Every finding on record at Santa Anita Convalescent Hospital

Based on observation, interview and record review, the facility failed to provide Restorative Nursing Services (a program available in nursing homes to help residents maintain any progress made during therapy treatments, enabling them to achieve their highest practicable level of functioning) treatment as ordered by the physician to increase, prevent, or maintain range of motion (ROM, full movement potential of a joint) for two (2) of three (3) sampled residents (Resident 1 and 3). This deficient practice placed Resident 1 and 3 at risk for decline in physical functions and developing contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) in the extremities (a limb of the body, such as the arm or leg) for not receiving the ordered exercises). Findings:1. During a review of Resident 1's admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE], with the diagnoses including but not limited to autonomic neuropathy (when damage occurs to the nerves that control involuntary body functions, like heart rate, blood pressure, digestion, and bladder control), contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) in the left ankle, left foot, right ankle, right foot and generalized muscle weakness. During a record review of Resident 1's Minimum Data Set (MDS, a resident assessment and tool), dated 6/6/2026, the MDS indicated Resident 1 had severely impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 1 had impairment on one side in the Upper Extremities (UE: shoulders, elbows, wrists, hands) and both sides in the Lower Extremities (LE: hips, knees, ankles, and feet). The MDS also indicated Resident 1 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) for toileting hygiene, oral hygiene, shower/ bathe self, lower dressing, putting on/ taking off footwear, roll left and right, sit to lying, lying to sitting on the side of bed, chair /be-to chair transfer, and tub / shower transfer. During a record review of Resident 1's Mobility Assessment, dated 6/17/2026, the assessment indicated Resident 1's Range of Motion (ROM, means how far and in what direction you can move a joint or muscle) on her left shoulder (flexion, extension and abduction) was poor, left elbow (flexion, extension) was poor, left wrist and fingers (flexion, extension) were poor, left and right knee (flexion, extension) were poor, left and right (plantar/ dorsi flexion) were poor. The assessment also indicated muscle strength on her left and right shoulder, left and right elbow, left and right wrist, left and right knee and left and right ankle were poor. During a record review of Resident 1's Care Plan (CP) dated 6/10/2026, the Care Plan indicated Resident 1 had potential for further decline in ROM and at risk for contracture. The CP interventions indicated, RNA Program: RNA to assist with application of [NAME] and Left Pressure Relief Ankle Foot Orthosis (PRAFO, is a specialized medical boot designed to float the heel completely off surfaces to prevent or treat pressure ulcers while supporting the foot and ankle) splints up to RNA 2 to 4 hours or as tolerated, every day for 5 days per week or as tolerated. Monitor if there are any signs and symptoms (s/s) of skin breakdown.RNA program for passive range of motion (PROM, the range that can be achieved by external means such as another person or a device) exercises for both LE everyday 5 times a week or as tolerated. To maintain ROM and to decrease risks of contractures. During a record review of Resident 1's Order Summary Report for 8/2026, the order summary report indicated the following:- On 6/10/2026- RNA program for PROM Exerciser for both LE every day five (5) times a week or as tolerated. To maintain ROM and to decrease risks of contractures.- On 6/10/2026- RNA to assist with application of Right and Left PRAFO. It protects the heel, stops foot drop, and controls foot and ankle movement for bedridden or walking patients) splints up to 2 to 4 hours or as tolerated, every day five (5) times a week or as tolerated. Monitor If there Is any sign and symptoms (s/s) of skin breakdown. To maintain ROM and to decrease risks of contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints).- On 8/18/2026- RNA to perform bilateral UE Active Range of Motion (AROM, the ability to move a joint independently using your own muscle strength) exercises every day five (5) times a week or as tolerated. During a record review of Resident 1's RNA Administration Record for the months of 6/28/2026 and 8/22/2026, it indicated Resident 1's order for RNA services for PROM exercises in both LE as tolerated every day 5 times a week. It also indicated the order for RNA to apply PRAFO splints to both LE every day 5 times a week for 2 to 4 hours or as tolerated. The RNA Record indicated 9 missed treatments for the following weeks of the months of June 2026 up to August 2026:- Week 1: 6/28/2026 to 7/4/2026 (one missed treatment)- Week 2: 7/5/2026 to 7/11/2026 (one missed treatment)- Week 3: 7/12/2026 to 7/18/2026 (one missed treatment)- Week 4: 7/19/2026 to 7/25/2026 (one missed treatment)- Week 5: 7/26/2026 to 8/1/2026 (one missed treatment)- Week 6: 8/2/2026 to 8/8/2026 (two missed treatments)- Week 7: 8/9/2026 to 8/15/2026 (one missed treatment)- Week 8: 8/16/2026 to 8/22/2026 (one missed treatment) During an observation on 8/21/2026 at 11:10 AM with Resident 1, inside Resident 1's room, Resident 1 was lying in bed with the head of the bed (HOB) elevated at 45-degree angle (a unit for measuring angles, where a full circle is 360 ). Resident 1 left arm was contracted and positioned close to her chest. During an interview on 8/21/2026 at 11:42 AM with Restorative Nurse Aide 1 (RNA 1), RNA 1 stated If they were not able to provide RNA therapy to Resident 1, Resident 1 were not able to exercise for that day. It can be reason for less functional improvement; it might slow down their progress. During an interview on 8/21/2026 at 11:52 AM with RNA 2, RNA 2 stated If they were not able to provide completed 5 times per week of RNA therapy to the residents, the residents can become stiff, and there would be slow improvement in their mobility. They need to help the residents with mobility, to prevent stiffness, which residents may not be able to move their legs if we do not provide the complete days of RNA therapy. During a concurrent interview and record review on 8/21/2026 at 4:05 PM with the Director of Staff Development 1 (DSD 1), Resident 3's Nurses' Progress Notes (NPN) dated 6/28/2026 to 8/21/2026 was reviewed. The NPN indicated, The RNA Record indicated 9 missed treatments for the following weeks of the months of July to August 2026. DSD 1 stated Resident 1 received 4 days of RNAs every week, but missing 1 day for Resident 1's RNA treatment order per week. If the RNAs did not follow the RNA treatment orders for Resident , Resident 1 could be put at risk of having joint stiffness or if she had contractures, it could get worse. During a concurrent interview and record review on 8/21/2026 at 4:08 PM with DSD 1, Resident 1's Care Plan (CP) dated 6/10/2026 was reviewed. DSD 1 stated Resident 1's RNA CP was not followed by the staff, because RNAs were missing days of RNA treatments. RNAs did not follow the CP because the RNA exercises should have been for 5 days but Resident 1 was always missing 1 day every week. 2. During a review of Resident 3's admission Record, the admission record indicated Resident 3 was admitted to the facility on [DATE], with the diagnoses including but not limited to cerebral infarction (refers to damage to tissues in the brain due to a loss of oxygen to the area) with left side weakness, Chronic obstructive pulmonary disease (COPD, is a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and Pulmonary edema (when fluid collects in the air sacs of the lungs, making it difficult to breathe) During a record review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident 3 needed substantial/ maximal assistance (helper does more than half the effort. helper lifts, holds trunk or limbs, and provides more than half the effort) in toileting hygiene, shower/ bathe self, lower dressing, putting on/ taking off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting on the side of bed, sit to stand, chair /be-to chair transfer, toilet transfer, and tub / shower transfer. During a record review of Resident 3's RNA Administration Record for the months of 6/28/2026 and 8/22/2026, it indicated Resident 3's order for RNA services to provide bilateral elbow extension splint 3 days a week or as tolerated. RNA to apply PRAFO splints to both LE for 4 hours every day 5 times a week or as tolerated. RNA to provide PROM on bilateral UE every day for 5 days per week or as tolerated. The RNA Record indicated 4 missed treatments for the following weeks of the months of 6/28 2026 up to 8/22/2026:- Week 6: 8/2/2026 to 8/8/2026 (one missed treatment)- Week 7: 8/9/2026 to 8/15/2026 (two missed treatments)- Week 8: 8/16/2026 to 8/22/2026 (one missed treatment) During a concurrent observation and interview on 8/21/2026 at 1:34 PM with Resident 3, inside of Resident 3's room, Resident 3 was sitting on his bed with HOB elevated 90 degrees, Resident 3 was wearing bilateral ankle boots. Resident 3 stated RNA does not come in frequently. The RNA did not exercise his bilateral legs. Resident 3 stated he does not remember who they are and he has not seen them. Resident 3 stated he only wears his left ankle splint once a week and bilateral upper extremity once a week. During a concurrent observation and interview on 8/21/2026 at 1:51 PM with RNA 3, inside Resident 3's room, RNA 3 was explaining to Resident 3 that she will have to put on Resident 3's ankle splints. RNA 3 stated Resident 3wears his ankle splints for 30 minutes to 1 hour. RNA 3 stated if RNA therapy was not provided the complete 5 days for Resident 3, Resident 3 can decline on his functional mobility, and all his extremities would become stiff. During an interview on 8/21/2026 at 2:11 PM with DSD 2, DSD 2 stated once in a while we receive complaints from Residents saying they did not get their RNA exercises at the right time and the correct number of days. The RNA will try to catch up until the end of the week. If the Residents did not get the RNA exercises, they might decline in their physical or muscle strength and will not regain their strength. During a concurrent interview and record review on 8/21/2026 at 4:13 PM with DSD 2, Resident 3's Physician Orders (PO) were reviewed. The PO orders indicated,On 8/7/2026, RNA to provide bilateral elbow extension splint 3 days a week or as tolerated to maintain ROM and prevent contracture every day (AM) shift.On 6/5/2026, RNA program for bilateral LE PRAFO for 4 hours every day for 5 days per week or as tolerated to maintain ROM every AM shift.On 7/19/2026, RNA to provide PROM on bilateral UE 5 days per week or as tolerated to prevent contractures and maintain ROM every day (AM) shift DSD 2 stated The RNA has to follow the PO orders. The RNA needs to provide the RNA exercises to Resident 3 for the correct number of days per week. During a concurrent interview and record review on 8/21/2026 at 4:20 PM with DSD 2, Resident 3's Nurses' Progress Notes (NPN) dated 7/1/2026 to 8/21/2026 was reviewed. The NPN indicated, The RNA Record indicated 4 missed treatments for the following weeks of the months of July to August 2026. DSD 2 stated There was no documentation that Resident 3 was refusing his RNA exercises, or he was transferred to the hospital. There were no reasons why RNAs were not giving the RNA exercises to Resident 3. Resident 3 will become a high risk for functional decline. During a concurrent interview and record review on 8/21/2026 at 4:27 PM with DSD 2, Resident 3's Care Plan (CP) for RNA for Resident 3's risk of contracture initiated on 7/19/2026. The CP interventions indicated,PROM on BUE every day 5 days per week or as tolerated.Bilateral ankle split for 4 hours every day 5 days per week or as tolerated.Bilateral elbow extension splint 4 hours every day 5 days per week or as tolerated. DSD 2 stated the RNAs were not following orders by missing number of days of RNA therapy for Resident 1 and Resident 3. The RNA record did not indicate reason why the RNA was not given to Resident 3. Resident 3 must do RNA exercises 5 times per week, it means RNAs have to provide exercises 5 times a week. If they missed days, Resident 3's contractures could worsen. During a concurrent interview and record review on 8/21/2026 at 4:31PM with the Director of Nursing (DON), The facility's policy and procedure (P&P) titled, Restorative Nursing Program Guidelines revised on 6/17/2017. The P&P indicated the Restorative Nursing Program provides nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. This program actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning. In conjunction with the Attending Physician and staff, therapists will propose a rehabilitation or restorative care plan that provides an appropriate intensity, frequency and duration of interventions to help achieve anticipated goals and expected outcomes. An order will be obtained from the Attending Physician as indicated for participation in the Restorative Nursing program or for skilled rehabilitation services (e.g. physical, occupational, or speech therapy). The Restorative Nurse's Aide (RNA) carries out the restorative program according to the Care Plan and documents daily. DON stated the RNA should have followed the Residents' CP and Physician's orders. The Residents' Care Plans indicated RNA exercises for the Residents, 5 times per week. The staff did not follow the CP and the PO orders because the RNAs were missing days of RNA treatment for Resident 1 and Resident 3. The staff were not documenting if Residents refused their RNA treatments. The staff should have documented why there was no RNA treatment for the missing days. Missing RNA treatments the Residents had the potential to have functional decline, or develop contractures, and will worsen their mobility and function.

