 1. On [DATE], Residents 285 and 131 were immediately assessed for food allergies and food preferences by the Assistant Director of Nurses (ADON). PCP 1 was informed by the ADON. The food preferences and food allergies were communicated to the DSS and updated the Kardex (a reference that is separate from the resident ' s chart). 2. On [DATE], Resident 285 was interviewed by the Interdisciplinary Team (IDT - a group of professionals all working collaboratively toward a common goal) for food allergies. 3. On [DATE], findings of Residents 285 and 131 ' s food preferences and food allergies were documented on Resident 285 and 131 ' s electronic medical record and meal cards so it could be reflected when diet types are printed and used during meal tray verification prior to serving the resident ' s meal trays. 4. On [DATE], the DON, ADON, RD and DSS conducted a review of all current residents for verification of food allergies through resident/responsible party interviews and record reviews to ensure food allergens (a substance that causes an allergic reaction) and dislikes are not served to residents with known food allergies and dislikes. 5. On [DATE], nine residents (Residents 113, 57, 28, 99, 117, 131, 31, 108, and 285) were identified with food allergies. The food allergies and food preferences identified were documented on each of the residents ' medical records and meal cards. Residents 113, 57, 28, 99, 117, 131, 31, 108, and 285 ' s food preferences and allergies would reflect in the residents ' diet orders were printed and used during meal tray verification prior to serving the resident ' s meal trays. 6. On [DATE], The DSS and Licensed Nurses (all Licensed Nurses) conducted food preference assessment to all active residents and updated diet care plans. 7. On [DATE], the RD started reassessments of all residents ' Nutritional Status to ensure nutritional plan, dietary restrictions and food preferences are up to date. 8. On [DATE], the Director of Staff Development (DSD) provided in-service to all Licensed Nurses to check the dietary slip for food allergies or food references prior to serving meal trays to the residents. 9. On [DATE], the DON and DSD provided in-service and training to the RD and the DSS regarding the facility ' s system in place for all newly admitted residents having thorough verification for food allergies conducting through resident/responsible party interviews and record reviews to ensure food allergens were not served to residents with known food allergies. 10. On [DATE], the ADM, and the RD interviewed Resident 285 for lactose intolerance. Resident 285 ' s care plan and Kardex (allergic to fish, lactose intolerance, no milk) was immediately updated, and offered Resident 285 with soy milk. 11. On [DATE], the facility signed a contract and implemented a new menu system, called Menus 2U which integrated in the facility ' s Electronic Health Records (EHR-electronic version of a patient ' s medical history) to ensure that all new dietary orders, food allergies and food references that were entered in EHR would be automatically generated. The software would include printing of the updated diet slip for each meal by the DSS or designee and the dietary would reference the meal preparation during tray line avoiding inaccuracies and identifying food dislikes and allergies list. Included in the diet slip are Diet Order, Diet Consistency, Diet Texture, Likes and Dislike, Food Allergy, Beverage Preference, Tray Instruction, and Feed Instructions. 12. On [DATE], a list of residents (Residents 113, 57, 28, 99, 117, 131, 31, 108, and 285) with food allergies and dislikes was posted in the kitchen meal preparation area. Thus, allowing all dietary staff to easily identify all residents with allergies, and help with accuracy. 13. On [DATE], Licensed Nurses assessed all residents on PO (per orem -by mouth) meals to ensure accuracy on the meal served for breakfast. 14. As of [DATE], the Registered Nurse Supervisor would oversee the allergy report upon admission. 15. As of [DATE], upon admission, Registered Nurse Supervisor/Licensed Nurses would input the allergy information obtained from the residents to the facility ' s EHR and provide a printout to Dietary Department, Activity Department. Nursing Department, and Dietary Department should ensure a Dietary list in each Meal Cart. 16. Starting on [DATE], Residents 113, 57, 28, 99, 117, 131, 31, 108, and 285 ' s diet orders to match in the individual meal tray cards with identified food allergies written in bold red font with orange sticker attached and in addition those residents identified will wear orange bands. 17. As of [DATE], identified residents (Residents 113, 57, 28, 99, 117, 131, 31, 108, and 285) with food allergies and food dislike upon admission would be given/served alternate/substitute meals. 18. As of [DATE], upon admission, the DSS would conduct a food preference interview with the resident including food allergies, food preferences and ensure to communicate with nursing to input in the EHR. In addition, the RD would include food allergies/food preferences when conducting assessment during quarterly, annually and/or significant change assessment and would include in RD recommendation report to nursing if any identified food allergies and food preferences that was not captured prior to nutritional assessment. Findings: 1.A review of Resident 285 ' s Admission Record indicated the facility admitted the resident on [DATE], with diagnoses that included severe protein-calorie malnutrition [occurs when an elderly does not eat enough protein and energy (measured by calories) to meet nutritional needs], muscle weakness, age-related cognitive decline (overall slowness in thinking and difficulties sustaining attention, multitasking, holding information in mind and word-finding due to aging), and adult failure to thrive (happens when an older adult has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal). A review of a facility document titled Resident Meet and Greet, dated [DATE], completed by the DSS for Resident 285, indicated No fish listed under food dislikes, and No milk listed under beverage of choice. A review of Resident 285 ' s Minimum Data Set (MDS, a standard assessment tool that measures health status), dated [DATE], indicated Resident 285 was cognitively intact (able to understand and process information). The MDS indicated Resident 285 needed set up or clean up assistance for eating and needed supervision or touching assistance (helper provided verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for oral/personal hygiene. A review of Resident 285 ' s Order Summary Report, dated [DATE], indicated Resident 285 had a diet order of regular diet with regular texture, and regular/thin consistency since [DATE]. During a concurrent observation and interview on [DATE] at 9:45 AM, with Resident 285 in Resident 285 ' s room, a glass of milk covered with a plastic food wrap with written HPN was on Resident 285 ' s meal tray. Resident 285 stated Resident 285 was severely allergic to fish and mildly with milk but the facility served Resident 285 with fish on [DATE], during dinner time and milk with almost every meal. During an observation on [DATE] at 12:57 PM, in Resident 285 ' s room, a meal card was observed on Resident 285 ' s meal tray indicating No fish, No milk. A glass of milk covered with a plastic food wrap with written HPN was on Resident 285 ' s meal tray. During a concurrent observation and interview on [DATE] at 12:30 PM with Resident 285 in Resident 285 ' s room, a glass of milk covered with a plastic food wrap with written 4 oz HPN, was on Resident 285 ' s meal tray. Resident 285 stated, Resident 285 ' s meal card indicated No milk but the facility kitchen staff gave Resident 285 milk again. During an observation on [DATE] at 6:45 AM, in the kitchen, the DSS was observed making HPN. The HPN was made out of 2% milk (reduced fat milk) with a cup of sugar. During an observation on [DATE] at 7:15 AM, by the facility hallway in front of the kitchen, two food carts were observed coming out of the kitchen. Treatment Nurse (TN) 1 and TN 2 were reading from a printout titled Diet Type Report dated [DATE], during meal verification of each resident ' s meal trays. During a concurrent interview and record review of the Dietary Type Report dated [DATE] and a random resident ' s (Resident 102 ' s) tray card, on [DATE] at 7:17 AM, with TN 1 and TN 2, TN 1 stated that licensed treatment nurses (all treatment nurses) were responsible for using the Diet Type Report, to compare with each residents ' tray card during meal tray verification to check for the right diet, texture, and any additional directions. TN 1 stated, when a resident had preferences or any other instruction for eating, the information would be included in the tray card, and Diet Type Report written under Additional Directions. TN 1 stated, when a resident ' s food allergies and preferences were not listed in the Additional Directions or the resident ' s tray card, the licensed nurses would not know. TN 2 stated, resident ' s tray card only listed likes and dislikes. TN 2 stated a resident ' s tray card had no section that listed food allergies and preferences. During a concurrent interview and record review of the Dietary Type Report, dated [DATE] and Resident 285 ' s tray card, on [DATE] at 7:20 AM with TN 2, TN 2 stated there was no information listed under Additional Direction indicating Resident 285 was allergic to fish. TN 2 stated Resident 285 ' s tray card listed No fish, No milk under the Dislikes section of the tray card. TN 2 stated that the dislike meant that Resident 285 did not like eating fish or drinking milk. TN 2 stated, there should be no fish and no milk in Resident 285 ' s meal tray. During a concurrent interview and record review of Resident 285 ' s Nutritional Assessment Form, dated [DATE], on [DATE] at 7:37 AM, the Form indicated NKFA under the Food Allergies section of the Form. The RD stated Resident 285 had no known food allergy, according to the information in Resident 285 ' s EHR. The RD stated, she would know if a resident had any food allergy by looking at the EHR because it would show under the resident ' s dashboard. The RD stated the information was entered by the admitting licensed vocational nurse (LVN 8) who admitted the resident to the facility. The RD stated she used the admitting licensed nurse ' notes and progress notes to complete Resident 285 ' s Nutritional Assessment and RD recommendations. The RD stated she did not interview Resident 285 personally. The RD stated, the RD would not know Resident 285 ' s food preferences because the DSS took care of it (Resident 285 ' s food references). The RD stated it was important to make sure the facility ' s staff (in general) knew Resident 285 ' s food allergies because consuming food allergens could lead to allergic reaction and death. During an interview on [DATE] at 8:14 AM, the DSS stated, Resident 285 disliked fish and milk because Resident 285 told him I don ' t eat fish, and no milk. The DSS stated, he did not ask Resident 285 why Resident 285 did not eat fish and stated, no milk. The DSS stated Resident 285 ' s fish allergy and milk intolerance were not documented in Resident 285 ' s medical records. The DSS stated, it was important to document Resident 285 ' s or any resident ' s food allergies int the medical record because it could cost their life. During a concurrent record review and interview of Resident 285 ' s Nursing-Dietary Communication Form (resident ' s meal order form) dated [DATE] (Saturday), on [DATE] at 8:32 AM, with the DSS in the DSS ' s office, the DSS stated that the communication form was handwritten by Resident 285. The DSS stated the communication form indicated Allergic to Fish. The DSS stated the DSS did not know (did not review the communication form) and did not update the information (fish allergy) indicated in Resident 285 ' s Nursing-Dietary Communication Form because the DSS received all communication forms submitted over the weekend on the following week/Monday ([DATE]) to keep for records purposes only. During a concurrent interview and record review of a facility document titled, Winter Menu, undated, on [DATE] at 8:38 AM, the DSS stated, the main dinner menu served to the residents (including Resident 285 and 131) on [DATE] was seashell tuna bake, made from canned tuna, a type of fish. During a concurrent interview and record review on [DATE] at 8:45 AM, the DSS stated, when a resident (in general) was allergic to any food from the facility ' s main menu, the resident would be served with the alternative menu or whatever the resident would order using the Nursing-Dietary Communication Form. The DSS stated, the DSS could not find any Nursing-Dietary Communication Form that Resident 285 submitted on [DATE] for dinner, to indicate that Resident 285 ordered an alternative menu, aside from Seashell tuna bake that was served on [DATE]. During an interview on [DATE] at 9 AM with Cook 1 in the DSS ' s office in the absence of the DSS, Cook 1 stated she was in charge of receiving the Nursing-Dietary Communication Forms and cooked during the weekend. Cook 1 stated, she received the Nursing-Dietary Communication Forms, kept the forms for record purposes and handed them to the DSS, on Monday of the following week. Cook 1 stated, she was aware that Resident 285 was allergic to fish because she remembered one of Resident 285's Nursing-Dietary Communication Forms indicated allergic to fish was handwritten by Resident 285 on [DATE]. Cook 1 stated she did not inform anyone from the facility, including the DSS about Resident 285 ' s Nursing-Dietary Communication form of allergic to fish. Cook 1 stated she just left all communication forms on the DSS ' s desk. During an interview on [DATE] at 9:45 AM, with the DSS, the DSS stated he did not have a printout list of all residents in the facility with food allergies, intolerances, or preferences. The DSS stated he had a binder with all the residents ' nutrition assessments, titled Resident Meet and Greet. The DSS stated he would just go through the binder as needed. During the time of the interview, the DSS stated the facility had a total of four (4) residents with identified food allergies (not nine residents). During a concurrent interview and record review of Resident 285 ' s physician orders, admission assessments, care plans, and medication records since admission on [DATE], on [DATE] at 10:28 AM, Registered Nurse (RN) 1 stated she could not find documented evidence of Resident 285 ' s food allergy to fish or milk. RN 1 stated when a resident was admitted to the facility, the licensed nurses (in general) must complete an Admission Data Collection form for a thorough assessment that included the resident ' s allergies. RN 1 stated the information the licensed nurses entered in the Admission Data Collection Form were all based on the information that the acute hospital provided to the facility through a discharge paper packet and phone call for report, which did not include Resident 285 ' s food allergies. During the same interview, on [DATE] at 10:28 AM, RN 1 stated that when Resident 285 informed the facility staff (Cook 1) of an allergy, Cook 1 had to report to the DSS, and the DSS had to document Resident 285 ' s food allergy in the EHR, so Resident 285 ' s allergy information could be updated. RN 1 stated, it was important to make sure Resident 285 had the most updated allergy list because the resident could die from an allergic reaction. During an interview on [DATE] at 12:15 PM, with Dietary Assistant (DA) 2, Cook 1 and the DSS in the kitchen, DA 2 stated he worked with Cook 1 on [DATE]. DA 2 stated a nurse (DA 2 could not recall who) came to the kitchen during dinner time on [DATE], to return Resident 285 ' s dinner plate, stating that Resident 285 complained about having fish in her pasta plate, and requested a replacement. Cook 1 stated, when serving the main dinner menu for all residents on [DATE], she served pasta with tuna fish (Seashell tuna bake). During an interview on [DATE] at 1:30 PM with Resident 285, Resident 285 stated, she had severe allergic reaction to fish. Resident 285 stated, her face and throat were swollen, and she could not breathe when she ate fish in the past during her teenager year (could not recall the exact year) that led to her transfer to an acute hospital. Resident 285 stated, she never ate fish again after that incident. Resident 285 stated, she could have died from eating fish. Resident 285 stated, when ingesting milk or milk products on an empty stomach, she would have abdominal bloating, nausea and stomach upset. Resident 285 stated, she did not want to be served with milk due to uncomfortable experience with milk. During a concurrent interview and observation on [DATE] at 1:10 PM, with Resident 285 in Resident 285 ' s room, Resident 285 stated the facility kitchen staff served her milk again during breakfast, and stated she was upset because facility staff did not respect her food preferences. During an interview on [DATE] at 1:20 PM, the RD stated she did not ask Resident 285 if Resident 285 was lactose intolerant. The RD stated she assumed Resident 285 was not intolerant to milk because Resident 285 could take ice-cream and a little bit of milk with cereal for breakfast. During another interview with Resident 285, on [DATE] at 1:30 PM, in the presence of the ADM and the RD, Resident 285 stated she was lactose intolerant, and she did not want milk. Resident 285 stated that in the morning when breakfast did not taste good, she had no choice but to take a little bit of milk for the cereal. Resident 285 stated she could not take a lot of milk or take milk on an empty stomach because milk always gave her discomfort. 2. A review of Resident 131 ' s Admission Record indicated the facility admitted the resident on [DATE], with diagnoses that included osteomyelitis (inflammation or swelling that occurs in the bone) and type 2 diabetes mellitus (a disease that occurs when blood sugar level is too high). A review of Resident 131 ' s MDS dated [DATE], indicated Resident 131 was cognitively intact, independent (resident competes the activity by themselves with no assistance from a helper) in eating, oral hygiene, and personal hygiene. A review of Resident 131 ' s Allergy Report indicated in the EHR with created date [DATE], indicated Resident 131 had a food allergy and the allergen was Fish. The Allergy Report severity indicated Moderate. The Allergy Report did not indicate an information under Reaction Manifestation and was left blank under Reaction Note. A review of a facility document titled, Resident Meet and Greet dated [DATE], indicated Resident 131 was allergic to fish. The document did not have Resident 131 ' s allergy manifestation or reactions. A review of Resident 131 ' s Nutrition assessment dated [DATE], indicated Resident 131 was allergic to fish. A review of Resident 131 ' s physician diet order dated [DATE], indicated Resident 131 ' s diet order of consistent carbohydrates (CCHO, the same amount of carbohydrate served each meal) with regular texture, and regular/thin consistency. During a concurrent interview and record review of the Dietary Type Report dated [DATE], on [DATE] at 7:20 AM with TN 2, TN 2 stated there was no listed allergy information for Resident 131 in the Dietary Type Report. During a concurrent interview and record review of Resident 131 ' s physician orders, admission assessments, care plans, and medication records since admission to the facility from [DATE], on [DATE] at 12:33 PM, the MDS nurse stated Resident 131 was known to be allergic to fish since admission to the facility on [DATE]. The MDS nurse stated the facility did not develop a care plan to address Resident 131 ' s fish allergy since admission. The MDS nurse stated the RD needed to create the care plan to address Resident 131 ' s food allergies. The MDS nurse stated she did not know how to pull up a list of residents with allergies in the EHR. The MDS stated the facility did not have a list of residents with food allergies. A review of Resident 131 ' s Care Plan Conference Summary, dated [DATE] at 4 PM, indicated Resident 131 was allergic to fish, and during the facility ' s IDT conference meeting with Resident 131, the Care Plan Conference Summary indicated, Resident 131 informed the IDT that he was also served with seashell tuna bake on [DATE]. During an interview on [DATE] at 8:39 AM with the Social Service Assistant (SSA) in the SSA ' s office, the SSA stated she came and talked to Resident 131 on [DATE]. The SSA stated that Resident 131 told her that he was served with fish by the facility but could not remember the exact date. The SSA stated Resident 131 told her that when Resident 131 was served with fish in the facility, he pushed the tray away and called a Certified Nurse Assistant (CNA [unable to recall who]) in to replace the food. A review of the facility ' s policy and procedure (P&P) titled, Food Allergies and Intolerances, revised [DATE], indicated the following: -Residents are assessed for history of food allergies and intolerances upon admission and as part of the comprehensive assessment. -All resident reported food allergies and intolerances are documented in the assessment notes and incorporated into the resident ' s care plan. -Severe food allergies are noted on the face of the chart (in the form of a sticker or permanent marking indicating Severe Food Allergy: (number of food) and communicated in writing directly to the dietitian and the director of food and nutrition services. -Residents with food intolerances and allergies are offered appropriate substitutions for foods that they cannot eat. A review of the facility ' s P&P titled, Nutritional Assessment, revised [DATE], indicated the following: -As part of the comprehensive assessment, the nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition. -The nutritional assessment will be conducted by the multidisciplinary team and shall identify at least the following components .Food preferences and dislikes (including flavors, textures, and forms); Food restrictions, including food allergies and cultural or religious practices affecting food choices. A review of the facility ' s P&P titled, Diet Orders and Profile Card (Kardex Card), revised [DATE], indicated a current profile card shall be maintained for each patient (resident), indicating diet order, likes, dislikes, allergies to foods, diagnosis and instructions or guidelines to be followed in the preparation and serving of food for the patient (resident). A review of the facility ' s P&P titled, Dietary Services Manager-Job Description, dated [DATE], indicated responsibilities included the following: -Visit resident/family on admission to complete diet history/nutritional assessment and to review dietary requirements and preferences of each resident admitted . -Maintains a record of diet orders and food preferences. Ensures an accurate menu or tray card is available for each meal for each resident. A review of the facility ' s P&P titled, Registered Dietician-Job Description, dated [DATE], indicated responsibilities included the following: -Ensures that a current, legible diet card with resident ' s name, room number, diet order, food preferences and any other pertinent information is available for all residents who receive meals and is updated as needed. -Ensures documentation is accurate, informative, and descriptive of resident ' s condition, care provided and resident ' s response.