Based on interview and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 1) received necessary monitoring, medical treatments, care and notification of change of condition (COC) to the doctor, in accordance with the resident's care plan, facility's policy and procedure (P&P) titled Care Planning, dated 10/24/2022 and facility's P&P titled Change of Condition Notification, dated 6/1/2017 by failing to ensure Resident 1 was being monitored and treated for pain and notify physician when Resident 1 complained pain on the left leg. These deficient practices has the potential to delay in the required medical services, treatments and care, to ensure Resident 1's health, wellbeing and quality of life.Findings:During a review of Resident 1's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE], with the diagnoses that including but not limited to the muscle weakness, history of falling, osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D) and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/13/2026, the MDS indicated the resident was severely impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated the resident 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 oral hygiene and personal hygiene but requires 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 putting on/taking off footwear. The MDS indicated that the resident is dependent (helper does all of the effort. Residents do none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with toileting hygiene and shower/bathe self. During an interview on 7/30/2026 at 11AM, RNA 1 stated, on Wednesday 7/15/2026, the RNA noticed Resident 1 was having pain and refused to exercise. RNA 1 also stated she reported to Licensed Vocational Nurse 1 (LVN 1). RNA 1 further stated, on Thursday 7/16/2026, pain and swelling were noted on Resident 1's left leg, and it was reported to Registered Nurse 1 (RN 1). Resident 1 refused to exercise his left leg. During an interview on 7/30/2026 at 11:31AM, LVN 2 stated, on 7/16/2026, Resident 1's left leg looked swollen and abnormal. LVN 2 also stated Resident 1 had facial grimacing when his left leg was touched. LVN 2 stated he called the doctor to obtain orders. During an interview on 7/30/2026 at 12:10PM, LVN 1 stated the doctor was not notified on 7/15/2026 of Resident 1 pain in the left leg. During an interview on 7/30/2026 at 1:37PM, the Quality Assurance (QA) Nurse stated if a Certified Nursing Assistant (CNA) or RNA reported pain in a resident, the licensed nurse should assess the pain, monitor the pain and call the doctor. During the same interview on 7/30/2026 at 1:37PM, Resident 1's Care Plan with focus of osteoporosis, dated 5/12/2026, was reviewed. The care plan indicated to monitor for complaints of sudden, sharp, or worsening pain particularly in the spine, legs and arms. QA Nurse stated Resident 1's pain should be monitored according to the care plan. During a review of Resident 1's progress notes, dated 7/15/2026, the progress notes indicated Resident 1 was complaint of the pain and did not receive RNA's (Restorative Nursing Assistant) services to exercise the left lower extremity. The progress notes also indicated LVN 1 was made aware. During a review of Resident 1's progress notes, dated 7/16/2026, the progress notes indicated Resident 1 was complaint of the pain and did not receive RNA's (Restorative Nursing Assistant) services to exercise the left lower extremity. The progress notes also indicated LVN 2 was made aware. During a review of Resident 1's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 7/16/2026. The SBAR indicated Resident 1 showed signs of pain such as facial grimacing, distressed pacing, fidgeting and pain upon touch. The SBAR also indicated physician recommended x-ray of the left lower extremity and pain management. The SBAR further indicated that the resident was sent to general acute care hospital (GACH) for evaluation. During a review of Resident 1's Radiology Results Report, dated 7/16/2026 at 9:51PM, the results indicated a periprosthetic fracture (a broken bone that happens around a joint replacement implant, such as a hip or knee) of the left femur shaft (the long, straight central section of the left thighbone). During a review of Resident 1's physician orders, dated 7/16/2026, the physician orders indicated may be send to GACH emergency room (ER) for femur fracture (a break or crack in the femur, which is your thighbone). During a review of Resident 1's Interdisciplinary Team (IDT - a coordinated group of health workers) Post Event Review, dated 7/27/2026, the IDT indicated the x-ray results showed acute vs subacute displaced periprosthetic fracture. During a review of the facility's P&P titled Change of Condition Notification, dated 6/1/2017, the P&P indicated to ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner. The P&P also indicated the license nurse will notify the resident's attending physician when there is an incident/accident involving the resident or a significant change in the resident's physical condition or clinical complications. During a review of the facility's P&P titled Care Planning, dated 10/24/2022, the P&P indicated the policy serves as a course of action where the resident, resident attending physician and IDT work to help the resident move towards resident-specific goals that address the resident's medical, nursing, mental and psychosocial needs. The P&P also indicated the care plan will describe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on interview and record review, the facility failed to maintain accurate clinical records as required by professional standard and practice, when Licensed Vocational Nurse 2 (LVN 2) added lorazepam (Ativan-a central nervous system depressant, a medication used to treat anxiety disorder [a group of mental health conditions characterized by persistent, excessive, and uncontrollable fear, worry, or dread that interferes with daily life]) to the medication list for one (1) of two (2) sampled residents (Resident 1) without obtaining an order from Resident 1's physician. This deficient practice had the potential for Resident 1 to receive Ativan, resulting in medication error and lead to adverse reactions (any unexpected reactions to a drug) and the accidents that are associated with adverse reactions.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that including but not limited to cerebral infarction (stroke- a type of tissue death in the brain when blood flow to a part of the brain is reduced or completely blocked), hemiplegia and hemiparesis following cerebral infarction affecting right non-dominate side (paralysis or significant weakness on the entire right side of the body), and unspecified cirrhosis of liver (permanent scarring of the liver caused by chronic, long-term liver disease and injuries). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 5/29/2026, the MDS indicated Resident 1 was assessed having intact memory and cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 1 required supervision or touching assistance with eating, oral hygiene, and personal hygiene. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with upper body dressing, rolling left and right, sitting to lying, and toilet transfer. The MDS further indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, shower/bathe self, sit to stand, and walk 10 feet (ft.- unit of measurement). During an interview on 6/12/2026, at 12:03 PM, with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 1 did not display any behaviors or verbal aggression towards staff or residents during his stay in the facility. During a concurrent interview and record review on 6/12/2026, at 12:34 PM, with the Assistant Administrator (AADM), Resident 1's physician's orders dated 5/29/2026, 4:57 PM were reviewed. AADM stated Resident 1 had a onetime order for lorazepam injection solution 2 milligrams (mg- unit of measurement for weight)/1 milliliter (ml- unit of measurement for liquid) inject 0.5 ml intramuscularly (inject into a muscle) for anxiety manifested by verbal aggression until 5/29/2026 11:59 PM, give 1mg/0.5ml. During the same concurrent interview and record review on 6/12/2026, at 12:34 PM, with the Assistant Administrator (AADM), Resident 1's progress notes and Medication Administration Record (MAR) were reviewed. AADM stated Resident 1 did not have any progress notes on or before 5/29/2026 indicating Resident 1 had anxiety as manifested by verbal aggression. AADM also stated Resident 1's Ativan order was charted as Code 13 (no dose required) in Resident 1's MAR on 8:55 PM. During an interview on 6/12/2026, at 1:29 PM, with LVN 1, LVN 1 stated Resident 1 was not anxious or verbally aggressive towards her or other residents on 5/29/2026. LVN 1 stated there was also no report from the previous shift that Resident 1 had anxiety or verbally aggressive behavior. LVN 1 stated she did not know who ordered the Ativan or why Ativan was ordered for Resident 1 on 5/29/2026 because he did not have aggressive behavior that day. During an interview on 6/12/2026, at 4 PM, with LVN 2, LVN 2 stated she entered the Ativan order under Resident 1's name on 5/29/2026. LVN 2 stated Resident 1 was never ordered to take Ativan by his physician for anxiety or verbally aggressive behavior. LVN 2 stated she placed the Ativan order under Resident 1's name only to show the new unnamed LVN she was training how to put in new medication orders. LVN 2 stated she forgot to delete the Ativan order after she was done teaching the new LVN how to do it. LVN 2 stated she should not have entered the Ativan order under Resident 1's name even if it was for teaching purposes. LVN 2 stated entering a medication that was not ordered for Resident 1 could have caused a medication error and cause Resident 1 to receive an unnecessary medication. LVN 2 stated Ativan was a form of chemical restraint and should not be administered to a resident without an order or consent from the physician. During an interview on 6/12/2026, at 4:15 PM, with the Director of Nursing (DON), the DON stated Resident 1 was not ordered by his physician to receive Ativan for anxiety or verbal aggression on 5/29/2026. The DON stated the Ativan order was for another resident and not for Resident 1. The DON stated LVN 2 entered the Ativan order on 5/29/2026 under Resident 1's name because Resident 1's electronic medical record (eMAR) was open while LVN 2 was teaching a new LVN how to enter medication orders. The DON stated LVN 2 should have entered the order under the resident that was ordered for Ativan. The DON stated entering an order under the wrong resident could cause a medication error and cause the resident to experience side effects and adverse reactions that the resident would not otherwise experience. During a review of the facility's policy and procedure (P&P), titled, Documentation-Nursing, revised 6/1/2017, the P&P indicated, Nursing documentation will be concise, clear, pertinent, and accurate.

Based on interview and record review, the facility failed to report an unusual occurrence (events or situations that do not happen daily or that may have had an impact on the residents) for one of two sampled residents (Resident 1) to State Agency (SA) within 2 hours in accordance with the facility's policy and procedure titled Abuse Prevention and Prohibition Program. This deficient practice prevented SA from going to do thorough investigation and had potentially led to ongoing unusual occurrence for Resident 1 or other residents in the facility.Findings:During a review of Resident 1's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with the following but not limited to diagnoses of contracture of both knees, left elbow and right hand, disorders of bone density and structure, and dementia.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/18/2026, the MDS indicated the resident was moderately impaired in cognitive skills for daily decision making. The MDS also indicated the resident 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) with eating, oral hygiene, and upper body dressing but was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear and personal hygiene.During a review of Resident 1's Fall Risk Assessment, dated 2/4/2026, the assessment indicated the resident is at high risk for potential falls.During a review of Resident 1's Change of Condition (COC - a significant alteration in an individual's physical, mental, or functional status compared to their established baseline), dated 6/7/2026, the COC indicated the resident was noted with abnormality to the left upper arm. The COC also indicated the resident had pain and was moaning, frightened and tense. The COC further indicated Resident 1 was transferred to a general acute care hospital (GACH).During a review of Resident 1's Skin Observation, dated 6/7/2026 indicated abnormality and swollen on left upper arm and the left upper arm.During a review of Resident 1's Progress Notes (PN), dated 6/7/2026 at 11:05AM, the PN indicated at 10:55am the Licensed Vocational Nurse 1 (LVN 1) informed the Registered Nurse 1 (RN 1) that Resident 1's left upper arm was noted swollen and resident was having facial grimaces.During a review of Resident 1's PN, dated 6/7/2026 at 11:55AM, the progress notes indicated the resident was evaluated by nurse practitioner (NP). The PN also indicated Resident 1 was noted redness on the left arm and like it is fractured (complete or partial break in the bone).During an interview on 6/10/2026 at 12:53PM, the Restorative Nursing Assistant 1 (RNA 1) stated, on 6/7/2026, RNA 1 was about to put the left elbow splint on Resident 1 and that was when RNA 1 noted Resident 1's left inner elbow was purple. RNA 1 further stated as she lifts up Resident 1's sleeve, she observed Resident 1's left upper arm was purple, swollen and had a bump.During an interview on 6/12/2026 at 9:35AM, Licensed Vocational Nurse 1 (LVN 1) stated Resident 1's arm looks swollen and the resident was moaning.During an interview on 6/12/2026 at 9:39AM, Certified Nursing Assistant 1 (CNA 1) stated RNA 1 and himself noted a lot of inflammation on Resident 1's left arm and it was reported to LVN 1 around 7:50AM.During an interview on 6/12/2026 at 10:15AM, Registered Nurse 1 (RN 1) stated she was told by LVN 1 that Resident 1's left arm was abnormal. RN 1 also stated she noted resident left arm was purple, swollen with a bump and the resident was in a lot of pain. RN 1 further stated NP came to assess the resident and gave orders to be transferred to the hospital. RN 1 stated she does not know what happened to the resident and that is considered an injury of unknown origin which needed to be reported within 2 hours, but it was not reported.During an interview on 6/12/2026 at 11:22AM, Quality Assurance (QA) Nurse stated the swelling and bruising of Resident 1's left arm is considered an injury of unknown origin and needed to be reported within 2 hours, but it was not reported.During an interview on 6/12/2026 at 12:02PM, Administrator (ADM) stated Resident 1's left arm bruising and swelling, ADM stated it is an injury of unknown origin which should have been reported within 2 hours, but it was not reported.During a review of the facility's Policy and Procedure (P&P) titled Unusual Occurrence Reporting, revised 10/1/2017, the P&P indicated unusual occurrences are reported to the appropriate agency within 24 hours by telephone and then confirmed in writing.During a review of the facility's P&P titled, Abuse Prevention and Prohibition Program, revised 6/25/2025, the P&P indicated the facility will report allegations of injuries of unknown source, immediately, by phone but not later than 2 hours after forming the suspicion.

Based on observation, interview, and record review, the facility failed to develop an individualized resident-centered care plan (a plan that prioritizes the unique health needs and desired outcomes of the resident) with measurable objectives, timeframe, and interventions to meet the resident's oxygen needs for one of two sampled residents (Resident 1).This deficient practice has the potential in delay the necessary care, services, recovery and wellbeing of Resident 1's Activities of Daily Living (ADLs - activities such as bathing, dressing and toileting a person performs daily) and result in injury and/or fall. Findings:During a review of Resident 1's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with the following but not limited to diagnoses of contracture of both knees, left elbow and right hand, disorders of bone density and structure, and dementia.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/18/2026, the MDS indicated the resident was moderately impaired in cognitive skills for daily decision making. The MDS also indicated the resident 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) with eating, oral hygiene, and upper body dressing but was dependent (helper does all of the effort. Residents do none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) with toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear and personal hygiene.During a review of Resident 1's General Acute Care Hospital (GACH) documents titled Patient Results, dated 2/1/2026, the GACH documents indicated diffuse osteopenia (a widespread reduction in bone mass and density throughout the skeleton, rather than localized bone loss).During a review of Resident 1's Fall Risk Assessment, dated 2/4/2026, the assessment indicated the Resident 1 is at high risk for potential falls.During an interview on 6/12/2026 at 10:15AM, Registered Nurse 1 (RN 1) stated there was supposed to be a care plan for Resident 1's diagnoses of osteopenia but there is not. RN 1 also stated it is important to have an ADL care plan for Resident 1's bone density, so the facility staff can properly care for the Resident 1.During a concurrent interview and record review on 6/12/2026 at 11:15AM, Resident 1's Care plans, dated 4/18/2025 to 6/7/2026, were reviewed. The MDS Coordinator stated Resident 1 does not have an ADL care plan related to bone density and the resident should have had one upon admission on 2/2026 to ensure the Resident 1 is properly cared for and ensure her safety.During an interview on 6/12/2026 at 11:22AM, Quality Assurance (QA) Nurse stated the resident ADL care plan for bone density should have been done on 2/2026 to ensure Resident 1 receives proper care during ADLs like changing and repositioning.During a review of the facility's Policy and Procedure (P&P) titled Care Planning, revised 6/12/2026, the P&P indicated the facility is to ensure that a comprehensive person-centered care plan is developed for each resident based on their individual assessed needs. The P&P also indicated a licensed nurse will initiate the care plan, and the plan will be finalized in accordance with resolution of current problems.

Based on interview and record review, the facility failed to ensure that the facility staff had an accurate and complete progress note in the resident's medical record for one (1) of three sampled residents (Resident 1) per facility's policy and procedure. The progress notes dated 6/4/2026 did not include licensed nurse's post monitoring documentation regarding Resident 1's specific behavior after Ativan oral tablet (Lorazepam, is used to treat anxiety disorders) was given to the resident. This deficient practice had the potential to result in miscommunication and improper delivery of care and inaccurate information of the care provided to the residents which could negatively affect the overall wellbeing of Resident 1.FindingsDuring a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 1's diagnoses included mood affective disorder (a type of mental health condition where there is a disconnect between actual life circumstances and the person's state of mind or feeling), anxiety disorder (mental health condition marked by persistent excessive worry, fear, or nervousness that interferes with daily life), major depressive disorder (or also called clinical depression, it affects how you feel, think and behave and can lead to a variety of emotional and physical problems), psychosis (a mental disorder characterized by a disconnection from reality) and dementia (a progressive state of decline in mental abilities) During a review of Resident 1's Minimum Data Set (MDS, resident assessment tool), dated 5/18/2026, the MDS indicated Resident 1 had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 1 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) in toileting hygiene, shower/ bathe self, lower body dressing, putting on/ taking off footwear, personal hygiene, sit to lying, lying to sitting on the side of the bed, sit to stand, chair/ bed-to-chair transfer, toilet transfer, tub/ shower transfer, walking 10 feet, and walking 50 feet with two turns. During a review of Resident 1's Physician Order (PO) dated 6/4/2026. The PO indicated,Ativan oral tablet 1 MG. Give 1 tablet by mouth every 6 hours as needed (PRN) for anxiety for 14 days. 1-Music/TV. 2- 1:1 (one to one) Conversation. 3-Activity. 4-Verbal cues/Encouragement. 5-Redireclion/Refocus/Diversion. 6-Reassurance/Orientation. 7-Removal of stimuli. 8- Rest/sleep, Manifested By (m/b) restlessness ordered on 5/26/2026Behavior Monitoring -Anxiolytic (Ativan): Document Number of Episodes per shift of target behavior ( m/b restlessness) every shift for Anxiolytic Use, non-pharmacological intervention (NPI, is any treatment, therapy, or lifestyle change that improves health, manages symptoms, or enhances well-being without the use of medications) Codes for psychotropic medication use: 1-Music/TV. 2-1:1 Conversation. 3-Activity. 4-Verbal cues/Encouragement. 5-Redirection/Refocus/Diversion. 6-Reassurance/Orientation. 7-Removal of stimuli. 8-Rest/sleep During a review of Resident 1's Care Plan (CP) for Ativan for anxiety related to adjustment issues, anxiety disorder manifested by getting up from wheelchair and walking out to the unit without assistance. The CP interventions indicated:Administer Antianxiety (a drug used to treat symptoms of anxiety, such as feelings of fear, dread, uneasiness, and muscle tightness, that may occur as a reaction to stress) medications as ordered by the physician. Monitor for side effects and effectiveness every shift.Monitor the resident for safety.Monitor/document/report PRN any adverse reactions to antianxiety therapyMonitor/record occurrence of for target behavior symptoms (nervousness without cause, pacing, wandering, inappropriate response to verbal communication, violence/aggression towards staff/others. etc.) and document per facility protocol. During an interview on 6/4/2026 at 4:47 PM with Licensed Vocational Nurse (LVN 1), LVN 1 stated, on 6/4/2026 CNA 1 told LVN 1 on Resident 1 was agitated, so LVN 1 administered Ativan at 2:30AM to Resident 1. LVN 1 added after 1 hour after administering the Ativan, Resident 1 was still agitated and was still trying to get out of bed. During a concurrent interview and record review on 6/5/2026 at 2:05 PM with Quality Assurance Nurse (QAN), Resident 1's Nurses' Progress Notes (NPN) dated 6/4/2026 was reviewed. QAN stated Ativan, was given to Resident 1 on 6/4/2026 at 2:30 AM, and NPN indicated effective. QAN also stated LVN 1 did not describe Resident 1's behavior at the time of reassessment and it was not accurate documentation if LVN 1 was saying Resident 1 was still agitated and was still trying to get out of bed after an hour from giving the Ativan. During a concurrent interview and record review on 6/5/2026 at 2:48 PM with QAN, the facility's policy and procedure (P&P) titled, Documentation - Nursing revised 6/1/2017 was reviewed, the P &P indicated,(a) Describe the resident's condition, include what you see, hear, smell, feel, etc.(b) Use the resident's own words if needed.(c) Describe what you have done in response to what is going on with the resident.(d) Describe how the Resident responded to the actions.QAN stated Resident 1's reassessment documented in NPN should have a description of Resident 1's behavior during the time of LVN 1's reassessment after the Ativan was given. QAN also stated documenting effective is not enough documentation for Resident 1's behavior and LVN 1 should have included the accurate description of what LVN 1 saw and heard. LVN 1 should have documented Resident 1 was still agitated and trying to get up from bed if that's what LVN 1 saw. During a concurrent interview on 6/5/2026 at 3:21 PM with the Administrator (ADM), ADM stated inaccurate and/ or inaccurate documentation of licensed staff may affect the quality of care for the residents. During a record review of the facility's P&P titled, Documentation - Nursing revised 6/1/2017, the P&P indicated nursing documentation will be concise, clear, pertinent, and accurate. The P&P also indicated narrative charting, as outlined in specific policies and procedures, will be used for initial treatments or procedures.