Based on interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the facility's policies and procedure for one of three sampled residents (Resident 1), when it failed to: 1. Provide oversight to ensure all appropriate medical records that included treatments and other follow up discharge orders were provided to the facility prior to or upon the resident's admission to the facility as indicated in the facility's policy titled Admissions Policy. 2. Ensure Resident 1's general acute care hospital (GACH 1) discharge orders and discharge diagnoses were verified with the attending physician (Physician 1) upon admission to the facility on [DATE], to ensure continuity of care and implement appropriate care plan interventions while resident was residing in the facility. As a result of this deficient practice, Resident 1 did not receive the care and services that included routine laboratory work, outpatient consultations/procedures, and the development of care plan interventions necessary for the resident's diagnoses which are essential to the resident's continued care and medical treatment in the facility from 10/21/22 to 12/2/22. Resident 1 was transferred back to GACH 1 on 12/2/22 due to increasing altered mental status and found with marked urinary retention (a condition in which you are unable to empty all the urine from the bladder), hyperkalemia (a potassium level in the blood that's higher than normal [normal levels are between 3.5-5.0 milliequivalents per liter [mEq/L]) with potassium level of 6.9 mEq/L, metabolic acidosis (a serious disorder characterized by an imbalance in the body's acid-base balance [a mechanism developed by the body to keep bodily fluids as close to a neutral pH as possible]), significant anemia (a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues), and delirium (serious disturbance in mental abilities that results in confused thinking and reduced awareness of surroundings). Resident 1 was admitted to GACH 1's Intensive Care Unit (ICU [a department of a hospital in which patients who are dangerously ill are kept under constant observation]). Resident 1 was seen by a Nephrologist (a doctor who specializes in the diseases and disorders of the kidneys) and was assessed being hypovolemic (occurs when a person does not have enough fluid [blood] volume circulating in the body) with acute kidney injury, uremia (urine in the blood?and refers to?the effects of the waste product accumulation which causes fluid and electrolyte imbalances). Resident 1 received emergent (requiring immediate action) hemodialysis (a machine filters wastes, salts, and fluid from the blood), intravenous fluids (administration of fluids into a vein by means of a steel needle or plastic catheter to correct fluid volume/imbalance), and blood transfusion (given directly through the vein to replace blood and blood components that may be too low). Cross reference to F711, F692, F842 Findings: 1. A review of Resident 1's GACH 1 Discharge Documentation/Discharge Action Plan dated 10/21/22 timed at 2:34 PM, indicated Resident 1 was discharged to the facility on [DATE]. The GACH Discharge Documentation indicated a Discharge Summary of Resident 1's diagnoses, discharge medications, and issues to address on discharge that included: a. Psychiatric (relating to mental illness) care for further titration (a way to limit potential side effects by taking time to see how your body will react to a drug) of psychiatric care medications for bipolar disorder (a mental health condition that causes extreme mood swings) and delirium management. b. Outpatient cardiology (medical specialty concerned about the heart) follow-up regarding Atrioventricular [NAME] Reentrant Tachycardia ([AVNRT] sudden episodes of irregularly fast heartbeat), on metoprolol (medication to treat high blood pressure) 25 milligrams (mg, unit of measure) twice a day. c. Outpatient Fine Needle Aspiration ([FNA] a procedure that uses a thin needle to take out cells from a nodule [growth of abnormal tissue] in the thyroid gland (releases hormones into the bloodstream to control metabolism). d. Monitor Basic Metabolic Panel ([BMP] a blood test that gives information about fluid balance, levels of electrolytes [minerals in blood that carry an electric charge] and how well the kidneys are working) weekly and liberalize (loosen restrictions) fluid restriction if sodium (electrolyte that maintain a balance of body fluids) remains normal. e. Diet of regular, mechanical soft (any foods that can be blended, mashed, pureed, or chopped using a kitchen tool), and a fluid restriction (when an individual is advised to take a limited amount of fluid each day) of 2.5 liters. A review of the GACH 1 Discharge Documentation indicated GACH 1's Discharge Summary dated 10/21/22 timed at 2:34 PM, indicated seven diagnoses listed in the record. The Discharge Summary indicated the following diagnoses including toxic metabolic encephalopathy (a broad term that describes brain dysfunction characterized by symptoms of delirium and/or confusion), acute on chronic lithium toxicity (occurs when a person take too much lithium [a mood-stabilizing medication]), history of bipolar disorder, hypernatremia (imbalance of sodium and water in the body) secondary to lithium toxicity induced diabetes insipidus (an uncommon disorder that causes an imbalance of fluids in the body. This imbalance produces large amounts of urine), acute kidney injury (AKI) secondary to lithium toxicity versus lithium toxicity versus AKI, AVNRT versus atrial tachycardia (a fast heartbeat), and thyroid nodules (an unusual lump [growth] of cells on the thyroid gland). The Discharge Summary indicated a discharge diet of regular, mechanical soft, and a fluid restriction of 2.5 liters. A review of Resident 1's Admission Record indicated the facility admitted the resident on 10/21/22 with diagnoses that included toxic encephalopathy (brain dysfunction caused by toxic exposure), acute kidney failure, bipolar disorder, atrial fibrillation (a disease of the heart characterized by irregular and often faster heartbeat), and iron deficiency anemia (a condition in which blood lacks adequate healthy red blood cells). The Admission Record did not indicate Resident 1's history of hypernatremia, lithium toxicity induced diabetes insipidus, and AVNRT versus atrial tachycardia as indicated in GACH 1's Discharge Summary. A review of Resident 1's Facility Admission orders dated 10/21/22, did not indicate the following physician orders were ordered in the facility, as described from GACH 1's Discharge Documentation/Discharge Action Plan dated 10/21/22: 1. Outpatient cardiology follow-up regarding AVNRT. 2. Outpatient FNA a procedure that uses a thin needle to take out cells from a nodule in the thyroid gland. 3. Monitor BMP weekly and liberalize fluid restriction if sodium remains normal. 4. Diet of regular, mechanical soft, and a fluid restriction of 2.5 liters. A review of Resident 1's History and Physical (H&P) (undated) in the facility, indicated a handwritten statement from Physician 1 that the resident did not have the capacity to understand and make decisions. The undated H&P indicated Physician 1 saw Resident 1 in the GACH (no date indicated) and was found to have metabolic encephalopathy (problem in the brain that is caused by a chemical imbalance in the blood). The Physical Examination portion of the undated H&P was blank indicating see attached but there was no attachment. The Diagnosis portion of the undated H&P was blank. The H&P indicated Physician 1 signed the undated H&P but did not indicate a date of completion and when it was signed. A review of the facility's Physician 1 Progress Note dated 11/17/22, indicated a handwritten statement from Physician 1 that wrote See attached but there was no attachment found in Physician 1's Progress Note. A review of Resident 1's Nursing Progress Notes in the facility for November and December 2022 indicated the following information: 1. On 10/22/22 indicated an Admission Summary note from Registered Nurse (RN) 1 indicating the resident's primary admission diagnoses of acute on chronic lithium toxicity, metabolic encephalopathy, history of bipolar, hypernatremia secondary to lithium toxicity induced diabetes insipidus, acute kidney injury, AVNRT VS atrial tachycardia, and thyroid nodules with a diet at mechanical soft, no added salt. 2. On 11/3/22 timed at 10 AM, indicated Resident 1 was found sliding himself down from his wheelchair, then lie on the floor. The Note indicated Physician 1 was notified and informed that Resident 1 was already on psychotropic medications. 3. On 11/9/22 timed at 4:48 PM, indicated Resident 1's increasing aggressive behavior and unable to be redirected by facility staff. The Progress Note indicated Physician 1 was notified with an order to transfer Resident 1 to the GACH for uncontrolled behavior. 4. On 11/10/22 and 11/11/22, indicated Resident 1 would undress himself, confused, and disoriented and exhibiting abnormal behavior endangering self and others. Resident 1 was talking to self loudly, taking off clothes while walking in the facility hallway. The Note indicated visual checks were implemented on these days. 5. On 11/11/22, timed at 1:02 PM, Resident 1 was seen and evaluated by the PNP, with new medication orders (Benztropine Mesylate- used to treat symptoms of involuntary movements due to the side effects of certain psychiatric drugs) on the same date. 6. On 11/11/22, timed at 6:48 AM, Resident 1 was talking to self loudly and crawling on the floor. 7. On 11/17/22, timed at 1:45 PM, Resident 1 was seen and examined by Physician 1 inside the room. The Note indicated Physician 1 did not have any new orders. 8. On 11/30/22, timed at 2:50 PM, Registered Nurse (RN) 2 indicated that Family 1 was requesting for Resident 1 to be transferred to the GACH to check on him. The Note indicated that Family 1 verbalized concern with Resident 1's health was declining. The Note indicated RN 2 Made the doctor aware. Waiting for response. 9. On 11/30/22, timed at 2:50 PM, Registered Nurse (RN) 2 wrote that Family 1 requested for Resident 1 to be transferred to the GACH and to check on him. The Note indicated that Family 1 verbalized concerns about Resident 1's declining health. The Note indicated RN 2 Made the doctor aware. Waiting for response. 10. On 12/2/22, timed at 8 PM, Resident 1 was transferred to GACH 1 via ambulance. The Note indicated the facility staff informed Physician 1 and Family 1. The Note indicated Resident 1's vital signs were 129/90 (blood pressure), 99 (heart rate), 96% (oxygen saturation -the measure of how much oxygen is traveling through the body) on room air. The Note indicated Resident 1 did not have signs of acute distress and no changes in behavior or level of consciousness. On 12/15/22 at 10:10 AM, during a concurrent interview and record review of Resident 1's Progress Notes and Physician Orders for November and December 2022 with Quality Assurance Nurse (QAN) 1, QAN 1 stated she could not find documented evidence that the facility followed-up with Physician 1, regarding Family 1's request to transfer Resident 1 to the GACH on 11/30/22. QAN 1 stated there was no documented evidence in the Nursing Progress Notes of the reason why Resident 1 was not transferred to GACH 1 until 12/2/22. During an interview with the Director of Nursing (DON) and Health Information Director (HIMD) 1 on 1/3/2023 at 3:28 PM, the DON stated there was no other H&P (with date and signature) in Resident 1's medical records at the facility from 10/21/2022 to 1/3/2023. HIMD 1 stated he checked Resident 1's medical records and found that Resident 1's H&P indicated to see attached, handwritten by Physician 1 and did not have a date of encounter. HIMD 1 stated there were no other documents attached in the H&P. HIMD 1 stated there was no attachments found in Physician 1's progress notes dated 11/17/22. On 1/3/2023 at 4:24 PM, during a concurrent interview and record review of Resident 1's admission records and GACH 1 records, the MDS (Minimum Data Set - a care assessment tool) coordinator stated she based the resident's diagnoses she coded on Resident 1's MDS assessment and the facility's admission record from the GACH 1 records provided to the facility. The MDS coordinator stated the GACH 1 records should have been reviewed by Physician 1. The MDS coordinator stated, after she review the H&P and GACH Discharge Summary to check the diagnoses to update the facility records because sometimes the attending physician might add a diagnosis or discontinue some of the diagnoses from the acute hospital. MDS stated she did not see Physician 1's documented diagnoses in the facility's H&P and physician progress notes therefore, the diagnoses included in Resident 1's MDS assessment and admission records were derived from the GACH 1 records the facility had received on Resident 1's admission (10/21/22). On 1/6/2023 at 1:47 PM, during a concurrent interview and record review of Resident 1's entire facility records from 10/21/22 to 12/2/22 and GACH 1 records received by the facility upon resident's admission with the DON and the Administrator, the DON stated they did not see the discharge orders in the GACH 1 records the facility had in Resident 1's records. The DON stated the GACH 1 records the facility had on file only included Resident 1's previous Medication Administration Records (MAR) in the GACH 1 for October 2022 and did not indicate the actual GACH 1 discharge orders. The DON and the Administrator stated the GACH 1 MAR should not be used as a basis for admission orders to be ordered upon admission to the facility. The Administrator stated the admitting nurse, or any licensed nurse should have obtained the GACH 1 discharge orders and GACH 1 discharge summary to verify the admitting orders from Physician 1. On 1/6/2023 at 2:35 PM, a concurrent interview with the DON and record review of Resident 1's GACH 1 Discharge Documentation, Discharge Action Plan, and Discharge Summary dated 10/21/22 requested by the Department of Public Health from GACH 1 was conducted. Upon review of the GACH 1 discharge records, the DON stated she did not know if the facility had received the GACH 1 discharge records upon Resident 1's admission to the facility because the documents were not filed in Resident 1's records in the facility. The DON stated she could not find what GACH 1 record, Registered Nurse (RN) 1 (admitting nurse in the facility) reviewed to verify Resident 1's admission orders and admitting diagnoses for Resident 1. The DON stated she did not know if Physician 1 had reviewed the GACH 1 discharge orders dated 10/21/22 because they could not find it in the facility's paper and electronic resident records. On 1/6/2023 at 2:35 PM, during the same concurrent record review of GACH 1 Discharge Documentation/Discharge Action Plan dated 10/21/22, the DON stated that outpatient cardiology, outpatient FNA referral, delirium management, weekly BMP laboratory tests, and fluid restriction of 2.5 L were not ordered during Resident 1's entire stay in the facility (from 10/21/22 to 12/2/22). The DON stated that if Resident 1's BMP laboratory test was ordered by Physician 1 and was monitored by the facility weekly, Resident 1's decline in health status and transfer to GACH 1 could have been prevented. The DON stated if she saw GACH 1's Discharge Documentation/Discharge Action Plan in Resident 1's records, she would have followed up with Physician 1 to ensure the BMP, fluid restriction, and other consults/referrals were ordered. The DON stated she could not find documented evidence that the facility followed up with GACH 1 to obtain a copy of the 10/21/22 GACH 1 discharge orders and discharge summary. During the same interview, on 1/6/2023 at 2:35 PM, during a concurrent interview and record review of Resident 1's care plans from 10/21/22 to 12/2/22, the DON stated the facility did not develop care plans for diabetes insipidus, delirium management, and fluid restriction, in accordance with the GACH 1 Discharge Documentation and Discharge Action Plan dated 10/21/22. During the same interview, on 1/6/2023 at 2:35 PM, the Administrator stated the facility's policy indicated Physician 1 should perform medical evaluation, write, sign, and date Resident 1's H&P and Physician Progress Notes on the day of the resident visit. The Administrator stated the facility staff working the following day, after Resident 1's admission (10/22/22), should have followed up with GACH 1 if the GACH discharge orders were missing in Resident 1's records upon admission to the facility, to ensure continuity of care. During an interview with Registered Nurse (RN) 1 on 1/7/2023 at 8:09 AM, RN 1 stated she remembered reviewing a printout of GACH 1's actual Discharge orders dated 10/21/22. RN 1 stated she knew that she should be using the reconciled medications (a process of identifying the most accurate list of all medications a patient is taking) from GACH 1 to review for Resident 1's admission orders. RN 1 stated Resident 1 arrived at the facility on 10/21/22, during change of shift at around 11 PM. RN 1 stated she worked during the 11 PM to 7 AM shift on 10/21/22 and entered the GACH 1 discharge orders. RN 1 stated she entered all the medication orders in the facility's electronic record but could not remember if there were laboratory orders or consults in the GACH 1 discharge orders. RN 1 stated she did not talk to Physician 1 to verify Resident 1's facility admission orders on 10/21/22 during the night shift. RN 1 stated she sent a text message to Physician 1 to inform Physician 1 that Resident 1 had arrived at the facility. RN 1 stated Physician 1 did not call back during her shift (11 PM to 7 AM) to verify the admission orders. RN 1 stated she did not know why the GACH 1 discharge records were not found in Resident 1's paper records anymore. RN 1 stated she endorsed to the morning shift for 10/22/22 (7 AM to 3 PM) to check all the admission orders entered during the night shift and verify all admission orders to Physician 1. RN 1 stated she did not know if the morning shift licensed nurse (Licensed Vocational Nurse [LVN] 1) verified Resident 1's admission orders on 10/22/22. RN 1 stated she did not document in the progress notes that she had endorsed Resident 1's admission orders to the next shift. During an interview on 1/11/2023 at 1:50 PM, the DON stated Licensed Vocational Nurse (LVN) 1 was the nurse during the 7 AM to 3 PM shift on 10/22/22, after Resident 1's admission to the facility. The DON stated she did not know if LVN 1 had verified the admission orders with Physician 1 because she was not there during that day. The DON stated she could not find documentation that LVN 1 had spoken to Physician 1 to verify Resident 1's admission orders. A review of the facility's Change in Condition (COC) Evaluation to Resident 1, on 12/2/22 timed at 1:44 PM, indicated Resident 1 had generalized body weakness on 12/2/22, during the afternoon. The COC evaluation indicated Physician 1 was notified on 12/2/22 timed at 2 PM and ordered to transfer Resident 1 to GACH 1 emergency room (ER) Department due to generalized weakness for further evaluation and treatment as needed per Family 1's request. A review of Resident 1's Physician phone orders dated 12/2/22 timed at 1:59 PM, indicated to transfer Resident 1 to GACH 1 due to weakness for further evaluation and treatment as needed per Family 1's request. A review of Resident 1's GACH 1 Emergency Documentation dated 12/2/22 timed at 10:13 PM indicated Resident 1 presented to the GACH 1 Emergency Department on 12/2/22, with concern for generalized weakness for two days and mild altered mental status with low cognitive (thought process) baseline. A review of Resident 1's GACH 1 Consultation Notes dated 12/2/22 timed at 11:26 PM indicated a Nephrology (the branch of medicine concerned with the kidney) Consultation indicated Resident 1 appeared hypovolemic. The Consultation Note indicated the following issues: a. Acute Kidney Injury - Uremia - The Note indicated the resident's creatinine level (a waste product in the body typically removed through the kidneys and should leave the body through urine [normal levels are