Based on observation, interview, and record review, the facility failed to fully inform the resident/ resident's responsible party (RP) in advance, of the risks and benefits of proposed care for two of five sampled residents (Residents 218 and a) reviewed for unnecessary medications in accordance with the facility policy by failing to ensure: 1. An informed consent was obtained from Resident 1 /RP for the use of Valproic Acid (a prescribed anticonvulsant used as a psychotropic medication [a drug that changes brain function and results in alterations in perception, mood, consciousness or behavior]) to stabilize moods in bipolar disorder [a mental illness that causes unusual shifts in mood, energy, and concentration]).2. An informed consent was obtained from Resident 1, who was receiving Rexulti (antipsychotic medication for depression [mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities], schizophrenia [chronic brain disorder that impairs how an individual interprets reality], and dementia-related agitation) and Seroquel (antipsychotic that treats schizophrenia and bipolar disorder [mental health condition causes extreme mood swings that include emotional highs called mania, and lows, known as depression]). This deficient practice had the potential for Residents 1 and 218 not to be able to exercise their right to choose their treatment plan. Findings: 1. During a review of Resident 218's admission Record (AR), the AR indicated Resident 218 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included metabolic encephalopathy (a broad term for any brain disease that alters brain function or structure), dementia (the loss of cognitive functioning [thinking, remembering, and reasoning] to such an extent that it interferes with a person's daily life and activities), major depression disorder (mood disorder that causes a persistent feeling of sadness and loss of interest in life), unspecified psychosis (severe mental condition involving abnormal thinking, perceptions, and loss of contact with reality), anxiety disorder (a group of mental disorders characterized by significant feelings of fear that affect with daily activities), and bipolar disorder. The AR indicated Resident 218's responsible party (RP) is RP 1. During a review of Resident 218's Order Summary Report (OSR), the OSR indicated Resident 218 had a physician order on 2/14/2026 for Valproic Acid oral (by mouth) capsule 250 mg (milligram, unit of weight) to give 1 capsule by mouth two times a day for bipolar disorder manifested by verbal aggression. During a review of Resident 218's care plan related to the use of Valproic Acid, dated 2/15/2026, the care plan indicated the goal was for the resident to be free or remain free of drug related complications and the interventions included to educate the resident and the resident's family about risks, benefits and the side effects (an unintended, secondary response to a medication or medical treatment that occurs in addition to the primary, intended effect) and/or toxic symptoms of medication. During a review of Resident 218's [NAME] Data Set (MDS, a resident assessment), dated 2/18/2026, the MDS indicated Resident 218's was severely impaired (difficulty with or unable to make decisions, learn, or remember things) with cognitive skills for daily decision making. During a concurrent interview and record review on 5/28/2026 at 10:30 AM with Assistant Director of Nursing (ADON), Resident 218's Electronic Health Record (a digital version of a patient's medical chart) and physical medical chart (the official, systematic documentation of a patient's medical history and clinical care) from 2/15/2026 to 5/28/2026 were reviewed. ADON stated that Resident 218 has been receiving Valproic Acid since 2/15/2026 but there was no consent on file for its use. During an interview on 5/28/2026 at 3:12 PM with RP 1, RP1 stated he was not aware that Resident 218 was receiving Valproic Acid for verbal aggression. RP 1 stated that the facility did not inform RP 1 about the use of Valproic Acid, did not explain the associated risks and benefits, and did not indicate whether any alternative interventions were attempted before initiating the medication on Resident 218. During an interview on 5/28/2026 at 5:07 PM with the Director of Nursing (DON), the DON stated that prior to initiating Valproic Acid, consent should have been obtained from RP1 to review the purpose of the medication, its potential side effects and reactions, and how the medication would help the resident's condition. During a review of the facility's policy and procedures (P&P) titled, Guidelines for Psychotherapeutic Medications, revised June 2017, the P&P indicated When anticonvulsants are utilized for treatment of behavior, monitoring of behaviors and side effects shall be completed. Informed consent shall be obtained and documented for each new order. 2. During a review of Resident 1's admission Record indicated a readmission to the facility on [DATE] with diagnoses that included vascular dementia (a decline in thinking and memory skills caused by restricted or blocked blood flow to the brain), schizophrenia (severe, chronic brain disorder that impairs a person's ability to interpret reality, causing symptoms like hallucinations, delusions, and disorganized thinking), unspecified mood (affective) disorder (mental disorders characterized by a disturbance in mood which is abnormally depressed or elated). During a review of Resident 1's History and Physical Assessment (H&P) dated 3/1/2026 indicated Resident 1 had good decision-making capacity. During a review of Resident 1's Order Summary Report indicated the following physician's orders: Seroquel Oral Tablet 25 milligram (mg, unit of measure) give 1 tablet via gastrostomy (g-tube, medical device inserted through the abdomen directly into the stomach) two times a day for schizophrenia manifested by yelling out without cause, ordered 4/21/2026 and discontinued on 5/11/2026. Rexulti Oral Tablet 1 mg (Brexpriprazole) give 1 tablet via g-tube one time a day for dementia manifested by yelling without cause, ordered 5/15/2026. During a review of Resident 1's Informed Consent for the use of Seroquel, dated 4/21/2026, the Informed Consent did not reflect a signature from Resident 1 or Resident 1's Representative to indicate that an informed consent was obtained. During a review of Resident 1's Consents for the use of Rexulti dated 5/15/2026, the Informed Consent did not reflect a signature from Resident 1 or Resident 1's Representative to indicate that an informed consent was obtained. During an interview with the DON on 5/28/2026 at 4:47 PM, the DON stated Informed Consent is explained to resident/responsible party by the Physician. The resident or family will then agree or disagree with the treatment or medication. The DON stated the informed consent on the electronic medical record is printed out for the resident/responsible party and physician to sign. The DON stated the hard copy with the signature is left in the resident's physical medical chart. The DON stated if the signed consent is not found in the physical medical chart, it should be found on the electronic medical chart, uploaded in the documents section. The DON stated it was important for the informed consent to be completed and signed because it validates that the resident/family agreed to the treatment. A review of the facility's policy and procedure (P&P) titled Informed Consent, dated 4/1/2024 indicated the Informed consent must be signed by the resident or the resident's representative and the physician who provided the material information. The P&P indicated copies of the signed informed consent form shall be given to the resident or the resident's representative.

Based on observation, interview, and record review the facility failed to ensure call lights (communication system in care facilities that allowed residents to instantly alert nursing staff when help was needed) were within reach and readily accessible for four of 35 residents (Resident 38, 77, 301, and Resident 386) by failing to: Provide an adaptive call light (customized version of a call light that allowed resident's with limited strength, mobility, or dexterity to easily call for help) when the resident was observed not being able to use the call light provided.Place Resident 77's call light within reach and provide an adaptive call light when the resident was observed not being able to use the call light provided.Place Resident 301's call light within reach and provide an adaptive call light when the resident was observed not being able to use the call light provided.Place Resident 386's call light within reach. These deficient practices placed Resident 38, 77, 301, and Resident 386 at risk for delayed staff response, unmet needs, and potential negative outcomes related to resident safety and well-being.Findings: 1. During a review of Resident 38's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included adult failure to thrive (a decline caused by chronic disease and functional impairments which could cause weight loss, decreased appetite, poor nutrition, and inactivity), lack of coordination, and muscle weakness. During a review of Resident 38's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 4/11/2026, the MDS indicated the resident had severe cognitive impairment (problems with a person's ability to think, learn, remember, used judgement, and make decisions). The MDS indicated the resident was dependent (helper did all of the effort and the resident did none of the effort to complete the activity) on facility staff in all functional abilities. During a review of Resident 38's Occupational Therapy (OT) Evaluation & Plan of Treatment dated 3/23/2026 to 4/19/2026, the Evaluation indicated the resident's medical factors included bilateral upper extremity (BUE) joint contractures (a stiffening/shortening at any joint, that reduced the joint's range of motion) and Resident 38 was dependent of all Activities of Daily Living (ADLs, routine tasks/activities such as bathing, dressing, and toileting a person performs daily to care for themselves). The Evaluation indicated during Resident 38's Musculoskeletal System Assessment, the resident's upper extremity range of motion (ROM) and strength were impaired. The Evaluation indicated the reason for Resident 38's skilled services included the resident presenting with impairments in fine motor coordination (the ability to use small muscles, mostly in your hands and fingers to make precise, controlled movements), mobility, and strength. During an observation in Resident 38's room on 5/26/2026 at 3:54 PM, the resident was observed with the call light in the resident's right hand and Resident 38 was asking for milk. Resident 38 was asked to pull the call light to request facility staff for assistance but was unable to physically pull the call light. During a concurrent observation and interview in Resident 38's room on 5/26/2026 at 4:34 PM, Licensed Vocational Nurse (LVN) 16 stated the resident was unable to use the call light because Resident 38's right hand doesn't really work well. LVN 16 stated Resident 38 should have been able to use the call light to call for help when the resident needed assistance otherwise the facility would not know and if there was an emergency the resident would not be able to call the facility staff. 2. During a review of Resident 77's AR, the AR indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included hemiplegia (partial weakness) and hemiparesis (total or near-total paralysis) affecting left non-dominant side, left hand contracture, and muscle wasting and atrophy (muscles shrink, lose tissue mass, and become weak). During a review of Resident 77's MDS dated [DATE], the MDS indicated the resident had severe cognitive impairment. The MDS indicated the resident needed substantial/maximal assistance (helper did more than half the effort) from facility staff for transfers, upper/lower body dressing, and oral/toileting hygiene. During a review of Resident 77's OT Evaluation & Plan of Treatment dated 5/15/2026 to 6/25/2026, the Evaluation indicated Resident 77 was dependent on all ADLs. The Evaluation indicated Resident 77 required total assistance from basic ADLs due to limited strength which significantly impacted the resident's ability to perform functional tasks independently. During an observation in Resident 77's room on 5/26/2026 at 10:43 AM, Resident 77's call light was observed behind the resident's right shoulder and when the resident was asked to call the facility staff for assistance, the resident was unable to reach or physically pull the call light. During a concurrent observation and interview in Resident 77's room on 5/26/2026 at 10:54 AM, Certified Nursing Assistant (CNA) 4 stated the call light was used for residents to call the facility staff for anything the resident needed. CNA 4 stated Resident 77 did not have the call light within reach and was unable to pull the call light. CNA 4 stated if the call light was not within reach and the resident was unable to use the call light; Resident 77 could fall or get hurt and break a bone. During a concurrent observation and interview in Resident 77's room on 5/26/2026 at 11:15 AM, LVN 17 stated the call light was used to call facility staff for care or if the resident have questions and should have always been within the resident's reach otherwise the facility staff would not be notified if the resident needed something or something happened to the resident. LVN 17 stated Resident 77 was not able to physically pull the call light but should have been able to if the resident was provided with the adaptive call light which is appropriate for the resident's need. LVN 17 stated if the resident was unable to pull or use the call light, Resident 77 would not be able to get the help the resident needed. 3. During a review of Resident 301's AR, the AR indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included mild neurocognitive disorder (any condition that caused a decline in brain function, affecting memory, thinking, or reasoning), cerebral ischemia (blood flow to the brain was blocked or reduced), and dementia (a progressive state of decline in mental abilities). During a review of Resident 301's History & Physical (H&P) dated 7/9/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 301's MDS dated [DATE], the MDS indicated the resident had severe cognitive impairment. The MDS indicated the resident required substantial/maximal assistance and/or was dependent on facility staff in all functional abilities. During a review of Resident 301's OT Evaluation & Plan of Treatment dated 10/2/2025 to 10/8/2025, the Evaluation indicated Resident 301 was dependent on all ADLs and the resident's Mobility Function Score was zero (ranged from zero to 12, 12 being the highest). The Evaluation indicated the resident's right and left upper ROM was impaired. The Evaluation indicated the reason for Resident 301's skilled services included impairments in gross motor coordination and mobility resulting in limitations and/or participation restrictions in the areas of self-care. During an observation in Resident 301's room on 5/26/2026 at 10:47 AM, Resident 301's call light was observed clipped to the top right-hand side of the bed and when the resident was asked to call the facility staff for assistance, the resident was unable to reach or physically pull the call light. During a concurrent observation and interview in Resident 301's room on 5/26/2026 at 10:59 AM, CNA 4 stated Resident 301 did not have the call light within the resident's reach and the resident was unable to use the call light. CNA 4 stated the call light should have been within Resident 301's reach and the resident should have been able to use the call light otherwise Resident 301 could fall or get hurt and break the resident's arm. During a concurrent observation and interview in Resident 301's room on 5/26/2026 at 11:23 AM, LVN 17 stated the resident was not able to pull the call light to call for facility staff assistance. LVN 17 stated if the resident was unable to call for facility staff due to the call light is not appropriate for the resident, Resident 301 would not get the help the resident needed. 4. During a review of Resident 386's AR, the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included muscle weakness, hemiplegia and hemiparesis affecting the right dominant side, and heart failure (condition that developed when the heart did not pump enough blood for the body's needs). During a review of Resident 386's H&P dated 5/14/2026, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 386's MDS dated [DATE], the MDS indicated the resident had severe cognitive impairment. The MDS indicated the resident required substantial/maximal assistance from facility staff for transfers and was dependent on facility staff for lower body dressing, toileting hygiene, and walking 10 feet. During a review of Resident 386's OT Evaluation & Plan of Treatment dated 5/14/2026 to 6/10/2026, the Evaluation indicated the resident was referred to OT due to a decline in ability to perform functional activities without physical assistance, ADL participation, functional mobility/capacity, and strength. The Evaluation indicated the resident required partial/moderate assistance, substantial/maximal assistance, and was dependent on facility staff for all ADLs. The Evaluation indicated the resident's right and left upper extremity strength was impaired. The Evaluation indicated the reason for Resident 386's skilled services was due to impairments in fine motor coordination, mobility and strength resulting in limitations and/or participation restrictions in areas of mobility and self-care. During an observation in Resident 386's room on 5/26/2026 at 11:07 AM, the resident's call light was observed hanging from the wall and the clip attached to the call light was broken and unable to be secured. Resident 386 could not reach the call light while in bed. During a concurrent observation and interview in Resident 386's room on 5/26/2026 at 10:40 AM, LVN 17 stated the resident's call light clip was broken and did not clip on the bed. LVN 17 stated this must have been missed during the morning rounds, but the call light should have been placed within Resident 386's reach so the resident could get help when needed. During an interview on 5/28/2026 at 4:30 PM, the Director of Nursing (DON) stated call lights should have been within the residents' reach and was used to let the facility staff know when the resident needed help. The DON stated if the call light was not within the resident's reach the facility staff would not know when the residents need help or assistance. The DON stated if a resident was unable to physically use the call light, the rehabilitation department (medical unit dedicated to helping people recover or improve skills needed for daily life) would have to evaluate and screen for a more appropriate device such as an adaptive call light to meet the resident's needs. During a concurrent interview and record review on 5/28/2026 at 4:33 PM with the DON, the facility's policy and procedure (P&P) titled Communication - Call System dated 10/24/2022 as reviewed. The P&P indicated the purpose of the P&P was to provide a mechanism for residents to promptly communicate with nursing staff. The P&P also indicated the facility would provide a call system (call light) to enable residents to alert the nursing staff from their beds and would be placed within the resident's reach in the resident's room. The P&P indicated an adaptive call bell or call light (e.g. flat pad call cord, hand bell, etc.) would be provided to a resident per the resident's needs. The DON stated the facility staff were not following the policy but should have been to ensure the resident's needs were being met. The DON stated if the facility was not following the policy there could be extended waiting times for the resident's needs to be met.

Based on observation, interview, and record review the facility failed to ensure the Minimum Data Set (MDS, a federal mandated resident assessment tool) was accurate for six of seven sampled residents (Residents 55,126, 134, 233, 263 and 346) in accordance with the facility's policy and procedure. This failure had the potential for Residents 55,126, 134, 233, 263 and 346 resulted in inaccurate documentation in the resident's medical record which could impact continuity of care, facility reporting accuracy, and regulatory compliance.Findings: 1. During a review of Resident 55's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (when problems with your metabolism cause brain dysfunction), and chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs).During a review of Resident 55's MDS, dated [DATE], the MDS for Section A indicated an incorrect Resident 55's first and last name.During a review of Resident 55's MDS dated [DATE], the MDS for Section A indicated an incorrect Resident 55's first and last name. 2. During a review of Resident 126's admission Record (AR), the AR indicated the resident was originally admitted to the facility on [DATE] and then readmitted on [DATE] with diagnoses including osteoarthritis of the hip (wear-and-tear condition where the protective cartilage covering the ends of the thigh bone (femur) and hip socket gradually wears away), chronic kidney disease ( when the kidneys are damaged for more than a few months). During a review of Resident 126's MDS dated [DATE], the MDS for Section A indicated an incorrect Resident 126's first and last name. During a review of Resident 126's MDS dated [DATE], the MDS for Section A indicated an incorrect Resident 126's first and last name. 3. During a review of Resident 134's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE] with diagnoses including cerebral ischemia (a condition that occurs when there isn't enough blood flow to the brain), end stage renal disease (when the kidneys no longer work well enough to meet the body's needs).During a review of Resident 134's MDS dated [DATE], the MDS for Section A indicated an incorrect Resident 134's first and last name. During a review of Resident 134's MDS dated [DATE], the MDS for Section A indicated an incorrect Resident 134's first and last name. 4. During a review of Resident 233's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE] with diagnoses including kidney failure (when your kidneys lose the ability to filter waste products from your blood effectively), type 2 diabetes mellitus (your body does not use insulin properly)During a review of Resident 233's MDS dated [DATE], the MDS for Section A indicated an incorrect Resident 233's first and last name. During a review of Resident 233's MDS dated [DATE], the MDS for Section A indicated an incorrect Resident 233's first and last name. 5. During a review of Resident 263's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE] with diagnoses including hypertension (high blood pressure), angina pectoris (chest pain or discomfort that occurs when a part of your heart doesn't get enough blood and oxygen)During a review of Resident 263's MDS dated [DATE], the MDS for Section A indicated an incorrect Resident 263's first and last name.During a review of Resident 263's MDS dated [DATE], the MDS for Section A indicated an incorrect Resident 263's first and last name. 6. During a review of Resident 346's admission Record (AR), the AR indicated the resident was originally admitted to the facility on [DATE] with diagnoses including anemia (the body does not have enough healthy red blood cells to carry oxygen to the body's tissues), cardiomyopathy (a disease of the heart muscle).During a review of Resident 233's MDS dated [DATE], the MDS for Section A indicated an incorrect Resident 233's first and last name.During a review of Resident 233's MDS dated [DATE], the MDS for Section A indicated an incorrect Resident 233's first and last name. During an interview and concurrent record review of Resident's 55,126, 134, 233, 263, and 346's MDS on 5/28/2026 at 12:55 PM with the MDS Nurse (MDSN), the MDSN stated she was responsible in making sure all the resident MDS assessments were completed and transmitted to the Centers for Medicare and Medicaid Services (CMS) system timely and accurately. MDSN stated the facilities MDS system auto populates the residents name from their electronic health care record. MDSN stated sometimes when residents are admitted , the admitting nurse will input names incorrectly and when business office corrects the names in the system, they should let her know so she can complete modification MDS and submit to CMS. MDSN stated this will notify the CMS on the change in the residents' name and the correct residents' information are being transmitted. MDSN stated she was unaware of the name changes that had been made to Resident's 55,126, 134, 233, 263 and 346 names and that is why she did not submit a modification MDS. During an interview on 5/28/2026 at 4:33 AM with the Director of Nursing (DON), the DON stated if there are any changes in a resident's status, names or if the MDS was not documented accurately, it could affect the continuation of care for the residents negatively and result in the incorrect tracking for the resident's outcome. DON stated all MDS should be documented correctly with correct patient's names to ensure the facility is assessing the residents accurately and transmitting the correct patient's information to CMS. During a review of the facility's Policy and Procedure (P&P), titled RAI Process, with a revision date of 10/01/2019, the P&P indicated, The facility will utilize the Resident Assessment Instrument (RAI) process as the basis for the accurate assessment of each resident's functional capacity and health status, as outlines in the CMS RAI manual.

Based on observation, interview, and record review, the facility failed to maintain a safe environment for four of five residents (Residents 187, 228, 275, and 338) in the accidents care area when:1. The facility did not ensure both of Resident 187's siderails were (a bar attached to the bed that is used to prevent patients from accidentally rolling off or falling) padded for seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) precautions as indicated in the facility's policy and procedure (P&P) titled, Seizure Precautions.2. The facility did not post an Oxygen in Use sign on the door frame of Resident 228's room, who was actively using an oxygen machine, as indicated in the facility's P&P titled, Oxygen Administration.3. The facility failed to ensure Certified Nurse Assistant (CNA) 1 verify the resident's need for substantial or maximal assistance (helper does more than half the effort. Helper lifts, or holds trunk or limbs and provides more than half the effort) to request help before attempting to transfer Resident 275 from the toilet seat to the resident's wheelchair and ensure LVN 1 revise the resident's plan of care specific to the resident's physical assistance needs with interventions that included the level of assistance to address the resident's left below knee amputation (LBKA, surgery to remove the lower part of the left leg) to reduce the risk of falls. 4. The facility failed to ensure bed brakes were locked for Resident 338 in accordance with the facility's policy and procedure (P&P) titled Fall Management Program These deficient practices placed Resident 187 at risk of injury in the event of a seizure and placed Resident 228 at risk of injuries from fire hazards and improper handling of oxygen equipment. In addition, it had the potential to create unintended bed movement resulting in potential injury to Resident 338 and resulted in Resident 275's slid down and his LBKA stump (the remaining part of an amputated arm or leg) hit the floor. Findings: 1. During a review of Resident 187's admission Record, the record indicated Resident 187 was admitted to the facility on [DATE] with diagnoses including epilepsy (a long-term brain disorder caused by sudden bursts of electrical activity in the brain that lead to repeated seizures, which can include uncontrollable shaking, staring spells, or brief loss of consciousness) and other disorders of the brain. During a review of Resident 187's Minimum Data Set (MDS- a resident assessment tool) dated 5/6/2026, the MDS indicated Resident 187 had severe cognitive impairment (a profound decline in mental functioning—affecting memory, language, reasoning, and understanding—that significantly impairs daily life and typically necessitates substantial supervision) and was dependent (helper does all the effort) for all cares including turning in bed. During an observation on 5/26/2026 at 10:19 AM, Resident 187 was observed in her bed. Resident 187's left siderail was padded but the right siderail was not. A siderail pad was observed under 187's bed. During a concurrent observation and interview with Licensed Vocational Nurse (LVN) 19 on 10/26/2026 at 10:26 AM, Resident 187's unpadded right siderail was observed. LVN 1 stated both of Resident 187's siderails should have been padded for seizure precautions. LVN 19 stated the pad should not have been left under Resident 187's bed and should have been placed back on the siderail after staff provided care. LVN 19 further stated all staff were responsible for ensuring the pads on the side rails were placed for residents with seizure precautions to ensure the residents did not suffer an injury in the event of a seizure. During an interview with the Director of Nursing (DON) on 5/28/2026 at 9:57 AM, the DON stated Resident 187 could have sustained injuries if the resident had a seizure and the pads were not on Resident 187's siderails. The DON further stated that staff should have ensured proper placement of the siderail pads every time they performed cares for residents on seizure precautions. During a review of the facility's Policy and Procedure (P&P) titled, Seizure Precautions and revised on 6/1/2017, the P&P indicated, The facility will provide preventative measures prior to and during seizure activity to prevent resident injury to the extent possible. The P&P further indicated that residents considered at high risk for seizure activity had seizure precautions initiated including seizure pads placed on the resident's side rails. 2. During a review of Resident 228's admission Record, the record indicated Resident 228 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing) and muscle weakness. During a review of Resident 228's MDS dated [DATE], the MDS indicated Resident 228 was cognitively intact and only required setup or clean-up assistance with most cares such as eating and personal hygiene. During a review of Resident 228's physician orders report dated 5/28/2026, the report indicated the following order, OXYGEN at two (2) liters per minute [lpm- a measure of oxygen flow] via nasal cannula [a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen] as needed for prevention of oxygen saturation [O2 sat- a measurement of how much oxygen the blood is carrying as a percentage] below 92%. During an observation on 5/26/2026 at 9:35 AM, Resident 228 was observed with a nasal cannula on and oxygen machine at the resident's bedside. There was no Oxygen in Use sign posted on the door frame of Resident 228's room. During an interview with LVN 19 on 5/26/26 at 9:40 AM, LVN 19 stated the staff forgot to put an Oxygen in Use sign on the door frame of Resident 228's room. LVN 19 further explained that the oxygen sign was a warning for anyone who entered Resident 228's room not to have an open flame near his oxygen machine in order to prevent a fire or explosion. During an interview with the DON on 5/28/2026 at 4:57 PM, the DON stated oxygen usage signs were supposed to be posted outside the resident's room to notify staff and visitors that oxygen was being used in the room. The DON stated if the sign was not posted, flammables could be brought close to the oxygen which could cause combustion. The DON further explained that not posting the Oxygen in Use sign was a safety issue. During a review of the facility's P&P titled, Oxygen Administration and revised 6/1/2017, the P&P indicated, residents using oxygen will have an 'Oxygen in Use' sign placed on the door frame of their room. 3. During a review of Resident 275's admission Record (AR), the AR indicated Resident 275 was admitted on [DATE] and readmitted on [DATE] with diagnosis that included diabetes mellitus (a group of diseases that result in too much sugar in the blood), left eye blindness (the complete or nearly complete loss of