between 0.8 to 1.3 milligrams per deciliter [mg/dL]) was 1.06 two months ago (prior to admission to the facility on [DATE]) and now 10.13 with BUN ([Blood Urea Nitrogen] a waste product created in the liver and normally filtered by the kidneys out by urinating [normal levels are between 6 to 20 mg/dL]) of 198 and had altered mental status. A urinary catheter (allows urine to drain from the bladder for collection) was placed, and the resident was put on a strict intake and output (to monitor how much liquid was consumed and how much was eliminated as urine). A line (access site through the vein for hemodialysis) was placed to Resident 1 for urgent hemodialysis due to hyperkalemia, metabolic acidosis, and AMS (altered mental status). b. Hyperkalemia - The Note indicated to administer Lasix (furosemide, medication used to reduce extra fluid in the body) after the intravenous fluid via bolus (any concentrate given as a single dose to achieve an immediate effect). c. High metabolic acidosis (develops when too much acid is produced in the body) - The Note indicated to perform hemodialysis d. Anemia - The Note indicated the resident's hemoglobin (a protein in red blood cells that carries iron) level (prior to admission to the facility on [DATE]) was 9.3 (normal levels are 12 grams per deciliter [g/dL] or higher for female and 13 or higher for male), and now presented with hemoglobin level of 6.4 g/dL. The Note indicated Resident 1 to have blood transfusion (medical procedure in which donated blood is provided through a narrow tube placed within a vein) to keep hemoglobin levels above 7 or 8 g/dL. A review of Resident 1's GACH 1 History and Physical Reports dated 12/3/22 timed at 1:42 AM, indicated Resident 1 was admitted to the ICU for emergent hemodialysis and had decreased mentation (process of reasoning and thinking) and found to be in acute renal failure with elevated BUN/Creatinine, secondary to obstructive uropathy (occurs when urine cannot drain through the urinary tract [the body's drainage system for removing urine]) with urinary retention (retaining urine in the bladder, not able to fully empty). The History and Physical Reports indicated Resident 1 also had significant anemia and appeared to be developing hematuria (blood in the urine). The Report indicated Resident 1 received blood and intravenous fluids (IVF specially formulated liquids that are injected into a vein). A review of Resident 1's GACH 1 Discharge Documentation dated 12/19/22 timed at 9:45 PM indicated Resident 1 was discharged from GACH 1 on 12/19/22 to another facility (total of 18 days). During an interview, on 1/4/2023 at 2:11 PM, the DON stated when RN 2 notified the DON of Family 1's request to transfer Resident 1 to GACH 1, RN 2 did not notice any change of condition with Resident 1 on 11/30/22 when Family 1 raised his concerns about Resident 1, that is why there was no documentation of RN 2's assessment to Resident 1. The DON stated they could not find other reasons for Resident 1 to transfer to GACH 1. The DON stated the facility staff indicated generalized weakness to Resident 1 as the reason for transfer to GACH 1 on 12/2/22. During an interview with Family 1 on 1/4/2023 at 2:20 PM, Family 1 stated he talked to the facility staff about his concerns for Resident 1's declining health while in the facility approximately before 11/27/22. Family 1 stated he had seen Resident 1 a few days before 11/27/22 and again on that following Tuesday (11/29/22) and informed the licensed nurses (unable to recall which nurses) that Resident 1 did not look too good. Family 1 stated Resident 1 looked so pale with gray colored lips, shivering, cold to touch, very confused, sleepy, and mumbling to himself. Family 1 stated the licensed nurses informed him that Resident 1 had been sleeping a lot. Family 1 stated he had been asking the facility to transfer Resident 1 to the GACH everyday prior to 11/27/22 and was only transferred on 12/2/2022, approximately one week. Family 1 stated if he had not forced the facility to transfer Resident 1 back to GACH 1, Resident 1 would not be evaluated for his declining health. Family 1 stated Physician 1 had not spoken or discussed Resident 1's health status with him. During an interview with Physician 1 on 1/10/2023 at 3:32 PM, Physician 1 stated that for newly admitted residents he would review the GACH records which included the discharge orders, and medications to make sure everything makes sense. Physician 1 stated when the licensed nurses called him about resident admission orders, he had to rely on the accuracy of the licensed nurses reviewing the GACH information since he does not necessarily have the GACH discharge papers in front of him to review. Physician 1 stated it is a standard of practice/routine to review the newly admitted resident's previous acute hospital records during regular physician visits to the facility. Physician 1 stated he could not remember the conversation with the admitting nurse regarding Resident 1's admission on 10/21/22. Physician 1 stated he could not remember if he had reviewed Resident 1's GACH 1 record when he visited the facility. Physician 1 stated he could not recall and did not know why laboratory works were not ordered for Resident 1 during his entire stay in the facility. During the same interview on 1/10/2023 at 3:32 PM, Physician 1 stated he is responsible for Resident 1's overall care in the facility and needs to know everything that was going on. Physician 1 stated the licensed nurses must call him and go over the acute hospital discharge paperwork and verify the admission orders for the resident. Physician 1 stated he is required to evaluate newly admitted residents in the facility within 72 hours of their admission, however, could not recall when he had seen Resident 1 in the facility. Physician 1 stated when he is in the facility, he would review the resident's discharge orders from the GACH and make sure the facility admission orders were correct. During the same interview, on 1/10/2023 at 3:32 PM, Physician 1 stated he relies on the licensed nurses when they call him for the resident's status and assessment. Physician 1 stated he did not recall any orders for management of delirium for Resident 1. Physician 1 stated he could not recall if Resident 1 should be on fluid restriction. Physician 1 stated he remembered being notified of Family 1's request to transfer Resident 1 but could not recall the date and details of the conversation with facility staff. Physician 1 stated the licensed nurse told him Family 1 did not feel Resident 1 was thriving (doing well) in the facility. When Physician 1 was asked if the licensed nurses described Resident 1's condition when he was notified by phone, that included shivering, cold, pale to gray lip color, and skin cold to touch, Physician 1 stated he did not remember that specific description from the licensed nurse's assessment because an assessment like that would get his attention. A review of the facility's policy titled Admission Criteria revised in October 2012, indicated prior to or at the time of admission, the resident's Attending Physician must provide the facility with information needed for the immediate care of the resident including orders covering at least: a. Type of diet (e.g., regular, mechanical, etc); b. Medication orders, including (as necessary) a medical condition or problem associated with each medication; and c. Routine care orders to maintain or improve the resident's function until the physician and care planning team can conduct a comprehensive assessment and develop a more detailed Interdisciplinary Care Plan.

Based on interviews and record reviews, the facility failed to ensure the facility's attending physician (Physician 1) reviewed one of three residents' (Resident 1) total program of care, including reviewing the resident's medications and treatments while residing in the facility from 10/21/22 to 12/2/22 in accordance with the facility's policy and procedure (P&Ps), by failing to: 1. Review Resident 1's general acute care hospital (GACH 1) Discharge Documentation/Discharge Action Plan and Discharge Summary, that indicated the GACH 1's discharge orders upon admission to the facility on [DATE], to ensure continuity of care in the facility. 2. Ensure Resident 1's History and Physical (H& P) and physician progress notes were completed and documented in the resident's facility medical records with each visit, from 10/21/22 to 12/2/22. As a result of these deficient practices, Resident 1 did not receive the necessary care and services essential to the resident's continued care and medical treatment while residing in the facility from 10/21/22 to 12/2/22. Resident 1 was transferred back to GACH 1 on 12/2/22 due to increasing altered mental status and found with marked urinary retention (a condition in which you are unable to empty all the urine from the bladder, hyperkalemia (a potassium level in the blood that's higher than normal [normal levels are between 3.5-5.0 mEq/L]), metabolic acidosis (a serious electrolyte disorder characterized by an imbalance in the body's acid-base balance), significant anemia (a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues), and delirium (serious disturbance in mental abilities that results in confused thinking and reduced awareness of surroundings). Resident 1 was admitted to GACH 1's Intensive Care Unit (ICU [a department of a hospital in which patients who are dangerously ill are kept under constant observation]). Resident 1 was seen by a Nephrologist (the branch of medicine concerned with the kidney) and was assessed being hypovolemic (occurs when a person does not have enough fluid [blood] volume circulating in the body) with Acute Kidney Injury ([AKI], also known as acute renal failure (ARF), a sudden episode of kidney failure or kidney damage that happens within a few hours or a few days with uremia having a buildup of toxins in the blood. It occurs when the kidneys stop filtering toxins out through your urine), uremia (urine in the blood and refers to the effects of the waste product accumulation which causes fluid and electrolyte imbalances). Resident 1 received emergent hemodialysis (a machine filters wastes, salts, and fluid from the blood), intravenous fluids (administration of fluids into a vein by means of a steel needle or plastic catheter to correct fluid volume/imbalance), and blood transfusion (given directly through the vein to replace blood and blood components that may be too low). Cross referenced to F635 and F692. Findings: A review of Resident 1's GACH Discharge Documentation/Discharge Action Plan dated 10/21/22 timed at 2:34 PM, indicated Resident 1 was discharged to the facility on [DATE]. The GACH Discharge Documentation indicated a Discharge Summary of Resident 1's diagnoses, discharge medications, and issues to address on discharge that included: 1. Psychiatric care for further titration (a way to limit potential side effects by taking time to see how your body will react to a drug) of psychiatric care medications for bipolar disorder (a mental health condition that causes extreme mood swings) and delirium management. 2. Outpatient cardiology (medical specialty concerned about the heart) follow-up regarding Atrioventricular [NAME] Reentrant Tachycardia ([AVNRT] sudden episodes of irregularly fast heartbeat), on metoprolol (medication to treat high blood pressure) 25 milligrams (mg, unit of measure) twice a day. 3. Outpatient Fine Needle Aspiration ([FNA] a procedure that uses a thin needle to take out cells from a nodule [growth of abnormal tissue] in the thyroid gland. 4. Monitor Basic Metabolic Panel ([BMP] a blood test that gives information fluid balance, levels of electrolytes [minerals in blood that carry an electric charge] like sodium and potassium, and how well the kidneys are working) weekly and liberalize fluid restriction if sodium remains normal. 5. Diet of regular, mechanical soft (any foods that can be blended, mashed, pureed, or chopped using a kitchen tool such as a knife, a grinder, a blender, or a food processor), and a fluid restriction (when an individual is advised to take a limited amount of fluid each day) of 2.5 liters. A review of the GACH 1 Discharge Documentation indicated GACH 1's Discharge Summary dated 10/21/22 timed at 2:34 PM, indicated seven diagnoses listed in the record. The Discharge Summary indicated the following diagnoses including toxic metabolic encephalopathy, acute on chronic lithium toxicity, history of bipolar disorder (a mental health condition that causes extreme mood swings), hypernatremia (imbalance of sodium and water in the body) secondary to lithium toxicity induced diabetes insipidus (an uncommon disorder that causes an imbalance of fluids in the body. This imbalance leads to produce large amounts of urine), acute kidney injury (AKI) secondary to lithium toxicity versus lithium toxicity versus AKI, AVNRT versus atrial tachycardia (a fast heartbeat), and thyroid nodules (an unusual lump [growth] of cells on the thyroid gland). The Discharge Summary indicated a discharge diet of regular home, mechanical soft, and a fluid restriction of 2.5 liters. A review of Resident 1's Admission Record indicated the facility admitted the resident on 10/21/22 with diagnoses that included toxic encephalopathy (brain dysfunction caused by toxic exposure), acute kidney failure ([AKI] condition in which the kidneys suddenly cannot filter waste from the blood), bipolar disorder, atrial fibrillation (a disease of the heart characterized by irregular and often faster heartbeat), and iron deficiency anemia (a condition in which blood lacks adequate healthy red blood cells). The Admission Record did not indicate Resident 1's history of hypernatremia, lithium toxicity induced diabetes insipidus, and AVNRT versus atrial tachycardia as indicated in GACH 1's Discharge Summary. A review of Resident 1's Facility Admission orders dated 10/21/22, did not indicate the following physician orders as described from GACH's Discharge Documentation/Discharge Action Plan: 1. Outpatient cardiology follow-up regarding AVNRT, on metoprolol 25 mg twice a day. 2. Outpatient FNA a procedure that uses a thin needle to take out cells from a nodule in the thyroid gland. 3. Monitor BMP weekly and liberalize fluid restriction if sodium remains normal. 4. Diet of regular, mechanical soft, and a fluid restriction of 2.5 liters. A review of Resident 1's History and Physical (H&P) (undated) in the facility, indicated a handwritten statement from Physician 1 that the resident did not have the capacity to understand and make decisions. The undated H&P indicated Physician 1 saw Resident 1 in the GACH (no date indicated) and was found to have metabolic encephalopathy (problem in the brain that is caused by a chemical imbalance in the blood). The Physical Examination portion of the undated H&P was blank indicating see attached but there was no attachment. The H&P indicated Physician 1 signed the undated H&P but did not indicate a date of completion and when it was signed. A review of a facility document titled Physician's Visit Log indicated Physician 1's handwritten signature with a stamped date of 11/17/22. A review of the facility's Physician 1 Progress Note dated 11/17/22, indicated a handwritten statement from Physician 1 that wrote See attached but there was no attachment found in Physician 1's Progress Note. During an interview with the Director of Nursing (DON) and Health Information Director (HIMD) 1 on 1/3/2023 at 3:28 PM, the DON stated there was no other H&P (with date and signature) in Resident 1's medical records at the facility from 10/21/2022 to 1/3/2023. HIMD 1 stated he checked Resident 1's medical records and found that Resident 1's H&P did not have a date of encounter and indicated to see attached, handwritten by Physician 1, but there were no other documents attached. HIMD 1 stated there was no attachment with physician progress notes on 11/17/22 found in Resident 1's medical records. A further review of Resident 1's Facility H&P dated 10/21/22 (received from the facility on 1/4/2023) indicated Physician 1 electronically signed the H&P on 1/3/2023 timed at 9:56 PM (74 days after Resident 1 was admitted to the facility on [DATE]). The H&P did not indicate Resident 1's history of hypernatremia (a high concentration of sodium in the blood) secondary to lithium (type of medicine known as a mood stabilizer) toxicity induced diabetes insipidus (an uncommon condition where the body produces too much urine and often feel thirsty) and AVNRT versus atrial tachycardia. The H&P did not indicate Resident 1's current medications to be continued in the facility, laboratory orders such as BMP, or treatment plans such as delirium management, outpatient physician referrals and follow ups. A review of Resident 1's Nursing Progress Notes in the facility for November 2022, indicated the following information: 1. On 10/22/22 indicated an Admission Summary note from Registered Nurse (RN) 1 indicating the resident's primary admission diagnoses of acute on chronic lithium toxicity, metabolic encephalopathy, history of bipolar, hypernatremia secondary to lithium toxicity induced diabetes insipidus, acute kidney injury, AVNRT VS atrial tachycardia, and thyroid nodules with a diet at mechanical soft, no added salt. 2. On 11/11/22, timed at 6:35 PM, the progress note indicated Resident 1 needed Registered Dietitian (RD) evaluation and monitoring for weight gain. 3. On 11/13/22, timed at 6:40 AM, Resident 1 was on monitoring for weight gain of 15 lbs. (pounds; unit of measurement) in one month. The Note indicated the resident was encouraged to adhere with dietary plan. A review of Resident 1's facility physician progress notes dated 11/17/22, indicated the name of Physician 1, and a chief complaint indicating SNF Visit. Physician 1's Progress Note did not indicate Resident 1's total program of care that included the follow up plan for Resident 1's current medications, follow up on laboratory orders/results (BMP and FNA) as indicated in GACH 1 discharge action plan, outpatient physician (cardiology) referrals/consults as indicated in GACH 1 discharge action plan. Physician 1's Progress Note did not indicate Resident 1's significant weight gain of 15 lbs. The document indicated Physician 1 electronically signed the Physician Progress Note on 1/3/2023 timed at 10:11 PM (74 days after Resident 1 was admitted to the facility on [DATE]). A review of Resident 1's Nursing Progress Notes dated 11/30/22, timed at 2:50 PM, indicated Registered Nurse (RN) 2 wrote that Family 1 requested for Resident 1 to be transferred to the GACH to check on him. The Note indicated that Family 1 verbalized concern about Resident 1's declining health. The Note indicated RN 2 Made the doctor aware. Waiting for response. A review of Resident 1's Physician orders dated 12/2/22 indicated to transfer Resident 1 to GACH 1 due to generalized weakness. On 1/3/2023 at 4:24 PM, during a concurrent interview and record review of Resident 1's admission records and GACH 1 records, the MDS (Minimum Data Set - a care assessment tool) coordinator stated she based the resident ' s diagnoses she coded on Resident 1's MDS assessment and the facility ' s admission record from the GACH 1 records provided to the facility. The MDS coordinator stated the GACH 1 records should have been reviewed by Physician 1. The MDS coordinator stated, after she review the H&P and GACH Discharge Summary to check the diagnoses to update the facility records because sometimes the attending physician might add a diagnosis or discontinue some of the diagnoses from the acute hospital. MDS stated she did not see Physician 1's documented diagnoses in the facility's H&P and physician progress notes therefore, the diagnoses included in Resident 1's MDS assessment and admission records were derived from the GACH 1 records the facility had received on Resident 1 ' s admission (10/21/22). During the same interview, on 1/3/22 at 4:24 PM, during a concurrent interview with the Minimum Data Set (MDS, a care assessment tool) coordinator and record review of Resident 1 ' s Progress Notes and Physician Orders from 11/30/22 (after 2:50 PM) to 12/1/22, the MDS coordinator stated there were no documented evidence found in the resident ' s medical records that indicated a follow through or monitoring of Resident 1 ' s change of condition by Physician 1, after RN 2 made Physician 1 aware of Family 1 ' s concerns with Resident 1 ' s declining health. The MDS coordinator stated, she could not find any new physician orders from 11/30/22 after 2:50 PM to 12/1/22. During an interview with Family 1 on 1/4/2023 at 2:20 PM, Family 1 stated if he had not forced the facility to transfer Resident 1 to GACH 1 since 11/30/22, Resident 1 would not have been transferred and evaluated for his declining health. Family 1 stated Physician 1 had not spoken to or discussed Resident 1's health status with him. A review of Resident 1's Change in Condition Evaluation on 12/2/22 timed at 1:44 PM indicated the resident had generalized body weakness on 12/2/22 in the afternoon. The evaluation indicated Physician 1 was notified on 12/2/22 timed at 2:00 PM with the recommendation to transfer resident to GACH ER (emergency room ) Department due to weakness for further evaluation and treatment per Family 1's request. A review of Resident 1's GACH 1 Emergency Documentation dated 12/2/22 timed at 10:13 PM indicated Resident 1 admitted to GACH ED (Emergency Department) on 12/2/22, with having generalized weakness for two days and mild altered mental status with low cognitive baseline (unable to make decision or understand). A review of Resident 1's GACH 1 Consultation Notes dated 12/2/22 timed at 11:26 PM indicated a Nephrology (the branch of medicine concerned with the kidney) Consultation indicated Resident 1 appeared hypovolemic (occurs when a person does not have enough fluid [blood] volume circulating in the body). The Consultation Note indicated the following issues: 1. Acute Kidney Injury - Uremia - The Note indicated the resident's creatinine level (a waste product in the body typically removed through the kidneys and should leave the body through urine [normal levels are between 0.8 to 1.3 mg/dL]) was 1.06 two months ago (prior to admission to the facility on [DATE]) and now 10.13 with BUN ([Blood Urea Nitrogen] a waste product created in the liver and normally filtered by the kidneys out by urinating [normal levels are between 6 to 20 mg/dL) of 198 and had altered mental status. A urinary catheter (allows urine to drain from the bladder for collection) was placed, and the resident was put on a strict intake and output (to monitor how much liquid was consumed and how much was eliminated as urine). A line (access site through the vein for hemodialysis) was placed to Resident 1 for urgent hemodialysis due to hyperkalemia, metabolic acidosis, and AMS (altered mental status). 