sight), and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). The AR indicated on 4/15/2026, Resident 275 had a new diagnosis of acquired absence of LBKA. During a review of Resident 275's care plan (CP) for the resident's risk for falls and/or injuries related to unsteady gait related to DM with foot ulcer (an open sore or wound on the foot that fails to heal properly), revised on 3/28/2026 the CP indicated the resident will reduce risk of falls and/or injury with added new interventions on 4/24/2026 that included to provide assistance with transferring and locomotion (the act or power of moving from one place to another) as needed. During a review of Resident 275's admission summary, dated [DATE], the summary indicated Resident 275 was readmitted to the facility with LBKA. During a review of Resident 275's Fall Risk Assessment, dated 4/15/2026, the assessment indicated Resident 275 was at a moderate risk for falling with weak gait. During a review of Resident 275's Physical Therapy Discharge Summary (PTDS) for the period of 4/16/2026 to 5/8/2026, the PTDS indicated on 4/16/2026, Resident 275 was dependent on chair-to-chair transfer and needed substantial/maximal assistance in sit to stand. During a review of Resident 275's Physician Progress Note (PPN), dated 4/17/2026, the PPN indicated Resident 275 was readmitted to the facility and on therapy services for decline in ADLs (Activities of Daily Living, daily self-care activities), function, mobility after hospitalization with a LBKA procedure on 4/9/2026. During a review of Resident 275's [NAME] Data Set (MDS, a resident assessment tool), dated 4/19/2026, the MDS indicated Resident 275's cognition (the ability to think, remember, and reason) is intact, Resident 275 utilized wheelchair as mobility device. During a review of Resident 275's Change in Condition Evaluation (CIC), dated 4/21/2026, indicated on 4/21/2026, in the afternoon time (not specify when), Resident 275 had an accidental slight impact to LBKA during patient care. The CIC indicated Resident 275 reported to LVN 1 that the resident's LBKA stump accidentally made contact with the floor, upon transfer by the CNA from the toilet back to his chair. During a review of Resident 275's Nurses Progress Notes (NPN) documented by LVN 1 on 4/21/2026, the NPN indicated on 4/21/2026 at around 6:50 PM, Resident 275 reported to LVN 1 that the resident's LBKA stump accidentally made contact with the floor, upon patient transfer by the CNA 1 from the toilet back to the resident's chair due to the CNA trying to put him (Resident 275) back onto the chair by herself. During a concurrent observation and interview on 5/26/2026 at 3:35 PM with Resident 275 at the facility's activity area, Resident 275 was sitting on his wheelchair with the LBKA stump covered with wound dressing. Resident 275 stated on 4/21/2026, CNA 1 attempted to transfer him alone by herself even though he normally required two staff members to assist him. Resident 275 stated, when transferring him from the toilet seat to his wheelchair, CNA 1 was unable to hold him up, causing him to slide down and his left stump hit the floor. During an interview on 5/29/2026 at 11:40 AM with LVN 1, LVN 1 stated on 4/21/26, CNA 1 asked for her assistance, and when she entered the room, Resident 275 was not on the floor, but the resident's left stump was touching the floor. LVN 1 stated, Resident 275 reported that CNA 1 was helping Resident 275 transfer from his toilet seat to his wheelchair when the resident slid down because CNA 1 could not hold him up. LVN 1 stated, CNA 1 had attempted to help Resident 275 by herself, but the resident was too heavy for CNA 1 to handle. During an interview on 5/29/2026 at 12:40 PM with CNA 1, CNA 1 stated on 4/21/2026 in the afternoon time (CNA 1 could not remember the exact time), she was helping to transfer Resident 275 from the toilet seat to the resident's wheelchair. CNA 1 stated, the wheelchair handles were facing away from Resident 275, he could not use them to stand up so CNA 1 tried lifting the resident up by holding under the resident armpits. CNA 1 stated Resident 275 was too heavy for her to lift, so he slid down and his left stump landed on the floor. CNA 1 stated Resident 275 was still on the edge of the toilet seat with his left stump on the floor when CNA 1 came out to call for help from LVN 1. CNA 1 stated she had never cared for Resident 275 before, had not received any change of shift report regarding the level of assistance that Resident 275 required, and therefore attempted to transfer the resident alone. During a concurrent interview and record review on 5/29/2026 at 1:43 PM with Rehabilitation Program Manager (RPM), Resident 275's PTDS dated 4/16/2026 and weight summary dated 4/21/2026, were reviewed. RPM stated, the record indicated Resident 275 was dependent on transferring from chair to chair including transferring from his wheelchair to the toilet seat. RPM added that due to Resident 275's new readmission diagnosis of LBKA and recorded weight of 212 pounds (unit of weight) on 4/21/2026, the resident required two-person physical assistance from the nursing staff and this information was communicated verbally to the nursing staff during daily huddle (to gather closely together in a small group) on 4/21/2026. During a concurrent interview and record review on 5/29/2026 at 2:41 PM with the MDS Nurse (MDSN), Resident 275's care plans for the resident's risk for falls were reviewed. MDSN stated when Resident 275 was readmitted on [DATE] after LBKA surgery, the fall risk care plan should be revised to reflect the resident' most current condition of LBKA. MDSN stated the added intervention of provide assistance with transferring on 4/24/2026 was too general and it should be specific on how much assistance and how many person physical assistance that Resident 275 required for transferring. During a concurrent interview and record review on 5/29/2026 at 2:50 PM with the MDS Nurse (MDSN), Resident 275's MDS dated [DATE] and care plan that address the resident's risk for falls and/or injuries related to unsteady gait with added new intervention on 4/24/2026 were reviewed. MDSN stated that the MDS indicated Resident 275 required maximal assistance for toilet hygiene and transfers. MDSN stated based on the resident's condition of 200pound in weight, and new LBKA, the resident required two-person physical assistance, which should have been clearly specified in the care plan for safety. The MDSN added that without adequate and proper assistance, the residents could fall. During an interview on 5/29/2026 at 3:40 PM with the Director of Nursing (DON), the DON stated the resident's care plan should be specific to the resident with the level of assistance needed for the resident to prevent fall. During a review of the facility's policy and procedures (P&P) titled Fall Risk Assessment, revised June, 2017, the P&P indicated: A)The Facility will ensure that the resident's environment remains as free of accident hazards as it possible, and that each resident receives adequate supervision and assistance to prevent accidents. B) An episode where a resident lost his/her balance and would have fallen, if not for staff intervention or if the resident caught themselves, is considered a fall. C)Facility Staff, with the support of the Attending Physician, will evaluate any post admission changes in a residents' functional and psychological status (a person's current mental [how a person thinks] and emotional [how a person feels] condition) that may increase fall risk, such as: changes in ambulatory ability, and balance. During a review of the facility's P&P titled, Fall Management Program, revised May 2026, the P&P indicated the program is to prevent resident falls and minimize complications associated with falls. The P&P indicated the facility will provide the highest quality care in the safest environment for the residents residing in the facility and the Fall Management Program is designed to prevent residents falls through meaningful assessments, interventions, education, and re-evaluation. The P&P also indicated the Nursing Staff will develop a plan of care specific to the resident's needs with interventions to reduce the risk of falls and interventions will be implemented or changed based on the resident's condition and response. 4. During a review of Resident 338's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included parkinsonism (a group of brain conditions that caused slowed movements, stiff muscles, tremors, and balance issues), osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D), and adult failure to thrive (a decline caused by chronic disease and functional impairments which could cause weight loss, decreased appetite, poor nutrition, and inactivity). During a review of Resident 338's Fall Risk (Morse) Assessment (a quick checklist used by healthcare providers to predict how likely a resident was to fall) dated 4/19/2025 at 12:04 PM, the Assessment indicated the resident was high risk for fall. During a review of Resident 338's History and Physical (H&P) dated 12/16/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 338's Physical Therapy Progress Report dated 5/1/2026 to 5/7/2026, the Progress Report indicated the resident was on precautions for falls and the resident's Functional Skills Assessment (evaluated how well a person could perform everyday tasks needed for independent living or work) indicated the resident was dependent (needing someone else for support, help, or survival). The Progress Report indicated the resident's Mobility Function Score was zero (ranged from zero to 12, 12 being the highest function). During a review of Resident 338's Minimum Data Set (MDS, resident assessment tool) dated 5/8/2026, the MDS indicated the resident had severe cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). During a review of Resident 338's History of Risk for Fall Care Plan dated 5/14/2026, the Care Plan indicated a goal for the resident to reduce the risk of falls or injury through appropriate interventions daily. The Care Plan indicated interventions to include a low bed, wheels locked, and call light within reach. During an observation in Resident 338's room on 5/26/2026 at 2:44 PM, the resident was observed in bed and the bed brake indicator was in the horizontal position with the left side of the indicator being green and the right side of the indicator being red. The indicator was not positioned toward the red marking that indicated the brakes were engaged or locked. During a concurrent observation in Resident 338's room and interview in Resident 338's room on 5/26/2026 at 3:02 PM, Certified Nursing Assistant (CNA) 5 stated the resident's bed was not locked and it should have been locked otherwise the bed could have moved and the resident could have fallen. During an interview on 5/26/2026 at 3:16 PM, Licensed Vocational Nurse (LVN) 18 stated Resident 338's bed was not locked because the bed brake indicator was in a horizontal position. LVN 18 stated the resident's brakes should have always been locked otherwise the resident could have fallen and have an injury or worse. During an interview on 5/28/2026 at 4:35 PM, the Director of Nursing (DON) stated bed safety features included for the bed to be lowered to the ground, and ensuring the beds were locked. The DON stated Resident 338's bed did not seem to be locked but should have been to prevent staff and resident injury. The DON stated if the bed was not locked, Resident 338 could have had a fall or fracture (break in the bone) and the resident could have been scared. During a concurrent interview and record review on 5/28/2026 at 4:49 PM with the DON, the facility's policy and procedure (P&P) titled Fall Management Program dated 6/1/2017 was reviewed. The P&P indicated the purpose of the P&P was to prevent resident falls and minimize complications associated with falls through the development of a Fall Management Program. The P&P also indicated the policy of the facility was to provide the highest quality of care in the safest environment for the residents residing in the facility. The P&P indicated universal fall prevention measured for all residents included placing the residents bed in the lowest position with the brakes locked. The DON stated the facility staff were not following the policy but should have been to prevent fall and injury like a fracture.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures to ensure the accurate acquiring, administering of drugs and biologicals to meet the needs for two (2) of three (3) sampled residents (Residents 2 and 202) observed for medication administration by failing to:Administer Resident 2's Lactulose oral solution (a medication used to treat chronic constipation)Administer Resident's 202's Rivaroxaban (to help prevent strokes or serious blood clots) oral tablet 20 milligrams (mg, units of measurement) and Venlafaxine Hydrochloride (a medication used to treat depression (a mood disorder characterized by persistent feelings of sadness, hopelessness, and a loss of interest in activities)) oral tablet 75 mg with foodThis deficient practice had resulted in Resident 2 and Resident 202 not receiving their medications as physician's order, which could negatively affect the residents' overall wellbeing.3. An accurate Controlled Drug (a drug or chemical whose manufacture, possession, and use are strictly regulated by the government because of its potential for abuse, misuse, or dependence) Record (CDR)s for Resident 2's use of hydrocodone-acetaminophen (a controlled drug to manage moderate to serve pain).This deficient practice had potential to lead to controlled drug abuse and diversion (when a medication is taken for use by someone other than whom it is prescribed or for an indication other than what is prescribed). Findings: 1. During a review of Resident 2's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems) and atrial fibrillation (an irregular and often very rapid heart rhythm). During a review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care planning screening tool), dated 4/11/2026, indicated Resident 2 had intact cognitive (ability to understand and make decisions) skills for daily decision making. The MDS indicated Resident 2 was independent with eating. The MDS indicated Resident 2 required partial/moderate assistance (helper does less than half) with toileting hygiene, shower/bathe self and chair/bed-to-chair transfer. During a review of Resident 2's Order Summary Report dated 5/28/2026, the Order Summary Report indicated a physician's order for Lactulose oral solution 20 grams (g-a unit of measurement) per 30 milliliters (ml-a unit of measurement) give 30 ml by mouth two times a day for bowel management, hold for loose stools. During a review of Resident 2's Medication Administration Record (MAR), dated May 2026, the MAR indicated Resident 2 to receive Lactulose oral solution 20 grams give 30 ml at 9 AM and 6 PM. During a concurrent medication pass observation and interview on 5/27/2026 at 9:19 AM with Licensed Vocational Nurse 12 (LVN 12), LVN 12 was observed preparing eight medications as listed below: 1.Cranberry (dietary supplement) 450 mg tablet 2.Depakote 125 (medication used to treat bipolar disorder (mental health condition causes extreme mood swings) mg tablet 3.Calcium Supplement (dietary supplement) 600 mg tablet 4.Stool Softener Docusate Sodium (medication for constipation)100 mg tablet 5.Cymbalta (medication used to treat depression) 60 mg cap tablet 6.Eliquis (anticoagulant medication) 2.5 mg tablet 7. Fish oil (dietary supplement)-1,000 mg tablet 8.Mutil Vitamin with minerals tablet During an observation on 5/27/2026 at 9:32 AM, LVN 12 brought the eight medications into Resident 2's room and started administering the medications. Resident 2 stated he did not see her Lactulose among the eight medications and asked LVN 1 where her Lactulose was. LVN 12 stated she forgot and returned to the medication cart to get Resident 2's Lactulose. LVN 12 stated the medication cart had an empty bottle of Lactulose and proceeded to ask LVN19 for Lactulose from the facilities medication storage room. During a follow up interview and observation on 5/27/2026 at 9:45 AM, LVN 19 was observed informing LVN 12 that the facility had run out of Lactulose, and she would be calling the pharmacy to ask them to deliver the medication as soon as possible. During an interview and record review on 5/28/2026 at 4:25 PM with the Director of Nursing (DON), the DON stated the licensed nurses should administer medications as scheduled to avoid medication error and prevent potential adverse effects from the underdosing and overdosing the residents. The DON 1 stated nurses should reorder medication before it runs out to prevent Residents from missing scheduled medications. 2.During a review of Resident 202's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE] with diagnoses including paraplegia complete (total loss of function, including the ability to feel sensation and move) and hypotension (low blood pressure). During a review of Resident 202's MDS, dated [DATE], indicated Resident 202's had intact cognitive skills for daily decision making. The MDS indicated Resident 202 requires supervision (helper provides verbal cues) with eating. The MDS indicated Resident 202 required partial/moderate assistance with oral hygiene, upper body dressing and personal hygiene. The MDS further indicated Resident 202 was dependent (helper does all of the effort) toileting hygiene, showers and lower body dressing. During a review of Resident 202's Order Summary Report dated 5/12/2026, the Order Summary Report indicated a physician's order for: Rivaroxaban oral tablet 20 mg give 20 mg by mouth one time a day for DVT (a blood clot that forms within the deep veins). Venlafaxine Hydrochloride (HCL) oral tablet 75 mg, given by mouth one time a day for depression manifested by verbalization of sadness. During a review of Resident 202's Medication bubble pack for Rivaroxaban oral tablet 20 mg, the medication bubble pack indicated take medication with food. During a review of Resident 202's Medication bubble pack for Venlafaxine HCL oral tablet 75 mg, the medication bubble pack indicated take medication with food. During a medication pass observation on 5/27/2026 at 9:04 AM with LVN 12, LVN 12 was observed administering Rivaroxaban oral tablet and Venlafaxine HCL oral tablet to Resident 202 with water and without food. After administering the medications, LVN 12 walked back to her medication cart to document Resident 202's medication administration record. During a concurrent interview and record review with LVN 12 on 5/27/2026 at 9:40 AM, LVN 12 stated she was aware that Resident 202's Rivaroxaban oral tablet and Venlafaxine HCL oral tablet required administration with food, but she assumed it was acceptable to administer them without food because Resident 202 had eaten breakfast around 7AM. During an interview and record review on 5/28/2026 at 4:20 PM with the Director of Nursing (DON), the DON stated Resident 202's medication bubble pack label indicated to administer Rivaroxaban oral tablet and Venlafaxine HCL oral tablet medications with food. The DON stated LVN 12 should have provided Resident 202 with a cracker or cookie if it was not mealtime and should not have administered the medications without food. The DON stated all licensed nurses administering medications should follow the medication orders to prevent potential undesired side effects. During a review of the facility's Policy and Procedure (P&P) titled, Medication Administration, revised 6/1/2017, the P&P indicated, Medications will be administered by a licensed nurse per the order of an attending physician or licensed independent practitioner. 3. During a review of Resident 2's admission Record (AR), the AR indicated the facility originally admitted Resident 2 on 10/21/2023 and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (a progressive, incurable lung disease that blocks airflow and makes it hard to breathe) and arthritis (a disease that causes damage in your joints). During a review of Resident 2's Minimum Data Set (MDS, an assessment and care planning tool), dated 4/11/2026, indicated Resident 2 had intact cognitive (ability to think and reason) skills for daily decision making. During a review of Resident 2's Order Summary Report, dated 5/29/2026, the report indicated the physician ordered to administer: 1. hydrocodone-acetaminophen oral tablet 5-325 milligram (MG, a measurement unit) one tablet by mouth every four hours as needed for moderate pain, starting on 4/15/2026. 2. administer hydrocodone-acetaminophen oral tablet 5-325 MG two tablets by mouth every four hours as needed for severe pain, starting on 5/27/2026. During a review of Resident 2's Controlled Drug Record (CDR) of hydrocodone-acetaminophen 5-325 MG 5-325 MG one-tablet and observation of the bubble pack, it showed the following: The CDR indicated a licensed nurse signature (not identified) on 5/27/26 at 1:40 AM on the line indicating 30 units/tablets (leaving 29 units/tablets) LVN 13's signature on 5/28/2026 at 12 AM on the line indicating 29 units/tablets (leaving 28 units/tablets). The bubble pack showed 28 tablets. The CDR did not reflect the medication administered on 5/27/2026 at 9:39 AM, which should leave the bubble pack with 27 tablets. During a review of Resident 2's CDR of hydrocodone-acetaminophen 5-325 MG 5-325 MG two-tablets and observation of the bubble pack, it showed the following: A licensed nurse signature (not identified) on 4/22/2026 at 6:55 PM on the line indicating 30 units/doses (leaving 29 units/doses = 58 tablets) LVN 12's signature on 5/27/2026 at 9:37 AM on the line indicating 29 units/doses (leaving 28 units/doses = 56 tablets) The bubble pack showed 29 units/doses = 58 tablets The bubble pack should have been left with 28 units/doses = 56 tablets. During a review of Resident 2's Medication Administration Record a(MAR), dated 5/1/2026 to 5/31/2026, the MAR indicated Resident 2 received hydrocodone-acetaminophen 5-325 MG one-tablet on 5/27/2026, timed at 9:39 AM. The MAR did not reflect that Resident 2 received hydrocodone-acetaminophen 5-325 MG one-tablet on 5/28/2026 at 12 AM. During a concurrent observation, interview, and CDR review on 5/28/2026 at 2:08 PM with LVN 12, LVN 12 stated she administered hydrocodone-acetaminophen 5-325 MG one tablet to Resident 2 on 5/27/2026 at 9:39 AM. LVN 12 stated she signed the CDR form indicating two tablets instead of the CDR indicating one tablet of hydrocodone-acetaminophen 5-325 MG. During an interview with LVN 13 on 5/29/2026 at 9:53 AM, LVN 13 stated Resident 2 complained of pain and had requested hydrocodone-acetaminophen 5-325 MG one tablet on 5/27/2026 at around 11:30 PM. LVN 13 stated she signed the CDR hydrocodone-acetaminophen 5-325 MG 5-325 MG one-tablet on 5/28/2026 at 12 AM. LVN 13 stated she did not end up administering the medication because Resident 2 refused. LVN 13 stated she should not have signed the CDR form prior to administration and since she did not administer it at all, she should have put a strike through on her signature and indicate error. LVN 13 stated it was important to have an accurate documentation to ensure necessary resident care was provided. During an interview with LVN 13 on 5/29/2026 at 9:57 AM, LVN 13 stated she conducted the narcotic count, including Resident 2's CDR, with LVN 14 on 5/27/2026 at 11 PM and with LVN 12 on 5/28/2026 at 7AM. During an interview with LVN 14 on 5/29/2026 at 11:07 AM, LVN 14 stated she conducted the narcotic count, including Resident 2's CDR, with LVN 12 on 5/27/2026 at 3PM and with LVN 13 on 5/27/2026 at 11PM. LVN 14 stated there were no discrepancies on Resident 2's CDR as compared to the bubble pack for both hydrocodone-acetaminophen 5-325 MG 5-325 MG and two tablets. During a concurrent review of Resident 2's CDR of hydrocodone-acetaminophen 5-325 MG 5-325 MG one and two tablets and observation of the bubble packs and interview with the Director of Nursing (DON) on 5/29/2026 at 2:40 PM, the DON stated the nurses should verify the discrepancies on the CDR and bubble pack. The DON stated the nurses should document correctly on the CDRs to ensure correct counts for the controlled medications. The DON stated the nurses should verify the physical doses of the controlled medication counts against the CDRs during their shift change controlled drug reconciliation. The DON further stated this will ensure all controlled medications were accounted for and are reported immediately if there are any discrepancies. The DON stated correct documentation and thorough controlled drug count could prevent abuse, diversion and ensure necessary care is provided to the residents. During a review of the facility's Policy and Procedure (P&P) titled, Medication Storage in the Facility-ID2: Controlled Substance Storage, dated 1/2022, the P&P indicated At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items is conducted by two licensed nurses and is documented. During a review of the facility's P&P titled, Medication Administration, dated 6/1/2017, indicated licensed nurse will chart the drug, time administered, and initial his or her name with each medication.