2. Hyperkalemia - The Note indicated to administer Lasix (furosemide, medication used to reduce extra fluid in the body) after the intravenous fluid via bolus (any concentrate given as a single dose to achieve an immediate effect). 3. High metabolic acidosis (develops when too much acid is produced in the body) - The Note indicated to perform hemodialysis 4. Anemia - The Note indicated the resident's hemoglobin (a protein in red blood cells that carries iron) level (prior to admission to the facility on [DATE]) was 9.3 (normal levels are 12 or higher for female and 13 or higher for male), and now presented with hemoglobin level of 6.4. The Note indicated Resident 1 to have blood transfusion (medical procedure in which donated blood is provided through a narrow tube placed within a vein) to keep hemoglobin levels above 7 or 8. A review of the GACH 1 History and Physical Reports dated 12/3/22 timed at 1:42 AM, indicated Resident 1 was admitted to the ICU for emergent hemodialysis and had decreased mentation (process of reasoning and thinking) and found to be in acute renal failure with elevated BUN/Creatinine, secondary to obstructive uropathy (occurs when urine cannot drain through the urinary tract [the body's drainage system for removing urine]) with urinary retention (retaining urine in the bladder, not able to fully empty). The History and Physical Reports indicated Resident 1 also had significant anemia and appeared to be developing hematuria (blood in the urine). The Report indicated Resident 1 received blood and IV fluids (IVF). A review of Resident 1's GACH Discharge Documentation dated 12/19/22 timed at 9:45 PM indicated Resident 1 was discharged from GACH 1 to another facility on 12/19/22 (total of 17 days stay in GACH). On 1/6/2023 at 1:47 PM, during a concurrent interview and record review of Resident 1's entire medical records from 10/21/22 to 12/2/22, the DON stated Resident 1's medical records did not indicate any laboratory orders (BMP, FNA of the thyroid gland), laboratory results, or outpatient cardiology order and/or consults including fluid restriction ordered by Physician 1. On 1/6/2023 at 2:35 PM, a concurrent interview and record review of Resident 1's GACH 1 Discharge Documentation, Discharge Action Plan, and Discharge Summary dated 10/21/22 timed at 1:47 PM, requested by the Department of Public Health from GACH 1 was conducted with the DON, in the presence of the MDS Nurse, QAN 1, and HIM 2. The DON stated they did not know if the facility had received GACH 1 discharge documents upon Resident 1's admission to the facility. However, the DON stated that RN 1's facility Progress Notes dated 10/22/22 timed at 4:02 AM titled Admission Summary, indicated the exact verbiage documented by RN 1 of Resident 1's seven primary diagnoses used and found in the GACH 1 Discharge Documentation dated 10/21/22 timed at 1:47 PM. On 1/6/2023 at 2:35 PM, during the same concurrent record review of GACH 1 Discharge Documentation/Discharge Action Plan dated 10/21/22, the DON stated that outpatient cardiology, outpatient FNA referral, delirium management, weekly BMP laboratory tests, and fluid restriction of 2.5 L was not ordered during Resident 1's entire stay in the facility (from 10/21/22 to 12/2/22). The DON stated that if Resident 1's BMP laboratory results was ordered by Physician 1 and was monitored by the facility weekly, Resident 1's decline in health status and transfer to GACH 1 could had been prevented. During the same interview, on 1/6/2023 at 2:35 PM, the Administrator stated the facility's policy indicated Physician 1 should perform medical evaluation, write, sign, and date Resident 1's H&P and Physician Progress Notes on the day of the resident visit. The Administrator stated the facility's Medical Director, Administrator, and the DON were responsible for enforcing the facility's policy to ensure the physician review the resident's total program of care and sign/date and document progress notes on each visit for all the facility's physicians. The Administrator stated, Physician 1 is the facility's current medical director. During an interview with RN 1 on 1/7/2023 at 8:09 AM, RN 1 stated she sent a text message to Physician 1 during her shift on 10/21/22 (11 PM to 7 AM) to inform Physician 1 that Resident 1 had arrived at the facility. RN 1 stated Physician 1 did not call back during her shift (11 PM to 7 AM). RN 1 stated she did not know why the GACH 1 Discharge papers were not found in Resident 1's paper records anymore. RN 1 stated that the facility practice was to endorse and for the oncoming (morning) shift for 10/22/22 (7 AM to 3 PM) to check all the admission orders entered by the night shift for Resident 1 and verify all orders were correct to Physician 1. During an interview with Physician 1 on 1/10/2023 at 3:32 PM, Physician 1 stated that for newly admitted residents he would review the GACH records which included the discharge orders, and medications to make sure everything makes sense. Physician 1 stated when the licensed nurses call him about resident admission orders, he had to rely on the accuracy of the licensed nurses reviewing the GACH information since he does not necessarily have the GACH discharge papers in front of him to review. Physician 1 stated it is a standard of practice/routine to review the newly admitted resident's previous GACH records during regular physician visits to the facility. Physician 1 stated he could not remember the conversation with the admitting nurse regarding Resident 1's admission on 10/21/22. Physician 1 stated he could not remember if he had reviewed Resident 1's GACH records when he visited the facility. During the same interview on 1/10/2023 at 3:32 PM, Physician 1 stated he is responsible for Resident 1's overall care in the facility and needs to know everything that was going on. Physician 1 stated the licensed nurses must call him and go over the GACH discharge paperwork and verify the admission orders for the resident. Physician 1 stated he is required to evaluate newly admitted residents in the facility within 72 hours of their admission, however, could not recall when he had seen Resident 1 in the facility. Physician 1 stated when he is in the facility, he would review the resident's discharge orders from the GACH and make sure the facility admission orders were correct. Physician 1 stated when he evaluates the resident in the facility, he would document using his office electronic medical record and not the facility's electronic records. Physician 1 stated he would try to get the resident documents (such as the H&P and Physician Progress Notes) to the facility timely, because the facility also needed to have the H&P on file within 72 hours. Physician 1 stated he did not always get his progress notes to the facility on time and sometimes he would forget. During the same interview, on 1/10/2023 at 3:32 PM, Physician 1 stated when the facility asked him for Resident 1's H&P and Progress Notes on 1/3/2023, for some reason he did not finish/complete the documents and did not electronically sign the documents until 1/3/2023. Physician 1 stated sometimes he is working a lot and forgets to sign. Physician 1 stated it is ideal for the facility H&P and Physician Progress Notes to be completed and filed in the resident's records timely, on the day the physician's visits. Physician 1 stated the physician needs to be informed or reminded by the facility. Physician 1 stated he could not remember whether the facility called him about Resident 1's H&P and Progress Notes up until recently, on 1/3/2023. A review of the facility's policy titled Admissions Policies revised in December 2006 indicated the objective of the facility's admission policy was to ensure to admit residents who can be adequately cared for by the facility. The policy further indicated that the facility would Assure that appropriate medical and financial records are provided to the facility prior to or upon the resident's admission. A review of the facility's policy titled Physician Visits revised in April 2013 indicated The Attending Physician will visit residents in a timely fashion, consistent with applicable state and federal requirements, and depending on the individual's medical stability, recent and previous medical history, and the presence of medical conditions or problems that cannot be handled readily by phone. The policy further indicated The Attending Physician must perform relevant tasks at the time of each visit, including a review of the resident's total program of care and appropriate documentation. A review of the facility's policy titled Physician Progress Notes revised in February 2008, indicated Physician progress notes must be maintained for each resident. The policy indicated Physician progress notes reflect the resident's progress and response to his or her care plan, medications, etc. The policy further indicated The resident's Attending Physician must write, sign, and date the physician progress notes upon each visit. A review of the facility's policy titled Admission Criteria revised in October 2012, indicated prior to or at the time of admission, the resident's Attending Physician must provide the facility with information needed for the immediate care of the resident including orders covering at least: a. Type of diet (e.g., regular, mechanical, etc.); b. Medication orders, including (as necessary) a medical condition or problem associated with each medication; and c. Routine care orders to maintain or improve the resident's function until the physician and care planning team can conduct a comprehensive assessment and develop a more detailed Interdisciplinary Care Plan.

Based on interview, and record review, the facility failed to ensure that one of three sampled residents (Resident 1) was free from sexual abuse. Resident 1, who had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . CNA 1 assisted Resident 1 during bathing in the facility's Shower Room on 6/13/2022 and 6/14/2022. CNA 1 stated that during the shower, Resident 1 was moaning and had an orgasm. This deficient practice resulted in Resident 1 to experience sexual abuse from CNA 1. Findings: A review of Resident 1's Admission Record indicated the facility admitted the resident on 6/12/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Admission Data Collection dated 6/12/2022, indicated Resident 1 had the ability to understand others and make herself understood. A review of Resident 1's Progress notes dated 6/16/2022 timed at 3:38 PM indicated and written by the Social Services Director (SSD), Resident 1 would like to be discharged against medical advice (AMA, leaving against the advice of the resident's physician) to home on 6/17/2022 regardless of isolation status with COVID-19. A review of a facility report to the Department of Public Health received dated 6/21/2022, indicated Resident 1's family member (Family 1) called the facility to report that Resident 1 informed her that Resident 1 had sexual relations with a male CNA during care while in the facility. During a telephone interview with Resident 1 on 6/22/2022 at 10:19 AM, Resident 1 stated she resided at the facility from Sunday (6/12/2022) to Friday (6/17/2022) in the facility's COVID unit and that she could not remember much of what happened. Resident 1 stated on Tuesday (6/14/2022) CNA 1 was very attentive. Resident 1 stated she could not recall what day it was, but CNA 1 gave her a shower and told her to stand up, turn around and squat, and he put his hand in my vagina. Afterwards, Resident 1 stated And then his penis was by my head, I had to give oral sex, I did it and he dried me off, and told me do not say a word to anybody . not a soul. Resident 1 stated she could hear CNA 1 telling a female staff in detail what happened in the shower. Resident 1 stated she heard the other person (female staff) say, You're kidding, you did that? You're not supposed to . Resident 1 stated she could not recall who the other person was but knew that it was a female voice. Resident 1 stated she started to feel that CNA 1 cared for her. Resident 1 stated she could not recall many details, because she was Fuzzy and off medications. During an interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 6/22/2022 at 12:25 PM, the ADON stated the Administrator (ADM) received a call about the allegation from Resident 1's family member (Family 1). The ADON stated Resident 1 was not at the facility very long. The DON stated as soon as ADM received the phone call, they talked to CNA 1 about the incident and CNA 1 was suspended and sent home right away. During an interview with the ADON on 6/22/2022 at 12:35 PM, the ADON stated Resident 1 was admitted into the facility's Red Zone (confirmed COVID-19 [a mild to severe respiratory illness] positive residents) on 6/12/2022 and discharged home on 6/17/2022. The ADON stated Resident 1 was brought to the facility for COVID-19 isolation. The ADON stated Resident 1 was discharged home against medical advice (AMA). During a concurrent interview and record review of staffing assignments with the DON, ADON, and in the presence of the Director of Staff Development (DSD) on 6/22/2022 at 12:52 PM, the DSD stated that CNA 1 worked in the facility's Red Zone on 6/13/2022 during the 7 AM to 3 PM shift and 6/14/2022 during the 7 AM to 3 PM shift. During an interview with the ADON on 6/22/2022 at 1 PM, the ADON stated Resident 1 was very alert and often stated I love (CNA 1), please assign him to me. During a telephone interview with Family 1, on 6/22/2022 at 8:48 PM, Family 1 stated that stated that Resident 1 was on certain medications that increased libido. Family 1 stated that Resident 1 was a flirt (to behave as if interested in someone, in a not serious way) and like a child. Family 1 stated Resident 1 was on antidepressant and that she informed someone at the facility not to have a male staff assigned to Resident 1 because she flirts and sometimes it could be inappropriate. Family 1 stated Resident 1 would call her and hear the stories about CNA 1. Family 1 stated she did not inform the facility right away because she was confused on what happened and did not understand. Family 1 stated Resident 1 got off medication and became loopy, got manic, and would often say He (CNA 1) cares about me and that he (CNA 1) wanted to visit Resident 1 when he can get one weekend off. During the telephone interview with Family 1, on 6/22/2022 at 8:48 PM, Family 1 stated, when Resident 1 was discharged home she started to remember more about her stay at the facility. Family 1 stated that that was the time Resident 1 told her Oh my god something happened don't be mad at me, he gave me a shower. Family 1 stated that Resident 1 told her that CNA 1 was in the shower and told Resident 1 to scoot down and squat and shoved his hand in the resident's vagina and gave the resident an orgasm. Family 1 stated Resident 1 told her that CNA 1 unzipped his pants and put dick (penis) in her mouth. Family 1 stated Resident 1 was terrified to go to another home (nursing home). Family 1 stated, she wanted Resident 1 to go home, and the facility stated the resident could not go home. Family 1 stated Resident 1 left the facility against medical advice (AMA). During a telephone interview with the ADM on 6/23/2022 at 4:52 PM, the ADM stated he received the call about the allegation from Family 1 on Monday (6/20/2022) at 10 AM. The ADM stated Family 1 informed him that CNA 1 showered Resident 1 and did something inappropriate and sexual. The ADM stated Family 1 stated (Resident 1) told us that she met this guy, he's great and she loves this guy, he loves her, and she wants to marry him. The ADM stated Family 1 stated He gave her a shower and at some point, stood her up and asked her to squat and put his fingers in her vagina and gave her an orgasm. And she sat down, he pulled down his pants, sat her down in the shower chair, and took his penis out to perform oral sex on him. During the same interview, on 6/23/2022 at 4:52 PM, the ADM stated CNA 1 denied everything when asked about the allegation. The ADM stated CNA 1 admitted giving Resident 1 a shower but stated nothing inappropriate happened. The ADM stated CNA 1 had been working at the facility since 3/9/2022 and was hired as the facility's Central Supply Coordinator and then started working as a CNA after receiving his certification. The ADM stated he notified the police after his phone call with Family 1 and was interviewed by the police. The ADM stated he asked CNA 1 if he tried to contact Resident 1 after the resident was discharged and why the resident had CNA 1's personal number. The ADM stated CNA 1 responded sometimes I do give them my number in case they need something. The ADM stated CNA 1 stated Resident 1 called him and CNA 1 called Resident 1 back and spoke with the resident briefly but stated he did not remember what the call was about. During a telephone interview with CNA 1 on 6/24/2022 at 10:55 AM, CNA 1 stated Resident 1 was very strong and hitting (trying to get someone to like you by flirting with them) on me also. CNA 1 stated Resident 1 told him You're very strong, you're [NAME], and she was hitting on me because I am very muscular. She was checking me out already, like sizing me up. I just smile and say okay. CNA 1 stated the first day Resident 1 started hitting on him and checking him out, the Administrator was present, and Resident 1 was flirting with the both of them. CNA 1 stated that whenever Resident 1 would come on very strong and start hitting on him, I just let it ride . When asked what CNA 1 meant, CNA 1 stated he just hear it in one ear and out the other ear. During the telephone interview with CNA 1 on 6/24/2022 at 10:55 AM, CNA 1 stated he gave Resident 1 shower once, and Resident 1 wanted many more after that. CNA 1 stated Resident 1 requested the shower. CNA 1 stated that during the shower (he could not recall what day), Resident 1 was getting aroused when I was bathing her around her boobs (breasts). CNA 1 stated We do what we got to do; she was making moaning sounds. CNA 1 stated Resident 1 was sitting on a shower chair and had no clothes from head to toe. When CNA 1 was asked what he did when Resident 1 was observed getting aroused and moaning while he was bathing the resident's breasts area, CNA 1 stated he told Resident 1 to stop and proceeded to finish up lathering Resident 1 up and down. When CNA 1 was asked what Resident 1 did when he told Resident 1 to stop, CNA 1 stated Resident 1 just chuckled and smiled. CNA 1 stated he rinsed the resident, and they were done. When CNA 1 was asked if CNA 1 also bathe or cleansed Resident 1's genital area, CNA 1 stated he lather the resident's vagina and anal part and butt cheeks with a towel and Resident 1 was orgasming (the rapid pleasurable release of neuromuscular tensions at the height of sexual arousal). CNA 1 was asked what he did when he observed Resident 1 having an orgasm, CNA 1 stated I rinsed her off, got her dressed and got her out of the bathroom. During the same telephone interview, on 6/24/2022 at 10:55 AM, CNA 1 stated that he never paid attention and did not know if there was a call light in the Shower Room because he did not call for another staff to assist him. CNA 1 was asked if he should have informed someone of Resident 1's behavior towards him (CNA 1). CNA 1 stated I guess I should have; it was all new to me because this was my first time being a CNA. CNA 1 stated before he started the shower, he remembered he informed Licensed Vocational Nurse (LVN) 1 that Resident 1 was hitting on him and LVN 1 responded You'll be fine. CNA 1 stated that he should have called someone after the resident's shower. CNA 1 stated he did not think much of Resident 1's behavior because she acted that way the whole time, she was in the facility. During the same telephone interview, on 6/24/2022 at 10:55 AM, CNA 1 stated he gave his personal cellphone number to Resident 1 just like he gave his number to other residents. CNA 1 stated that when he was running around the facility it was hard to see the call lights, that is why he gave out his cellphone number to residents. CNA 1 stated Resident 1 called many times. CNA 1 stated Resident 1 called his cellphone on 6/18/2022 after the resident was already discharged and asked him when he could come over. CNA 1 stated that Resident 1 told him that she would be Clean down there, so we can do it like rabbits.'' When CNA 1 was asked how he responded to Resident 1, CNA 1 stated he responded to Resident 1 with a chuckle and verbalized Like friends with benefits? CNA 1 stated he just started laughing it off. CNA 1 denied the allegation that Resident 1 gave him oral sex. CNA 1 stated Resident 1 had a behavior of walking around without underwear. CNA 1 stated Resident 1 had a behavior of exposing herself and stated he did not mention it to anybody. CNA 1 stated when he would walk into Resident 1's room to bring in the meal trays, Resident 1 would be up showing her buttocks. During a telephone interview with the DSD on 6/24/2022 at 1:26 PM, the DSD stated CNAs were educated and trained about abuse when they were hired and they watch the abuse video, including sexual harassment. The DSD stated after watching the videos, the CNAs would take a post test. The DSD was asked if it was appropriate for a facility staff/employee to give out their personal numbers to residents. The DSD stated facility staff should never give out their personal number. The DSD stated it was not allowed. The DSD was asked what a CNA should do if a resident started getting aroused during bathing/shower assistance. The DSD stated the CNA should not continue the shower and should report anything that makes staff uncomfortable or unusual. The DSD stated the staff should report right away to her or anyone in charge in the facility. A review of the facility's submitted Investigation Summary dated 7/6/2022 indicated an updated conclusion of the ADM to the facility investigation indicating that CNA 1 failed to provide all the necessary information for the facility to conduct a thorough investigation. The Summary indicated that when CNA 1 observed Resident 1's odd behavior during the shower, CNA 1 should have stopped and asked for help. The Summary indicated that CNA 1's employment was terminated from the facility. During a telephone interview with LVN 1 on 6/28/2022 at 4:20 PM, LVN 1 stated Resident 1 was alert and would frequently request CNA 1 and did not want anyone else. LVN 1 stated CNA 1 did not report or inform her of anything inappropriate or unusual. LVN 1 stated personal phone numbers of facility staff should never be given out to residents. On 7/6/2022 at 9:17 AM, during a concurrent telephone interview and review of Resident 1's CNA Activities for Daily Living (ADL) Worksheet for 6/2022 with the DSD, indicated CNA 1 performed ADL-Bathing to Resident 1 on 6/13/2022 (Monday) at 12 PM and 6/14/2022 (Tuesday) at 10:59 PM. The DSD stated the set schedule for Resident 1's shower was Mondays and Thursdays. During a telephone interview with the ADM on 7/6/2022 at 12:53 PM, the ADM stated he had a final interview with CNA 1, CNA 1 could not articulate why he did not tell the ADM all the details of what had happened during the alleged incident. The ADM stated that when he questioned CNA 1 again, CNA 1 responded I don't know, I did not have anything to hide. The ADM stated CNA 1 stated It wasn't a big deal, I finished showering her and it was quick. The ADM stated CNA 1 was suspended again on 6/28/2022 and was terminated from the facility on 7/5/2022. A review of the facility's policy and procedure titled Abuse Prevention Program dated 12/2016 indicated residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation, included but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse. The policy and procedure indicated as a part of the resident abuse prevention, the administration will protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. The policy and procedure indicated facility will require staff training/orientation programs that include such topics as abuse prevention, identification and report of abuse, stress management, and handling verbally or physically aggressive resident behavior.

Based on record and review and interview, the facility failed to ensure that one of six sampled residents (Resident 1), who was receiving [MEDICAL TREATMENT] (a procedure to remove fluids and toxins from the blood), received care and services according to Resident 1's plan of care and facility's policy and procedure. Resident 1's [MEDICAL TREATMENT] on the left upper arm (LUA)was not assessed and had no assessment documentation for bleeding, drainage, bleeding, redness, swelling, pain, bruit (swishing sounds heard with a stethoscope), thrill (vibration felt through palpation), and dressing site on admission and after [MEDICAL TREATMENT] treatment that started at 6:47 p.m. for three hours on [DATE] and between 5:45 a.m. and 9:10 a.m., on [DATE]. This deficient practice resulted in Resident 1 bleeding profusely (large amount) from her arteriovenous fistula (AV, an abnormal connection between an artery and a vein) on the LUA on [DATE] at 9:15 a.m. The facility staff found Resident 1 unresponsive (not replying or reacting to someone's question, request, demand) in her room. Cardiopulmonary resuscitation (CPR, an emergency procedure to attempt to revive a person in [MEDICAL CONDITION]) was initiated, and 911 (medical telephone emergency) was called. The paramedics were at the resident bedside at 9:27 a.m. The heart monitor indicated no heartbeat, and Resident 1 was pronounced dead in the facility on [DATE] at 9:47 a.m. Findings: A review of Resident 1's Admission Record indicated the facility admitted the resident on [DATE] and readmitted her on [DATE] (Monday) with [DIAGNOSES REDACTED]. A review of Resident 1's care plan initiated on [DATE], titled Resident Needs [MEDICAL TREATMENT], related to renal (kidney) failure indicated Resident 1 received [MEDICAL TREATMENT] treatment at 2:00 p.m. every Monday, Wednesday and Friday. The care plan interventions indicated the staff would monitor/document/report as necessary (prn) including changes in level of consciousness or bleeding. A review of Resident 1's Minimum Data Set (MDS - standardized assessment and care-planning tool) dated [DATE] indicated Resident 1 had severe cognition (ability to think and process information) impairment, cued to recall a piece of furniture, and dependent/required full staff support for bed mobility, transfers, toileting, and personal hygiene. Resident 1 did not walk and used a wheelchair for mobility. A review of Resident 1's physician's orders [REDACTED]. A review of Resident 1's Progress Notes dated [DATE] and timed 8:21 p.m. indicated the facility admitted Resident 1 from a general acute care hospital (GACH 1). There was no documentation Resident 1's AV fistula on the LUA was assessed upon admission for bleeding, drainage, bleeding, redness, swelling, pain, bruit, thrill, and dressing site. A review of Resident 1's GACH 1 medical record for [MEDICAL TREATMENT] indicated Resident 1's [MEDICAL TREATMENT] treatment was started on [DATE] at 6:47 p.m. for a duration of three hours. A review of the facility's Nurse's [MEDICAL TREATMENT] Communication Record indicated Pre-[MEDICAL TREATMENT] Assessment and Facility's Post [MEDICAL TREATMENT] Check to be completed by the facility's licensed nurse and to check access site for bleeding, drainage, redness, swelling, pain, bruit, thrill, and dressing site. A review of Resident 1's medical records indicated no documentation for a Nurse's [MEDICAL TREATMENT] Communication Record for post [MEDICAL TREATMENT] check that included assessment to check Resident 1's AV fistula for bleeding, redness, swelling pain, bruit, thrill, and dressing site after admission on [DATE] at 8:21 p.m. A review of Resident 1's Progress Notes dated [DATE] timed 5:04 a.m. completed by Licensed Vocational Nurse 2 (LVN 2) indicated Resident 1 was sleeping, easily arousable to tactile (touch) and verbal stimuli (stimulation). Resident 1 was not in distress or discomfort. Resident 1's AV fistula on the LUA was intact with bruit and thrill. No signs and symptoms of infection or active bleeding, temperature (T) 98.1, pulse (HR, heart rate) 76, respiration (RR) 18 and blood pressure (BP) ,[DATE]. A review of Resident 1's VCSL-SBAR/COC record, dated [DATE] and timed 10:44 a.m. completed by Registered Nurse 2 (RN 2) indicated Resident 1 was found unresponsive in her room, Life saving measures initiated, and unable to appreciate the resident's vital signs on [DATE]. The record indicated that at 9:15 a.m. Resident 1 was found bleeding profusely from the AV fistula on the LUA, pressure applied, and tourniquet applied above AV fistula site. At 9:20 a.m., Resident 1's oxygen saturation (a measurement of your blood oxygen) was at 82 percent (%) reference range (95% to 100%). Oxygen was administered at 15 liters per minute (LPM) via a non-rebreather mask and cardiopulmonary resuscitation (CPR, an emergency procedure that combines chest compressions and ventilation to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person who is in [MEDICAL CONDITION]) was initiated. Resident 1 was still bleeding from AV fistula site on the LUA. At 9:22 a.m., the paramedics arrived at the bedside. At 9:30 a.m., an intravenous (IV, into vein) was started at Resident 1's right lower leg and normal saline solution was administered. At 9:47 a.m., Resident 1 was in asystole (no heartbeat), on cardiac (heart) monitor and Resident 1 was pronounced dead by 9:47 a.m. A review of emergency response service (EMS, a system that provides emergency medical care) 911 run sheet dated [DATE] indicated Resident 1 was last seen normal by staff at 8:00 a.m. The run sheet indicated at 9:15 a.m., the resident was found unresponsive by staff with profuse (excessive) bleeding from [MEDICAL TREATMENT] fistula. The run sheet indicated Resident 1 pulled the fistula out and lost a, large amount of blood and that the area appeared to have been cleaned with ammonia (colorless gas with a characteristic pungent smell). Resident 1 did not have blood pressure or pulse (heart rate) from 9:27 a.m. to 9:45 a.m. During a telephone interview, on [DATE] at 7:54 a.m., the Occupational Therapist (OT) stated, on [DATE] at around 9:00 a.m., she observed Resident 1 in bed and thought the resident was sound asleep. However, the OT stated she noticed the resident's top blanket stained with blood, pulled back the blanket and saw a pool of blood on the resident's left trunk and the bottom sheet soaked with blood. The OT stated Resident 1 looked pale, like white color, and felt warm to touch. The OT stated she immediately called for help. During a telephone interview on [DATE] at 8:06 a.m., Certified Nurse Assistant 1 (CNA 1) stated on [DATE], he reported to work at 7:00 a.m. CNA1 stated at 8:00 a.m., he made rounds by walking in and out of the residents' rooms on assigned residents including Resident 1. CNA 1 stated at 8:55 a.m., he took his break and returned at 9:15 a.m. CNA 1 stated at 9:20 a.m., a therapist (did not know the name) came from Resident 1's room and stated the resident was bleeding. CNA 1 stated Resident 1's left side soaked in blood from under the arm to the waist line. CNA 1 stated he called LVN 1, called code blue (emergency response), brought oxygen, and started performing cardiopulmonary resuscitation. CNA 1 stated another CNA, LVN 1 and himself were the only staff in the room performing CPR on Resident 1. CNA 1 did not state Resident 1 received oxygen during CPR after asked multiple times or the AV fistula ruptured (break open). During a telephone interview on [DATE] at 8:21 a.m., LVN 1 stated she reported to work at 8:15 a.m., Because I was late. LVN 1 stated LVN 2 handed over that the facility admitted Resident 1 after [MEDICAL TREATMENT] treatment on [DATE] at 8:21 p.m., LVN 1 stated she did not assess Resident 1's [MEDICAL TREATMENT] during rounds and before medication administration. LVN 1 stated she started medication pass at 8:25 a.m. after making rounds. LVN 1 stated the OT alerted her that Resident 1's LUA was bleeding. LVN 1 stated Resident 1 had significant amount of blood on the bed and gown. LVN 1 stated she applied pressure to Resident 1's LUA. LVN 1 stated Resident 1 had a low oxygen saturation (amount of oxygen in the blood) 87 %. LVN 1 stated she called for help and one of the nurses applied pressure to Resident 1's LUA and relieved each other with the chest compressions. LVN 1 did not mention Resident 1's AV fistula ruptured. During an interview on [DATE] at 7:32 p.m., the Director of Nurses (DON) stated the Occupational Therapist (OT) found Resident 1 unresponsive and bleeding. The DON stated the licensed nurses must check Resident 1's LUA [MEDICAL TREATMENT] for thrill and bruit, signs of infection, pain, [MEDICAL CONDITION] (swelling) and or bleeding, assess Resident 1 for signs and symptoms of distress, and document on the progress notes every shift. Concurrently, a review of the Nurses' Progress Notes dated [DATE] timed 5:04 a.m., indicated the resident's AV fistula had a bruit and thrill. The DON stated there was no further assessment of the resident's AV fistula and or resident assessment done/documented until [DATE] at 5:04 a.m. The DON stated four hours had passed before the facility's staff identified Resident 1 was bleeding from AV fistula site. During a telephone interview on [DATE] at 1:01 p.m., Registered Nurse 2 (RN 2) stated a staff from the rehabilitation department and another nurse informed her that there was an emergency due to Resident 1's bleeding. RN 2 stated she immediately went to the resident's bedside, the resident was unresponsive and was bleeding a lot from the LUA fistula. RN 2 stated LVN 1 applied pressure on Resident 1's LUA and another licensed nurse applied a tourniquet (any device for arresting bleeding by forcibly compressing a blood vessel, as a bandage tightened by twisting) above the fistula. RN 2 stated LVN 1 and a certified nurse assistant (CNA) started performing cardiopulmonary resuscitation. RN 2 stated Resident 1 did not have a blood pressure, heart rate, respiration rate, and temperature. A review of Resident 1's Certificate of Death, indicated the resident died on [DATE] at 9:15 a.m., and cause of death listed as: cardiopulmonary arrest (abrupt loss of heart function, breathing and consciousness), exsanguination (the action of draining a person, animal, or organ of blood) line to ruptured left arm [MEDICAL TREATMENT] graft, and acute (sudden) [MEDICAL CONDITION] infarction ([MEDICAL CONDITION]). The certificate of death indicated Resident 1 had left arm [MEDICAL TREATMENT] fistula placement on [DATE]. Resident 1's physician signed the certificate of death on [DATE]. During a telephone interview, on [DATE] at 8:25 a.m., the Responsible Party (RP) stated Resident 1 had the AV fistula created on [DATE]. RP stated the facility admitted Resident 1 on [DATE] at 8:00 p.m., and the dressing remained clean, dry and intact pressure dressing on the resident's LUA remained clean, when RP left the facility. RP stated RN 2 contacted her on [DATE] at 9:15 a.m. and stated Resident 1 had massive bleeding on the [MEDICAL TREATMENT]. During a telephone interview with Resident 1's Physician (Physician 2) on [DATE] at 4:09 p.m., the Physician 2 stated the facility either phoned him or sent him a text on [DATE] that indicated Resident 1 died . The Physician 2 stated the facility indicated the resident bled from [MEDICAL TREATMENT] site. The Physician 2 stated Resident 1 died from severe [MEDICAL CONDITION] due to severe bleeding. The Physician 2 stated he completed the resident's certificate of death. During a telephone interview on [DATE] at 3:51 p.m. the Assistant Director of Nurses (ADON) stated the facility uses the Nurse's [MEDICAL TREATMENT] Communication Record for Residents who are dialyzed at a contracted [MEDICAL TREATMENT] center. The ADON stated licensed nurses and CNAs check on all residents' [MEDICAL TREATMENT] and check on each resident to identify any needs and concerns at the beginning of each shift and every two hours. During a telephone interview and concurrent record review of the facility's Nursing [MEDICAL TREATMENT] Communication Record, on [DATE] at 10:19 a.m., the DON stated the Nursing [MEDICAL TREATMENT] Communication Record was completed after a resident return back from [MEDICAL TREATMENT]. The DON stated after the post [MEDICAL TREATMENT] check was completed, the [MEDICAL TREATMENT] was checked every shift. A review of the facility's policy and procedure, titled [MEDICAL TREATMENT] Access Care Steps in the Procedure Care of AVFs and AVGs revised date ,[DATE] indicated to check for signs of infection (warmth, redness, tenderness, or [MEDICAL CONDITION]) at the access site when performing routine care and at regular intervals. A review of the facility's End-State [MEDICAL CONDITION], Care of a Resident, revised date, ,[DATE], indicated education and training of staff include a type of assessment data that was to be gathered about the resident's condition on a daily or per shift basis. The education and training included recognizing and intervening in medical emergencies such as hemorrhage (bleeding). A review of the facility's policy and procedure, titled Routine Resident Checks revised ,[DATE] indicated the staff shall make routine resident checks to help maintain resident safety and well-being. Routine checks involve entering the resident's room to determine if the resident's needs are being met, and identify any change in the resident's condition.

Based on interview, and record review, the facility failed to provide appropriate skin and wound assessment and care and treatments, for one out of two sampled residents (Resident 1) by failing to: 1. Provide wound and skin treatments as ordered by Resident 1's physician, in accordance with the plan of care. 2. Assess and document Resident 1's skin condition thoroughly. 3. Reassess Resident 1's pain levels after the administration of a pain relief medication, [MEDICATION NAME] 325 milligrams (mg) two tablets on 11/28/17. 4. Assess Resident 1's pain level (a rating scale to describe pain as no pain, mild pain, moderate pain, and severe pain) on 12/1/17 (from 11p.m., to 7 a.m.) Resident 1 was noted with signs of grimacing and moaning and did not receive pain relief medication. 5. Administer pain relief medication to Resident 1 as needed for pain when the resident showed signs of pain, such as grimacing and moaning. 6. Clarify the pain relief medication order with Resident 1's physician to adequately manage Resident 1's pain levels. These deficient practices resulted for Resident 1 to experience pain; wound progression from redness to unstageable pressure injury (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough (a mass of dead tissue separating from an ulcer) or eschar (dead tissue)); admission to an intensive care unit ((ICU), a unit that caters to patients with severe and life-threatening illnesses and injuries) at a general acute care hospital (GACH) on 12/5/17 with [DIAGNOSES REDACTED]. Findings: During an interview, on 2/7/18 at 2:10 p.m., a licensed vocational nurse (LVN 2) stated that the facility sometimes did not have enough wound treatment supplies to do treatments. LVN 2 stated that on 12/2/17, he was assigned to do wound treatments for Resident 1 and that he (LVN 2) did not complete the wound treatments for Resident 1. LVN 2 stated that he (LVN 2) did not remember the reason as to why the wound treatments were not done as ordered by the physician. A review of Resident 1's Admission Record indicated that the resident was admitted on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set ((MDS), a resident assessment and care-screening tool), dated 10/16/17, indicated the resident had severe impairment in cognitive skills and was total dependent with transfers, eating, toilet use and personal hygiene. The MDS indicated Resident 1 had one Stage I pressure ulcer (intact skin with non-blanchable redness of a localized area usually over a bony prominence). The MDS indicated that Resident 1 did not have unstageable pressure ulcers and that Resident 1 did not have any other ulcers, wounds or skin problems. A review of Resident 1's Risk for Pressure Ulcer Skin Breakdown, dated 11/19/17, indicated the resident was at risk for impaired skin integrity, skin breakdown, pressure ulcers, and the interventions were to perform skin maintenance and treatment as ordered. A review of Resident 1's Initial History and Physical, dated 11/20/17, indicated that the resident did not have the capacity to understand and make decisions. A review of Resident 1's Monthly Record of Vital Signs and Weights, dated (MONTH) (YEAR) (the date was not specified), indicated that Resident 1 weighed 64 pounds. A review of Resident 1's Short Term Goals, dated 11/20/17, indicated that rashes were noted in Resident 1's general body and the interventions were to provide protective treatment as ordered. a. Wounds/treatments: A review of Resident 1's Order Summary Report (a summary of the physician's orders [REDACTED]. (1). Cleanse with normal saline ((NS), sterile solution), pat dry with gauze the [MEDICAL CONDITION] site, change bag twice daily and PRN soilage, with an order date of 11/19/17. (2). Triple antibiotic (a medication that helps to prevent infection and provide temporary pain relief in minor cuts, scrapes, and other first aid emergencies) daily to the multiple abrasions on the left arm for fourteen days and to leave it open to air, with an order date of 11/20/17. (3) Triple antibiotic daily to left ear lobe redness daily for thirty days, with an order date of 11/20/17. (4). Triple antibiotic daily to the right earlobe redness daily for thirty days, with an order date of 11/20/17. (5). Triple antibiotic daily to the multiple abrasions (area on the skin, or some other surface of the body, that has been damaged by scraping or rubbing) on the right arm for fourteen days, with an order date of 11/20/17. (6). Zinc oxide (a skin moisture barrier cream) to abdomen redness twice daily for thirty days, with an order date of 11/20/17, and timed at 8 a.m. (7). Skin lotion, to left scapula (shoulder blade) pressure injury and to cover with silicone foam dressing (sterile dressing helps maintain a moist wound healing environment with no irritation upon removal, minimizes trauma to the wound, and reduces pain during dressing changes) every seven days or as needed (PRN) for thirty days daily for thirty days, with an order date of 11/21/17. (8). Zinc oxide to coccyx pressure injury and to cover with silicone foam dressing daily and PRN for thirty days, with an order date of 11/21/17. The Skin and Pressure Ulcer Record, dated 11/20/17, which was completed by a licensed nurse, indicated Resident 1 had a Stage III pressure ulcer (full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible) in the coccyx. The surgical and wound care notes, dated 11/21/17, which was completed by a physician, indicated the resident had a Stage II pressure ulcer (partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. (9). [MEDICATION NAME] Dp ([MEDICATION NAME]) 0.05% cream (a corticosteroid used on the skin to treat swelling, redness, itching, and allergic reactions) twice daily for thirty days for general body rash, with an order date of 11/22/17. (10). Cleanse with NS, pat dry, and apply duoderm (wound dressing) around the stoma (an opening), apply xeroform (dressing gauze) on the reddened area of the right lower quadrant [MEDICATION NAME] (pertaining to the area of skin surrounding a stoma in the abdominal wall) skin redness, cover daily, and change every three days for thirty days, with an order date of 11/28/17. A review of Resident 1's MDS dated [DATE], indicated Resident 1 had one Stage II pressure ulcer and one Stage III pressure ulcer. The MDS indicated that Resident 1 did not have unstageable pressure ulcers and that Resident 1 did not have any other ulcers, wounds or skin problems. During a review of Resident 1's Treatment Record and Profile Record, on 2/7/18 at 1:17 p.m., LVN 1 stated that Resident 1's Treatment Record and Profile, for (MONTH) (YEAR), indicated that Resident 1 did not receive [MEDICAL CONDITION] treatment as ordered twice daily (for 11 days), did not receive treatment for [REDACTED]. Resident 1 received A & D ointment (a skin protectant) on both earlobes instead of the triple antibiotic as ordered. LVN 1 stated that treatments were supposed to be done to prevent further skin damage and prevent potential infection. LVN 1 stated that vitamin A & D was for skin maintenance and that triple antibiotic was for infection. During the concurrent interview, LVN 1 stated that there was a discrepancy between Resident 1's Admission Assessment, dated 11/20/17, and Resident 1's Order Summary for (MONTH) (YEAR) regarding Resident 1's right scapula injury because Resident 1's Order Summary did not have orders to treat Resident 1's right scapula injury stage II (partial thickness loss of dermis presenting as a shallow open ulcer), and that the Admission Assessment form was not specific as how many Stage III sacrococcyx injuries Resident 1 had. During the concurrent interview, LVN 1 stated that Resident 1's Treatment Record and Profile for (MONTH) (YEAR), indicated that Resident 1 did not receive left ear lobe treatments (4 days), abdominal redness treatments (4 days), and that on 12/2/17 Resident 1 did not receive treatments for [MEDICAL CONDITION] care, right ear lobe, right arm abrasions, and body rash as indicated ordered. During an interview, on 2/7/18 at 3:53 p.m., the director of nursing (DON) stated that the facility did not take any photos of Residents' skin conditions for legal purposes because the nurses did not know how to describe the wounds. b. Pain: A review of Resident 1's Physician and Telephone Orders, dated 11/28/17, and timed at 2 p.m., indicated for Resident 1 to receive [MEDICATION NAME] 325 mg two tablets every 6 hours as needed for pain. The Physician and Telephone Orders did not specify the pain parameters that indicated what pain levels to treat. A review of Resident 1's untimed Change of Condition (C[NAME]) SBAR-Pain (Situation, Background, Assessment Recommendation - a tool to share patient information in a clear, complete, concise and structured format; improving communication efficiency and accuracy), dated 11/28/17, indicated that Resident 1 was noted with facial grimacing and moaning with a pain level of 6/10 and the resident received [MEDICATION NAME] 325 mg two tablets. The Change of Condition SBAR-Pain record did not indicate if Resident 1's pain level was reassessed after the administration of [MEDICATION NAME] 325 mg two tablets. A review of Resident 1's C[NAME] SBAR Progress Notes, dated 12/1/17 and timed from 11 p.m. to 7 a.m., indicated that Resident 1 showed signs of grimacing and moaning many times throughout the night. The C[NAME] SBAR Notes did not indicate that Resident 1 was assessed for pain and that Resident 1 did not receive pain relief medications. During a review of Resident 1's record with LVN 1, on 2/7/18 at 1:40 p.m., LVN 1 stated that Resident 1's Pain Assessment Record, dated 11/28/17, did not reflect Resident 1's 6/10 pain level and that there was no written evidence that Resident 1 as reassessed for pain. LVN 1 stated that Resident 1's Pain Assessment Record dated 12/1/17, did not reflect Resident 1's moaning and grimacing. LVN 1 stated that moaning and grimacing were signs and symptoms of pain and that the nurses should have assessed Resident 1 for pain. During a telephone interview, on 3/3/18 at 9:12 p.m., a registered nurse (RN 1) stated that licensed nurses were supposed to verify Resident 1's Physician and Telephone Orders, dated 11/28/17, and timed at 2p.m., for [MEDICATION NAME] 325 mg two tablets every six hours PRN pain because the orders did not indicate which pain levels to treat. A review of Resident 1's Licensed Personnel Progress Notes, dated 12/5/17, and time at 8:15 a.m., indicated that the resident was noted with labored breathing and his oxygen saturation (a measure of how much oxygen the blood is carrying as a percentage of the maximum it could carry) was at 75% (normal range 95%-100%) and that 911 (an emergency service) was called. A review of Resident 1's GACH History and Physical, dated 12/5/17 and timed at 1:40 p.m., indicated that the resident was admitted to ICU with [DIAGNOSES REDACTED]. A review of Resident 1's untimed GACH Infectious Disease Consultation, dated 12/5/17, indicated that Resident 1 had diffuse (spread over a wide area) maculopapular rash (both flat and raised [MEDICAL CONDITION] a marker for many diseases, allergic reactions, and infections, most of the time, the cause is a [MEDICAL CONDITION] infection and could indicate a serious disease). A review of Resident 1's GACH record Initial Impaired Skin Integrity Form, dated 12/5/17, indicated the following: a. Resident 1's left elbow had an abrasion with full thickness tissue loss in the wound bed (actual depth of the wound is completely obscured by slough and/or eschar) present on admission. This was a wound progression from abrasion to abrasion with full thickness tissue loss in wound bed. b. Resident 1's left ear had an unstageable pressure injury present on admission. This was a wound progression from redness to unstageable pressure injury. c. Resident 1's right ear had abrasion with full thickness tissue loss on admission. This was a wound progression from right ear lobe redness to abrasion with full thickness tissue loss. d. Resident 1's right side of torso (trunk of the human body) had moisture associated [MEDICAL CONDITION] (inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or mucus) with partial thickness tissue loss present on admission. This was a new skin condition for the resident. e. Resident 1's left upper back had abrasions with full thickness tissue loss on admission. f. Resident 1's right back had moisture associated [MEDICAL CONDITION] with partial thickness tissue loss present on admission. This was a new skin condition for the resident. g. Resident 1's sacrum coccyx had an unstageable pressure injury on admission. This was a wound progression from Stage II pressure ulcer to an unsteagable pressure ulcer. h. Resident 1's bilateral (both) buttocks had moisture associated [MEDICAL CONDITION] with partial thickness tissue loss (presents as a shiny or dry shallow ulcer without slough or bruising) on admission. This was a new skin condition for the resident. i. Resident 1's left hip had moisture associated [MEDICAL CONDITION] on admission. This was a new skin condition for the resident. A review of Resident 1's GACH record Initial Impaired Skin Integrity Form, dated 12/6/17, indicated the following: j. Resident 1's occiput (the back of the head or skull) had an abrasion with partial thickness tissue loss on admission. This was a new skin condition for the resident. k. Resident 1's left upper arm had abrasion with full thickness tissue loss on admission. A review of the facility's policy and procedure titled Pressure Ulcers Skin Breakdown, with a revised date of (MONTH) 2014, indicated that the nursing staff and attending physician would assess and document an individual's significant risk factors for developing pressure sores and the nurses should describe and document full assessment of pressure sore including, location, stage, length, width, and depth, pain assessment, and current treatments. The same Pressure Ulcers Skin Breakdown policy indicated that the physician would authorized pertinent order related to wound treatments, including wound cleansing and debridement approaches, dressings and application of topical agents if indicated for the type if skin alteration. A review of the facility's policy and procedure titled, Pain Assessment and Management, with a revised date of (MONTH) (YEAR), indicated that facility required licensed nurses to review the resident's clinical record to identify conditions or situations that might predispose the resident to pain including skin wounds conditions and that possible signs of pain were facial expressions such as grimacing, frowning, and to reassess the resident's pain. A review of the facility's policy and procedure titled, Medication, with a revised date of 2014, indicated that when recording PRN medication orders the licensed nurses were to specify type, route, dosage, frequency, strength, and the reason for administration, for example, Tylenol 500 mg by moth every four hours as needed for mild, pain.

Based on interview and record review, the facility failed to provide appropriate care and services to prevent and promptly treat signs and symptoms (s/s) of dehydration (a harmful reduction in the amount of water in the body) for one of two sampled residents (Resident 1) by failing to: 1. Follow Resident 1's Physicians orders to strictly monitor Resident 1's fluid intake and output ((I&Os) measurement of a patient's fluid intake by mouth, feeding tubes, or intravenous catheters, and output (amount of urine and fluid a resident excretes) from kidneys, gastrointestinal tract, drainage tubes, and wounds). 2. Ensure that Resident 1 received the recommended fluid intake of a minimum of two liters (2000 milliliters (ml)) per day as ordered by Resident 1's Physician. 3. Appropriately assess and document Resident 1's urine color, character, output, and s/s dehydration. These deficient practices resulted in Resident 1 not receiving the recommended fluid intake, and the resident was hospitalized due to dehydration, septic shock (life-threatening low blood pressure due to (sepsis) caused by an overwhelming immune response to infection), and urinary tract infection (UTI, an infection involving any part of the urinary system, including urethra, bladder, ureters, and kidney). Findings: A review of Resident 1's Admission Record indicated the resident was admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 1's admitting [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set ((MDS), a resident assessment and care-screening tool), dated 10/16/17, indicated that resident had severe impairment in cognitive skills and was total dependent with transfers, eating, toilet use and personal hygiene. A review of Resident 1's Initial History and Physical, dated 11/20/17, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1's Physician Order, dated 11/19/17, indicated for Resident 1 to receive strict intake and output with a minimum of two liters a day (2000 ml). A review of Resident 1's Physician and Telephone Orders, dated 11/20/17 and timed a 7 p.m., indicated for the licensed nurses to call Resident 1's physician at 8 a.m., to report I&Os. A review of Resident 1's Dehydration Risk Assessment, dated 11/19/17, indicated Registered Nurse 2 (RN 1) assessed Resident 1 at high risk for dehydration. Resident 1's dehydration risk score was 100 points (high risk = 50 points or above, moderate risk = 25-49 points, and low risk = 0-24 points). A review of Resident 1's Licensed Personnel Progress Notes, dated 12/5/17, and time at 8 a.m., indicated the resident was noted with labored breathing with oxygen saturation (a measure of how much oxygen the blood is carrying as a percentage of the maximum it could carry) of 75% (normal range 95%-100%). The progress notes indicated emergency service (911) was called. A review of Resident 1's Weekly Intake and Output Evaluation, dated 11/19/17 to 12/5/17 indicated the following: a. On 11/19/17, there was no record for intake and output. b. From 11/20/17 to 11/24/17, Resident 1's intake was 1,250 ml daily, and there was no record for output in ml. d. On 11/25/17, Resident 1's intake was 1,050 ml and there was no record for output in ml. e. On 11/26/17, Resident 1's intake was 1,250 ml and there was no record for output in ml. f. On 11/27/17, Resident 1's intake was 2,150 ml, and there was no record for output in ml. g. On 11/28/17, Resident 1's intake was 2,200 ml, and there was no record for output in ml. h. On 11/29/17, Resident 1's intake was 2,010 ml, and there was no record for output in ml. i. On 11/30/17, Resident 1's intake was 1,950 ml, and there was no record for output in ml. j. On 12/1/17, Resident 1's intake was 2,150 ml, and output was 800 ml. k.On 12/2/17, Resident 1's intake was 2,150 ml, and output was 625 ml. l. On 12/3/17, Resident 1's intake was 2,150 ml, and output was 700 ml. m.On 12/4/17, Resident 1's intake was 2,150 ml, and output was 780 ml. n. On 12/5/17, Resident 1's intake was 200 ml, and output was 200 ml. A review of Resident 1's Medication Administration Record [REDACTED]. A review of Resident 1's Medication Administration Record [REDACTED]. A review of Resident 1's Intake and Output Record, dated from 11/19/17 to 12/5/17, indicated the following sections were left blank: a. Average 24-hour intake: b. Average 24-hour output: c. Urine: color, odor, clarity, consistency d. Skin turgor (used clinically to determine the extent of dehydration or fluid loss in the body): e. [MEDICAL CONDITION] (condition characterized by an excess of watery fluid collecting in the cavities or tissues of the body): f. Mucous membrane (an [MEDICATION NAME] tissue that secretes mucus and that lines many body cavities): g. Symptoms of infections: h. Comments: Resident 1's intake, output, urine color, character, skin turgor, [MEDICAL CONDITION], mucous membrane, and the resident's symptoms of infection from 11/19/17 to 12/5/17 were not assessed A review of Resident 1's Monthly Record of Vital Signs and Weights, dated (MONTH) (YEAR), indicated that Resident 1 weighed 64 (sixty-four) pounds. During a telephone interview on 3/2/18 at 3:30 p.m., the facility's Acting Director of Nursing (ADON) stated that Resident 1's Intake and Output Record, dated from 11/19/17 to 12/5/17, was incomplete (16 days). The ADON stated the licensed nurses did not strictly monitor Resident 1's I&Os as ordered by the physician. The ADON stated the licensed nurse did not assess Resident 1's urine color, character, and output, skin turgor (used clinically to determine the extent of dehydration or fluid loss in the body), [MEDICAL CONDITION] (condition characterized by an excess of watery fluid collecting in the cavities or tissues of the body), or signs and symptoms of infection. During the concurrent telephone interview, the ADON stated Resident 1's Medication Record and Profile dated (MONTH) (YEAR) indicated that Resident 1 did not receive the recommended daily fluid intake. The ADON stated that s/s of dehydration included UTI, which could potentially lead [MEDICAL CONDITION], low blood pressure, and that the licensed nurses were supposed to ensure that Resident 1 received the recommended fluid intake to prevent dehydration, and the nurses were supposed to strictly monitor Resident 1's I&Os as ordered. During a telephone interview on 3/5/18 at 9:26 a.m., Resident 1's Physician (MD 1) stated he did not ensure whether Resident 1's I&Os were being monitored accurately. During a telephone interview on 3/7/18 at 8:45 a.m., the ADON stated that the Intake and Output Record was questionable and inaccurate. ADON stated that she did not know how the licensed nurses were able to measure Resident 1's output from 12/1/17 to 12/5/18. A review of Resident 1's Physician Order, dated 12/5/17, indicated to transfer to resident to an acute hospital via 911 (an emergency service) due to shortness of breath and oxygen desaturation (a measure of how much oxygen the blood is carrying as a percentage of the maximum it could carry). A review of Resident 1's general acute care hospital (GACH) Physician Consultation, dated 12/5/17, and timed at 11:46 p.m., indicated the resident was found with a significant alteration of level of consciousness prior to intubation (the introduction of a tube into a hollow organ (such as the trachea) to assist in breathing). The GACH Physician Consultation indicated Resident 1 was hypothermic (the condition of having an abnormally low body temperature, typically one that is dangerously low), and that his urine output has been only15 cc (cubic centimeter/ml). The GACH Physician Consultation indicated Resident 1 had [MEDICAL CONDITION] (low sodium level in the blood), and that very little information was provided from the facility. The GACH Physician Consultation indicated Resident 1was admitted to the intensive care unit ((ICU) cater to patients with severe and life-threatening illnesses and injuries) with [DIAGNOSES REDACTED]. Resident 1 was intubated on a ventilator (an appliance for artificial respiration (a respirator)). A review of the facility's policy and procedure titled, Intake Measuring and Recording, with a revised date of (MONTH) 2010, indicated that the purpose of the procedure was to accurately determine the amount of liquid a resident consumed in a 24 hour period. The policy indicated at the end of each shift staff to total the amounts of all liquids the resident consumed, record all fluid intake on the intake and output record in (ml). The policy indicated for staff to record the type of fluids consumed such as tea, milk, soup etc., and the signature and title of the person recording the data. According to https://www.mayoclinic.org/diseases-conditions/dehydration/symptoms-causes/syc- 086?p=1, indicated that dehydration can lead to serious complications, including UTI, electrolyte imbalance, such as with potassium and sodium, which could lead to involuntary muscle contractions and sometimes to a loss of consciousness, low blood volume shock (hypovolemic shock), one of the most serious, and sometimes life-threatening, complications of dehydration, occurs when low blood volume causes a drop in blood pressure and a drop in the amount of oxygen in the body. A review of the facility's policy and procedure titled, Nutrition and Hydration to Maintain Skin Integrity, with a revised date of (MONTH) 2010, indicated to ensure that the resident's intake of fluid was sufficient the amount of fluid needed to prevent dehydration and maintain health.

Based on interview and record review, the facility failed to ensure adequate supervision and assistance to prevent accidents as indicated in the comprehensive assessment and plan of care for one of three sampled residents with falls in a total of 27 sample residents (Resident 48). Resident 48 sustained a fall while using the toilet unassisted and unsupervised. This deficient practice resulted in Resident 48 sustaining a left [MEDICAL CONDITION]. Refer to F726 Findings: On 2/16/18 at 2:20 p.m., the Administrator was informed of a compliant investigation regarding Resident Accidents. A review of the Admission Record indicated Resident 48 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS - standardized assessment and care planning tool) dated 12/18/17, indicated Resident 48's cognition (reasoning) was impaired, was able to communicate, and required extensive assistance with one-person physical assist for transferring, walking, toilet use, and personal hygiene. A review of the Fall Risk assessment dated [DATE], indicated Resident 48's score was nine (score of 10 and above indicated high fall risk). A review of the Bowel and Bladder assessment dated [DATE] indicated Resident 48 was continent (able to control) of bowel and bladder functions. A review of the Care Plan dated 2/2/18, developed for Resident 48's risk for falls due to limited mobility, generalized weakness, poor balance and unsteady gait, indicated in the approaches to assist Resident 48 with walking and transfers. A review of the Care Plan dated 2/2/18 developed for Resident 48's bowel and bladder continent status, indicated in the approaches to assist Resident 48 to use the toilet as needed. A review of the Care Plan dated 2/2/18, developed for Resident 48's limitations with Activities of Daily Living (ADLs - such as: bed mobility, transfers, walking, personal hygiene, and toilet use), indicated in the approaches to assist Resident 48 to the toilet with one-person physical support. A review of the Report of Incident SBAR (Situation Background Assessment and Request/Response) - Actual or Suspected Fall form dated 2/8/18, indicated on 2/8/18 at 4:30 p.m., a staff nurse, Licensed Vocational Nurse 1 (LVN 1), observed Resident 48 sitting on the floor inside the bathroom beside his wheelchair. Resident 48 was unable to express why he was on the floor. The Situation section of the form, indicated Resident 48 sustained an unwitnessed/suspected fall from the toilet during self-transfer while going to the bathroom, and Resident 48 prior level of functioning was, needs assistance. The Background section indicated Resident 48 did not use assistive device and did not ask for assistance. The Assessment section indicated Resident 48 was oriented to person only, complained of pain to the left hip assessed as 3/10 (pain scale from zero to 10, zero indicating no pain and 10 the worst possible pain), and had no apparent physical injury. The Request/Response section indicated notification to Resident 48's attending physician (Physician 1) at 5 p.m. who ordered x-rays to both hip and spine. A review of the SBAR Progress Note date 2/8/18 timed at 4:30 indicated gentle passive/active range of motion to upper and lower extremities were rendered with pain 3/10 on the left hip. Resident 48 was unable to stand or walk and was put back in the wheelchair. At 4:40 p.m., RP visited and Resident 48 received two tablet of Tylenol 325 milligrams (mg) for pain. At 4:45 p.m. the x-rays were taken. At 6:15 p.m., Registered Nurse 4 (RN 4) obtained the faxed x-ray results and read there was no fracture. RN 4 relayed the results to Physician 1. However, a review of the x-ray of left hip dated 2/8/18 indicated a non-displaced (the bone cracks either part or the entire way through, but does move and maintains its proper alignment) fracture through the left femoral neck (broken bone on the upper portion of the thighbone near the hip). A review of the Licensed Personnel Progress Notes dated 2/13/18, timed at 10 a.m. indicated Resident 48 left to have a Computed Tomography scan (CT or CAT scan uses a combination of X-rays and a computer to create pictures of organs, bones, and other tissues. It shows more detail than a regular X-ray) of both hip at a General Acute Care Hospital (GACH). The CT scan result indicated displaced (the bone snaps into two or more parts and moves so that the two ends are not lined up straight) left femoral neck fracture. Resident 48 was then admitted to the GACH where he underwent surgical procedure on 2/14/18 to repair the [MEDICAL CONDITION]. A review of the GACH history and physical examination [REDACTED]. On 2/22/18 at 9 a.m., during an interview, RP stated the family was paying a private caregiver to care for Resident 48 from 10 a.m. to 4 p.m. because the nursing staff were too busy to attend Resident 38's needs. The RP stated on 2/8/18, Resident 48 told her he was using, The buzzer for someone to assist him to the toilet but no one came and he could not wait anymore and went to the restroom by himself and then he fell . The RP further stated RN 4 stated the X-ray results indicated there were no fractures but after the fall, Resident 48 would complain of pain when trying to stand and could not do his routine walking exercises. After four days, RP felt something was wrong and asked Physician 1 to order another type of X-ray to rule out a fracture. On 2/22/18 at 9:50 a.m., during an interview, Certified Nursing Assistant 6 (CNA 6 - who works the 3 p.m. to 11 p.m., and was assigned to care for Resident 48 when the fall occurred) stated that prior to the fall, Resident 48 used the call light when in bed and needed assistance to the bathroom. CNA 6 stated Resident 48 was able to walk using a walker or a wheelchair with one-person physical assist. CNA 6 stated she did not hear Resident 48's call light because she was in the break room. On 2/22/18 at 10:34 a.m., during an interview, RN 4 stated he was the RN supervisor when Resident 48 fell and he received the X-ray results by fax. RN 4 stated he read the results over the telephone to the physician and did not notice the report indicated there was a non-displaced fracture to the left hip. During an interview on 2/22/18, at 11:10 a.m., the Director of Nursing (DON) stated Physician 1 called, after the CT scan result showed a left [MEDICAL CONDITION], asking to check the X-ray result on 2/8/18, that was reported to him as showing no fracture. The DON stated she reviewed the X-ray report and it indicated there was a left hip non-displaced fracture. During an observation on 2/22/18 at 1:43 p.m., Resident 48 was in his wheelchair with the private caregiver. During a concurrent interview, with the caregiver as translator, Resident 48 stated he was calling for help to go to the restroom but did not get any help. He went to the restroom alone and fell . Resident 48 was not able to walk after the fall. On 2/22/18 at 6 p.m., during an interview, LVN 1 stated she worked the 7 a.m. to 3 p.m., and on 2/28/18, she was on her way out walking in the hallway and noticed the call light on outside Resident 48's room. Upon entering the room, she could see Resident 48's legs outside the restroom and summoned help.

Based on interview and record review, the facility failed to provide appropriate treatment and care for one of 27 sampled residents (Resident 61) for the management of diabetes (disease in which the body's ability to produce or respond to the hormone insulin is impaired) by failing to: 1. Administer insulin (medication to treat diabetes mellitus) per physician's orders [REDACTED].>2. Communicate changes in Resident 61's insulin orders from the diabetic specialist with the primary physician to ensure continuity of care. 3. Communicate with Resident 61's Diabetic NP regarding changes in condition for [DIAGNOSES REDACTED] (low blood sugar) to provide continuity of care. As a result, Resident 61 experienced multiple changes in condition, including: 1. Sluggishness and over-sleepiness on 1/21/18 2. Increased confusion, forgetfulness, and jerky body movements on 1/25/18 3. Low oxygen saturation level to 80% (Normal 95-100%) with decreased appetite, shakiness, and altered mental status on 1/26/18 4. [DIAGNOSES REDACTED] of 66 milligrams per deciliter (66 mg/dL) on 1/27/18 5. [DIAGNOSES REDACTED] of 54 mg/dL on 2/6/18 6. [DIAGNOSES REDACTED] of 50 mg/dL on 2/16/18 Findings: A review of the Admission Record indicated Resident 61 was admitted to the facility on [DATE] from a general acute care hospital (GACH 1) and was re-admitted on [DATE]. Resident 61's [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS - a standarized, comprehensive assessment and care planning tool), dated 9/13/17 and 12/22/17, indicated Resident 61 participated in the assessment and was able to make decisions and had no memory problems. A review of the facility's policy and procedure, titled, Nursing Care of the Resident with Diabetes Mellitus revised (MONTH) (YEAR), indicated [DIAGNOSES REDACTED] signs and symptoms included weakness, dizziness, or faintness; restlessness and/or muscle twitching; [MEDICAL CONDITION](increased heart rate); pale, cool, moist skin; excessive perspiration; irritability or bizarre changes in behaviors; blurred or impaired vision; headaches; numbness of the tongue and lips/thick speech; stupor, unconsciousness and/or convulsions; and coma. A review of the Report of Incident SBAR (Situation, Background, Assessment, Response/Request) for Actual or Suspected Fall, dated 12/10/17 at 12:45 p.m., indicated Resident 61 had an unwitnessed fall from the bed while attempting to reach for an object. Resident 61 was found lying on the floor next to the bed, complaining of left leg pain. Resident's blood sugar was not assessed. MD 2 was notified and provided orders to send Resident 61 to the hospital. A review of the physician's orders [REDACTED]. A review of the Orthopedic Consultation from GACH 2, dated 12/11/17, indicated Resident 61 had a left proximal tibial fracture (break of the lower leg bone, near the knee). A review of the Admission Record indicated Resident 61 was re-admitted to the facility on [DATE]. A review of the physician's admission orders [REDACTED] [MEDICATION NAME] Insulin 35 units SQ before breakfast; [MEDICATION NAME] Insulin 25 units SQ at bedtime; Fingerstick blood sugar monitoring daily before meals and at bedtime; and Humolog Insulin administration as follows for blood sugar: - 101-150: No coverage - 151-200: 2 units SQ - 201-250: 4 units SQ - 251-300: 6 units SQ - 301-350: 8 units SQ - Notify physician if blood sugar is below 70 or above 450 - (MONTH) give orange juice by mouth if blood sugar is below 70 - (MONTH) administer [MEDICATION NAME] 1 mg IM if blood sugar is below 70 and unable to swallow - (MONTH) give Glucogel 1 tube if blood sugar is below 70 and able to swallow A review of the physician's orders [REDACTED]. A physician's orders [REDACTED]. Inject [MEDICATION NAME] solution 40 units SQ at 7 a.m., Inject [MEDICATION NAME] solution 35 units SQ at 7 p.m., and check blood sugar before meals and at bedtime with sliding scale of [MEDICATION NAME]with the following parameters: - 80-100: 3 units SQ - 101-150: 6 units SQ - 151-200: 8 units SQ - 201-250: 10 units SQ - 251-300: 12 units SQ - 301-350: 14 units SQ - 351-400: 16 units SQ - 401-450: 18 units SQ - Greater than 450: 20 units and call physician - Hold sliding scale if resident did not eat his meals - Notify physician if blood sugar is below 70 or above 450 - (MONTH) give orange juice by mouth if blood sugar is below 70 - (MONTH) administer [MEDICATION NAME] 1 mg IM if blood sugar is below 70 and unable to swallow - (MONTH) give Glucogel 1 tube if blood sugar is below 70 and able to swallow During an interview on 2/16/18 at 3:42 p.m., LVN 10, the unit manager, stated that he confirmed Resident 61's new insulin order on 1/4/18 with Diabetic NP. LVN 10 was unable to locate the Diabetic NP's progress notes in Resident 61's clinical record. LVN 10 stated he had never seen a sliding scale like Resident 61's. LVN 10 stated that precautions involved with Resident 61's sliding scale included monitoring of hypoglycemic reaction, such as lethargy, perfuse sweating, and change of behavior. A review of the Diabetic NP Progress Note, dated 1/4/18, indicated Diabetic NP sent orders to the facility and attempted to call MD 2 to discuss care and rationale for adjustment. There was no indication/evidence whether Diabetic NP actually spoke with MD 2. A review of the MAR for 1/21/18 indicated Resident 61's blood sugar was 135 mg/dL at 6:30 a.m., requiring administration of six (6) units of insulin. A review of the MAR indicated [REDACTED] A review of the ADL (Activities of Daily Living) Tracking Form for 1/21/18 indicated Resident 61 refused breakfast. During an interview on 2/22/18 at 1:32 p.m., Diabetic NP stated that it was important to ensure the food was directly in front of Resident 61 prior to administrating the insulin to prevent [DIAGNOSES REDACTED]. A review of the facility's Change of Condition SBAR for Acute Change of Condition, dated 1/21/18 at 3 p.m., indicated Resident 61 had sluggishness and over-sleepiness. MD 2 was notified and provided an order to hold narcotics (drugs, such as opioids, that dull the sense, relieves pain, and induces profound sleep) to prevent over-sedation. A review of the MAR for 1/23/18 at 11:30 a.m. indicated Resident 61's blood sugar was 130 mg/dL. No insulin was administered. A review of the facility's Change of Condition SBAR for Acute Change of Condition, dated 1/25/18 at 8:00 a.m., indicated Resident 61 had increased confusion, forgetfulness, scattered thought, and increased involuntary jerky body movements. Resident 61's blood sugar was not taken at the time of the change of condition. A review of Change of Condition SBAR Progress Notes, dated 1/25/18 at 8:00 a.m., indicated the licensed nurse observed Resident 61 with occasional increased confusion, forgetfulness, scattered thought, and increased prominent involuntary jerky generalized body movements. The licensed nurse indicated that there were no signs or symptoms of hypo or [MEDICAL CONDITION] at this time. A review of the MAR indicated [REDACTED]. The facility's Change of Condition SBAR for Acute Change of Condition, dated 1/25/18 at 1:30 p.m., indicated the licensed nurse indicated Resident 61 continued to have increased involuntary and jerky generalized body movements. The licensed nurse called MD 2 and left a message on voicemail. On 1/25/18 at 2 p.m., MD 2 called back and was notified regarding Resident 61's condition, including behavioral changes and increased involuntary jerky movements. MD 2 provided a new order to make an appointment with a neurologist. A review of the Diabetic NP Progress Notes, dated 1/25/18, indicated a plan to continue on insulin. No changes were made to the insulin regimen. There was no indication that Diabetic NP was aware of Resident 61's change of condition in the morning. The MAR indicated [REDACTED]. On 1/25/18 at 9:00 p.m., Resident 61's blood sugar was 248 mg/dL, requiring 12 units of insulin. Further review of the Change of Condition SBAR Progress Notes for the Acute Change of Condition, dated 1/26/18 for the 11:00 p.m. to 7:00 a.m. shift, indicated Resident 61 continued to have increased involuntary jerky body movements with scattered thoughts. There was no indication of Resident 61's physician was notified of the continued involuntary movements 1/26/18 from the 11 p.m. to 7:00 a.m. shift. A review of the MAR indicated [REDACTED]. On 1/26/18 at 7:00 a.m., Resident 61 was given [MEDICATION NAME] 40 units. On 1/26/18 at 11:30 a.m., Resident 61's blood sugar was 170 mg/dL requiring eight (8) units of insulin. A review of the facility's Change of Condition SBAR for Respiratory, dated 1/26/18, indicated Resident 61 appeared lethargic at 3:00 p.m. On 1/26/18 at 4:00 p.m., Resident 61's sister called the facility after having a telephone conversation with the resident. Resident 61's family member asked the licensed nurse to send Resident 61 to the hospital for decreased appetite, shakiness, and altered mental status. The SBAR Progress Note indicated that the licensed nurse informed Resident 61's family member regarding to the process to send Resident 61 to the hospital, which included a licensed nurse assessment of resident and consultation with the physician. A review of the MAR indicated [REDACTED]. Further review of the Change of Condition SBAR Progress Notes indicated Resident 61's oxygen saturation was 80% on 1/26/18 at 5:00 p.m. Three liters (3 L) of oxygen was administered. MD 2 was notified and provided orders to transfer Resident 61 to the hospital for further evaluation. Resident 61 refused to transfer to the hospital. A review of the MAR indicated [REDACTED]. A review of the ADL Tracking Form, dated 1/26/18, indicated Resident 61 ate 90 percent of breakfast, refused lunch, and ate 100 percent of dinner. There was no indication Resident 61 was offered and provided nightly snacks. A review of the facility's Change of Condition SBAR for Hypoglycemic Episode, dated 1/27/18 at 12:00 a.m., indicated Resident 61 was sleeping with cold, clammy skin. Resident 61's blood sugar was 66 mg/dL and provided with [MEDICATION NAME] 1 mg IM. On 1/27/18 at 12:15 a.m., Resident 61's blood sugar was 78 mg/dL. On 1/27/18 at 12:30 a.m., Resident 61's blood sugar was 99 mg/dL. Resident 61 was offered snacks and juice to prevent drops in blood sugar. On 1/27/18 at 12:38 a.m., MD 2 was notified and stated to continue monitoring Resident 61. Further review of the SBAR Progress Notes indicated Resident 61's blood sugar was 48 mg/dL on 1/27/18 at 6:30 a.m. Resident 61 was provided with orange juice for low blood sugar. On 1/27/18 at 6:45 a.m., Resident 61's blood sugar was 61 mg/dL. On 1/27/18 at 7:00 a.m., Resident 61's blood sugar was 103 and breakfast was provided. On 1/27/18 at 7:05 a.m., MD 2 was notified regarding Resident 61's condition and provided new orders, which included: discontinue [MEDICATION NAME] 35 units at 7 p.m., administer [MEDICATION NAME] 30 units at 7 p.m., and labs for Hemoglobin A1C (lab test that indicates the average level of blood sugar over the past two to three months) in the morning. A review of the Resident 61's lab results, dated 1/31/18 indicated the Hemoglobin A1C level was 6.4 (reference range was less than 6.0). MD 2 was notified with no new orders. A review of the MAR for 2/6/18 at 6:30 a.m. indicated Resident 61's blood sugar was 94 mg/dL. No insulin was administered. On 2/6/18 at 11:30 a.m., Resident 61's blood sugar was 110 mg/dL. Four (4) units of insulin was administered. During an interview on 2/16/18 at 1:34 p.m., Licensed Vocational Nurse 6 (LVN 6) stated Resident 61 should have received three (3) units of insulin on 2/6/18 at 6:30 a.m. when blood sugar was 94 mg/dL. A review of the facility's Change of Condition SBAR for Hypoglycemic Episode, dated 2/6/18 at 5:30 p.m., indicated Resident 51 was sleeping in a geri-chair (large, padded, reclining chair). The licensed nurse attempted to wake Resident 61, however, Resident 61 was non-responsive. Resident 61's vital signs were assessed and blood sugar was taken. Resident 61's blood sugar was 54 mg/dL, requiring administration of [MEDICATION NAME] 1 ml IM as ordered. On 2/6/18 at 5:45 p.m., Resident 61's blood sugar rose to 154 mg/dL. A review of the Psychiatry Consultation, dated 2/6/18 at 6:00 p.m., indicated Resident 61 presented with aggressive behaviors, which included lashing out at staff and peers. However, Resident 61 denied having these problems. The Psychiatry Consultation indicated Resident 61 was presenting with hypoglycemic episode and indicated a plan to transfer Resident 61 to the emergency room . A review of the physician's orders [REDACTED]. A review of the History and Physical from GACH 3, dated 2/7/18, indicated Resident 61's regimen to manage diabetes, which included 40 units of [MEDICATION NAME] every morning and 30 units of [MEDICATION NAME] at lunch, was way too much. The plan included to check Resident 61's sugar before meals and at bedtime and to administer Insulin [MEDICATION NAME] (Humalog) with a correction scale. Resident 61 was re-admitted to the facility on [DATE]. A review of the physician's orders [REDACTED]. The physician's orders [REDACTED]. A review of the MAR for (MONTH) (YEAR) included continued orders for fingerstick blood sugar check before meals and at bedtime with sliding scale of [MEDICATION NAME]with the following parameters: - 80-100 mg/dL: 3 units SQ - 101-150 mg/dL: 6 units SQ - 151-200 mg/dL: 8 units SQ - 201-250 mg/dL: 10 units SQ - 251-300 mg/dL: 12 units SQ - 301-350 mg/dL: 14 units SQ - 351-400 mg/dL: 16 units SQ - 401-450 mg/dL: 18 units SQ - Greater than 450 mg/dL: 20 units and call physician - Hold sliding scale if resident did not eat his meals - Notify physician if blood sugar is below 70 mg/dL or above 450 mg/dL (MONTH) give orange juice by mouth if blood sugar is below 70 mg/dL - (MONTH) administer [MEDICATION NAME] 1 mg IM if blood sugar is below 70 mg/dL and unable to swallow - (MONTH) give Glucogel 1 tube if blood sugar is below 70 mg/dL and able to swallow A review of the MAR for 2/15/18 at 6:30 a.m. indicated Resident 61's blood sugar was 101 mg/dL. No insulin was administered. During an interview on 2/16/18 at 1:34 p.m., LVN 6 stated that Resident 61 should have received six (6) units of insulin on 2/15/18 at 6:30 a.m. when blood sugar was 101. A review of the Diabetic NP Progress Note, dated 2/15/18, indicated that orders were sent to the facility to discontinue any other insulin orders. The plan included to restart the following: check blood sugar before meals for coverage and per resident's request, administer 40 units of [MEDICATION NAME] at 6 am to 7 am, administer 30 units of [MEDICATION NAME] and administer [MEDICATION NAME] or Humalog per scale when eating only with the following parameters: - 80-100: 3 units SQ - 101-150: 6 units SQ - 151-200: 8 units SQ - 201-250: 10 units SQ - 251-300: 12 units SQ - 301-350: 14 units SQ - 351-400: 16 units SQ - 401-450: 18 units SQ - Greater than 450: 20 units and call physician A review of the MAR for 2/15/18 at 9:00 p.m. indicated Resident 61's blood sugar was 358 mg/dL, requiring 16 units of insulin. A review of the MAR for 2/15/18 indicated Resident 61 also received [MEDICATION NAME] 30 units SQ at 9:00 p.m. During an interview on 2/22/18 at 1:30 p.m. the Diabetic NP stated the [MEDICATION NAME] sliding scale order when eating only, it was important to ensure the food was directly in front of Resident 61 prior to administrating the insulin to prevent [DIAGNOSES REDACTED]. A review of the facility's Change of Condition SBAR for Hypoglycemic Episode, dated 2/16/18 at 6:30 a.m., indicated Resident 61's blood sugar was 50 mg/dL. Resident 61 refused [MEDICATION NAME] 1 mg IM, three times. Resident 61 stated that he wanted to eat cereal with milk. On 2/16/18 at 6:45 a.m., Resident 61's blood sugar increased to 55 mg/dL but still refused [MEDICATION NAME]. During an interview on 2/16/18 at 1:34 p.m., LVN 6 reviewed Resident 61's clinical record. LVN 6 was unable to locate progress notes from Resident 61's Diabetic NP appointments. During an interview on 2/16/18 at 2:15 p.m., the Medical Records Assistant (MR 1) was unable locate progress notes from Resident 61's Diabetic NP appointments in the clinical record. MR 1 stated that Resident 61's charge nurse should call the clinic to obtain actual documentation from clinic if the resident returned to the facility without documentation. During an interview on 2/16/18 at 3:42 p.m., LVN 10, the unit manager, reviewed Resident 61's clinical record. LVN 10 stated signs and symptoms of [DIAGNOSES REDACTED] included lethargy and change of behavior. LVN 10 stated the Diabetic NP was not informed of Resident 61's changes in condition, which included behavior change, loss of appetite, scattered thoughts, oxygen desaturation to 80%, and hypoglycemic episodes. During a follow-up interview on 2/16/18 at 4:36 p.m., LVN 10 stated the facility should have provided Resident 61's changes of condition to the Diabetic NP. During an interview on 2/16/18 at 4:36 p.m., the Director of Nursing (DON) reviewed Resident 61's clinical record, including the sliding scale. DON stated that blood sugar from 80 to 100 was usually considered normal range that did not require insulin. DON stated that giving three (3) units of insulin at a normal range could result in lower blood sugar. During a follow-up interview on 2/16/18 at 5:00 p.m., the DON stated that the worst complication from [DIAGNOSES REDACTED] was death due to lack of oxygen. During an interview on 2/20/18 at 9:53 a.m., Resident 61 stated that his symptoms of [DIAGNOSES REDACTED] included blurry vision, shaking, and twitching. During an interview on 2/20/18 at 2:23 p.m., MD 3, an internal medicine physician in the same clinic as Diabetic NP, stated that the facility did not notify the clinic regarding Resident 61's hypoglycemic events. During an interview on 2/20/18 at 3:56 p.m., DON stated that the facility did not have a policy regarding communication with outside clinics. During an interview on 2/22/18 at 1:32 p.m., the Diabetic NP stated working with Resident 61 since 8/18/16 when he lived at another facility. The Diabetic NP stated that Resident 61's insulin administration was not based on a traditional sliding scale but on evidenced-based practice of physiological blood sugar replacement. The Diabetic NP stated there was no consistent communication regarding Resident 61's condition from the nursing facility. During an interview on 2/23/18 at 11:46 a.m., MD 2 stated the resident's sliding scale was excessive and causing Resident 61's hypoglycemic episodes. MD 2 stated that long-term effects of uncontrolled [DIAGNOSES REDACTED] included altered mental status, [MEDICAL CONDITION] (blood flow stops to a part of the brain), and death.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was admitted to the facility with no pressure sore (a localized injury to the skin and / or underlying tissue, usually over a bony prominence, as a result of pressure), and was identified as high risk for developing pressure sores, was provided necessary treatment and services (weekly skin assessments and implementation care plan) for prevention and promote healing of pressure sores by failing to: 1. Identify and evaluate the risk factors and changes in the patient's condition (redness to sacrum and coccyx), per policy. 2. Reposition Resident 1 every two hours. 3. Provide a weekly skin assessment and assess the development of pressure sore to the sacral and coccyx area (tail bone), according to the care plan. These deficient practices resulted in Resident 1 developing an unstageable pressure sore (full thickness skin or tissue loss, actual depth of ulcer is obscured by slough (yellow, tan, gray, green or brown dead skin / tissue in the wound bed)) to the sacrum (the large wedge shaped bone at lower part of back), and a Stage IV pressure sore (full thickness tissue loss with exposed bone, tendon or muscle) to the sacrum, with acinetobacter buamannii complex (a rare but serious community acquired infection). Findings: A review of the Admission Record indicated Resident 1 was readmitted to the facility, on 9/4/15, with the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, an assessment and care screening tool), dated 9/10/15, indicated Resident 1 required extensive assistance in bed mobility which included repositioning and turning from side to side. Resident 1 also required extensive assistance with personal hygiene and was totally dependent with toilet use, needing an indwelling catheter to pass urine. A review of the Braden Scale, a tool used in predicting a pressure sore risk, dated 9/5/15, indicated Resident 1 was at high risk for pressure sores, with a score of 15. According to the Braden Scale form, a score of 17 or below required a weekly skin assessment and documentation in the medical record. A review of Resident 1's care plan, dated 9/8/15, indicated the resident was at high risk for developing pressure sores. The care plan interventions included assessment of pressure sore risk using the Braden scale and the resident was to be turned and positioned every two hours. A review of the weekly Licensed Nurse Progress records, dated 9/8, 9/15, and 10/6/15, indicated Resident 1 was not repositioned every two hours. During an interview and record review, on 12/11/15, at 11 a.m., the director of nursing (DON) stated Resident 1 was admitted to the facility with redness to the sacrum, coccyx (the smaller triangular bone at end of spinal column), and buttocks. The DON was unable to locate the documentation of Resident 1 having redness and was unable to locate a weekly skin assessment / documentation for over a three month period, per the Braden scale form. During an interview and record review, on 12/11/15, at 11:30 a.m., the licensed vocational nurse (LVN 1) stated Resident 1 was admitted to the facility with redness to the sacrum and coccyx area and that the facility policy indicated redness should be reported to the physician. During the record review, LVN 1 was unable to locate documentation of Resident 1's initial redness and notification to the physician. LVN 1 stated the skin assessments and repositioning should be documented. On 12/14/15, at 12:05 p.m., during an interview and record review the DON stated all records for Resident 1 were present. The DON stated she was unable to locate any documentation of Resident 1's redness and pressure sore in the nurse's notes. A review of the acute care hospital records, dated 10/8/15, indicated Resident 1 presented with an unstageable pressure sore to the sacrum. The resident was discharged back to the skilled nursing facility, on 10/9/15. A review of Resident 1's unstageable pressure sore care plan indicated to monitor for signs and symptoms of infection, Resident 1 was to receive supplements, and dietary was to assess diet for protein, calories, vitamins and minerals. On 11/5/15, the Resident 1 was readmitted back to the acute care hospital (less than one month later) for a seperate unrelated issue. A review of the consultation note, dated 11/5/15, indicated the resident had a Stage IV sacral pressure sore about three centimeters in diameter with subcutaneous tunneling and a foul-smelling discharge. A review of the microbiology report from the acute care hospital, dated 11/5/15, indicated Resident 1's Stage IV sacral pressure sore had a rare acinetobacter buamannii complex (the most difficult antimicrobial-resistant bacteria to treat) which was multi-drug resistant (antibiotics can no longer be used to treat or kill the bacteria). A review of the Discharge Summary Note, dated 11/12/15, indicated the Resident 1 was most appropriate for hospice care and had a poor prognosis. The facility's undated policy and procedures titled, Policy and Procedures for Wound Management, indicated the facility's ulcer (pressure sore) prevention and treatment program would include: a. Identifying patients at risk for developing pressure ulcers. b. Identifying and evaluating the risk factors and changes in the patient's condition. c. Implementing individualized, comprehensive plan of care to attempt to stabilize, reduce or remove underlying risk factors. d. Meeting the nutritional needs of the patient. e. Monitoring effectiveness of interventions. f. Modifying the interventions as appropriate. The policy indicated risk factors which have an impact on the development, treatment and / or healing of the pressure ulcers include: a. Undernutrition, malnutrition, and hydration deficits. b. Impaired / decreased mobility and decreased functional mobility. c. Healed ulcers which were Stage III or Stage IV were more likely to have recurrent breakdown. The policy indicated pressure sores were to be prevented by repositioning the patient every two hours and as needed. A turning schedule was followed and documented on the 24 hour flow sheet.