Based on observation, interview and record review, the facility failed to:1. Discard an expired Bottle and Dressing Pack (a sterile, single-use kit used to safely drain fluid buildup from the chest or stomach) and eight (8) boxes of expired Arginaid Oral Powder (an oral supplement to support nutritional needs of wound patients) in Unit 900's Medication Storage Room.2. Store Resident 147's lorazepam (a scheduled IV controlled medication [a drug regulated by the government because it carries a risk of misuse, abuse, or physical and psychological dependence] that can create mental and physical addiction or dependency and used to treat anxiety [fear of the unknown]) in a locked container separate from the other non-scheduled medications (drugs that not regulated under federal schedules and they have a low potential for abuse or dependence). inside the medication refrigerator in the Unit 900's Medication Storage Room. 3. Ensure medications were properly stored and secured for one of 15 Medication Carts when 10 loose medications were observed in two separate areas of Medication Cart Number One in Station Two.4. Store Resident 27's unopened Latanoprost (a prescription eye drop used to lower pressure inside the eye) in the refrigerator as instructed by pharmacy.5. Maintain a first aid kit in Unit 400's medication room when it the kit was found to be expired. These deficient practices had the potential to cause infection and malfunction of drainage system for the residents who required drainage care and had the potential to result in accidental consumptions and result in adverse reactions (undesired effects) from the supplements and harms for the residents. In addition, these deficient practices had the potential for medication theft or diversion (when a medication is taken for use by someone other than whom it is prescribed or for an indication other than what is prescribed) and had the potential to affect residents receiving medications from the medication cart through medication error (any preventable event that may cause or lead to inappropriate medication use or patient harm) and/ or contamination. 1. During a concurrent observation in Unit 900's Medication Storage Room and interview on 5/28/2026 at 11:40 AM with Licensed Vocational Nurse (LVN) 11, observed a sealed Bottle and Dressing Pack with the expiration date of 8/14/2025 on the shelf in the Medication Storage Room. LVN 11 stated the Bottle and Dressing Pack was used for drain fluid from a resident, but this pack was expired. LVN 11 stated the nurse should remove the expired Bottle and Dressing pack from the Medication Storage Room and discard it to avoid accidental usage on a resident to prevent infection and malfunction. During a concurrent observation in Unit 900 Medication Storage Room and interview on 5/28/2026 at 11:45 AM with LVN 11, observed four (4) boxes of Arginaid Oral Powder packets with the expiration date of 11/26/2025 and 4 boxes of Arginaid Oral Powder packets with the expiration date of 1/29/2026 stored in the shelf LVN 11 stated the 8 boxes of Arginaid Oral Powder packets were expired, should not be stored in the Medication Storage Room and it should have been discarded to avoid accidental consumption and cause adverse effects. 2. During a review of Resident 147's admission Record (AR), the AR indicated the facility originally admitted Resident 147 on 8/16/2021 and readmitted her on 4/3/2026 with diagnoses that included type II diabetes mellitus (a condition that happens when your blood sugar is too high) and chronic kidney disease (a disease that kidneys [an organ that filter waster from the blood] were damaged). During a review of Resident 147's Minimum Data Set (MDS, a resident assessment tool), dated 2/28/2026, indicated Resident 147 had moderately impaired memory and cognition (ability to think and reason). During a review of Resident 147's Order Summary Report, dated 5/29/2026, the report indicated the physician ordered to administer Lorazepam oral concentrate two milligram (MG, a measurement unit)/ milliliter (ML, a measurement unit) 0.5 ML every two hours as needed for anxiety, starting on 5/28/2026. During a concurrent observation in the Unit 900 Medication Storage Room and interview on 5/28/2026 at 12:06 PM with LVN 11, one bottle of Resident 147's Lorazepam oral concentrate was stored with other medications inside the medication refrigerator. LVN 11 stated Lorazepam was a controlled medication, and it was stored inside the locked refrigerator together with all other medications inside the refrigerator. During an interview on 5/29/2026 at 2:38 PM with the Director of Nursing (DON), the DON stated the nurses should check the medications and supplies in the medication storage rooms to ensure the medications, supplements and supplies were not expired to prevent accidental consumption and use that could cause undesired adverse effects to the residents. The DON stated according to the facility's policy, Lorazepam should be stored in a permanently affixed locked box within the refrigerator, separating from all other medications to prevent abuse or diversion. During a review of the facility's Policy and Procedure (P&P) titled, Disposal of Medications and Medication-Related Supplies-IE5: Medication Destruction for Non-Controlled Medications, dated 1/2022, the P&P indicated Unused, unwanted and non-returnable medications should be removed from their storage area and secured until destroyed. During a review of the facility's P&P titled, Medication Storage in the Facility-ID2: Controlled Substance Storage, dated 1/2022, the P&P indicated Schedule [II-V] medications and other medications subject to abuse or diversion are stored in a permanently affixed, double locked compartment separate from all other medications or per state regulation and Controlled-substances that require refrigeration are stored within a locked box within the refrigerator. This Box must be attached to the inside of the refrigerator. 3. During an observation of medication cart number one in Station Two, on 5/28/2026 at 1:22 PM, six loose medication pills were found in the second right hand drawer – four small round white colored pills, one larger round white colored pill, and one oval sized beige colored pill underneath the resident's medication blister packs (a safe, easy-to-use packaging method where the pharmacist organized your pills into clear plastic bubbles). During an observation of medication cart number one in Station Two, on 5/28/2026 at 1:35 PM, four loose medication pills were found in the third right hand drawer – two small round white colored pills, one slightly larger white colored pill, and one small round peach colored pill underneath the resident's medication blister packs. During an interview on 5/28/2026 at 1:25 PM, Licensed Vocational Nurse (LVN) 17 stated she did not know the type of medications that were found and did not know which resident's the medications belonged to. LVN 17 stated there should not have been any loose medications in the medication cart for residents' and staff's safety. LVN 17 stated having loose medications in the medication cart was a hygiene and safety issue and someone could take them. LVN 17 stated there were different types of medications within this section of the medication cart including blood pressure medications and if someone were to take them, that persons blood pressure could elevate or drop, especially if that person were not taking those types of medications. During an interview on 5/28/2026 at 4:38 PM, the Director of Nursing (DON) stated all medications should have been in a labeled container to know what medications were being administered to the residents. The DON stated that when there were medications not in labeled containers, the medications could be dropped on the floor, other resident's could have picked them up, and those resident's could have had an allergic reaction or adverse reaction (an unexpected, unwanted, or harmful physical response to a medication or treatment) to the medications. During a concurrent interview and record review on 5/28/2026 at 4:52 PM with the DON, the facility's policy and procedure (P&P) titled Medication Storage in the Facility dated January 2022 was reviewed. The P&P indicated medications and biologicals (advanced medicines made from living cells rather than artificial chemicals) were stored safely, securely, and properly, following manufacturer's recommendations. The P&P also indicated the provider pharmacy dispenses medications in containers that meet regulatory requirements, medications were to be kept in theses containers, and all medications dispensed by the pharmacy were to be stored in the container with the pharmacy label. The DON stated the facility staff were not following the policy but should have been to prevent medication and administration errors. The DON stated if the facility was not following the policy those loose medications could have been administered to residents and the residents could have had an adverse reaction or a side effect to the medication. 4. During a review of Resident 27's admission Record (AR), the AR indicated the facility admitted Resident 27 on 7/22/2025 with diagnoses that include diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension (high blood pressure). During a review of Resident 27's Physician's Order, dated 11/1/2025, the order indicated 1 drop of Latanoprost eye drop to be administered in each eye at bedtime every day. During a review of Resident 27's Minimum Data Set (MDS – resident assessment tool), dated 4/29/2026, the MDS indicated Resident 27 had moderate impairment in cognition (ability to understand and make decisions) and memory. During a concurrent observation and interview on 5/29/2026 at 10:34 AM with Licensed Vocational Nurse (LVN) 9 in Unit 300 hallway, an unopened Latanoprost was observed in medication cart 1. LVN 9 stated the unopened Latanoprost should be kept in the refrigerator. LVN 9 stated, the medication would not be effective since it was not kept in the fridge. During an interview on 5/29/2026 at 11:09 AM with Assistant Director of Nursing (ADON) ADON stated the directions from pharmacy for Latanoprost is to refrigerate the medication prior to opening it. ADON also stated that the Latanoprost that was stored in the medication cart needs to be disposed of because it is no longer effective for use. During a review of the United States Food and Drug Administration (FDA) label titled, Xalatan (Latanoprost), dated August 2011, the FDA indicated store unopened bottle(s) under refrigeration .once a bottle is opened for use, it may be stored at room temperature for six weeks. During a review of the facility's P&P titled, Medication Ordering and Receiving from Pharmacy, dated 1/2022, the P&P states medications are provided in packaging to facilitate accurate administration and accountability of the medication. The P&P also indicated medications that are not stored in the medication cart may have different regulations such as medications requiring refrigeration. 5. During a concurrent observation in Unit 400's medication storage room and interview on 5/27/2026 at 11:58 AM with Unit Manager Licensed Vocational Nurse (LVN) 10, an expired first aid kit was observed with the emergency supplies. LVN 10 stated, the first aid kit expired last 4/30/2019. During an interview on 5/29/2026 at 11:09 AM with ADON, ADON stated first aid kits are to be maintained with the emergency supplies. ADON also stated it is the responsibility of the nursing staff to check expiration dates prior to using materials for residents and maintenance is responsible for ensuring emergency supplies are available. ADON stated, using expired materials may lead to infection. During a review of the facility's P&P titled, Emergency Equipment and Systems, dated 4/1/2024, the P&P indicated the facility will maintain emergency equipment and the Director of Maintenance is responsible for documenting that the facility has the necessary emergency equipment.

Based on observation, interview, and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed for two of seven sampled residents (Residents 380 and 2) in accordance with the facility's policy and procedure when:1. Resident 380's Peripheral Inserted Central Catheter (PICC, a long, thin, flexible tube inserted through a vein in the upper arm and guided into a large vein near the heart) line dressing was not changed every seven (7) days) in accordance with the physician's order.2. Licensed Vocational Nurse 12 (LVN 12) did not wear gloves during an intramuscular (IM) injection medication administration of Resident 2's Ceftriaxone (medication used to treat bacterial infections) on 5/27/2026.These deficient practices have the potential to cause infection to Resident 2 and to Resident 380's PICC line site, which could result in other complications. 3. The lids of 7 of 20 disinfectant wipe containers were not closed.This failure had the potential to allow the disinfectant wipes to dry out and become exposed to environmental contaminants, decreasing their effectiveness in killing viruses and bacteria, which could increase the risk of infections in residents. 1. During a review of Resident 380's admission Record (AR), the AR indicated the Resident 380 was admitted on [DATE] and readmitted on [DATE] with diagnoses that include Extended-Spectrum beta-lactamase (ESBL, bacteria resistant to many common antibiotics, making infection harder to treat) resistance and presence of right artificial knee joint (right knee replacement). During a review of Resident 380's Minimum Data Set (MDS, an assessment and screening tool), dated 4/5/2026, the MDS indicated Resident 380 had intact cognitive (ability to understand and make decisions) skills for daily decision making. The MDS indicated Resident 380 required setup or clean-up assistance with eating, partial/moderate assistance (helper does less than half the effort) with oral hygiene and personal hygiene, and was dependent (helper does all of the effort) with toileting hygiene, shower/bathe self, and chair/bed-to-chair transfer. During a review of Resident 380's Order Summary Report, dated 5/27/2026, the report indicated the physician ordered to change transparent dressing and injection cap and extension for PICC line every day every 7 days and as needed if integrity is compromised, starting on 5/24/2026. During a concurrent observation and interview on 5/26/2026 at 10:54 AM with Licensed Vocational Nurse 7 (LVN 7), Resident 380 observed with a PICC line with a dressing covered at her right upper arm. T without a date and initial. LVN 7 stated there was no date and initial on Resident 380's PICC line dressing. During a concurrent observation and interview on 5/26/2026 at 10:56 AM with Registered Nurse (RN) 3, RN 3 stated Resident 380 has a PICC line for intravenous (IV, a medical technique used to deliver fluids, medications, or nutrients directly into a person's bloodstream through a vein) antibiotic (medications that treat bacterial infections) administration. RN 3 stated she does not know whether Resident 380's PICC line was changed or when it was changed because there was no date and initial on the resident's PICC line dressing. RN 3 stated Resident 380's PICC line dressing should be changed every 7 days per the facility's policy. RN 3 stated the nurse should date and initial on the PICC line dressing so other nurses would know when it was changed and when to change it again to prevent infection at the PICC line site. During an interview on 5/29/2026 at 2:33 PM with the Director of Nursing (DON), the DON stated the nurse should date and initial the PICC line dressing to ensure the dressing would be changed every 7 days to prevent infection at the PICC line site and prevent potential complications to the residents. During a review of the facility's policy and procedure (P&P) titled, PICC Line Dressing Change Protocol, dated 7/26/2010, the P&P indicated to Date and initial dressing. The P&P also indicated to change PICC line dressing every week. Findings: 2. During a review of Resident 2's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems), and atrial fibrillation (an irregular and often very rapid heart rhythm). During a review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care planning screening tool), dated 4/11/2026, indicated Resident 2's had intact cognitive (ability to understand and make decisions) skills for daily decision making. The MDS indicated Resident 2 was independent with eating. The MDS indicated Resident 2 required partial/moderate assistance toileting hygiene, shower/bathe self and chair/bed-to-chair transfer. During a review of Resident 2's Order Summary Report dated 5/28/2026, the Order Summary Report indicated a physician order for: 1.Ceftriaxone sodium injection 1 gram (GM-a unit of measurement), inject 1 GM intramuscularly one time a day for urinary tract infection (UTI) for 10 days with 1.2 milliliters (ML-a unit of measurement) lidocaine (sterile solution) During a medication pass observation on 5/27/2026 at 9:35 AM with Licensed Vocational Nurse 12 (LVN 12), LVN 12 was observed injecting Resident 2 in the right upper arm without wearing gloves. During an interview on 5/27/2026 at 9:39 AM with LVN 12, LVN 12 stated she should always wear gloves when administering injection medications to any residents. LVN 12 stated she got distracted while talking to Resident 2 and forgot to put on gloves before administering Resident 2's Ceftriaxone IM medication. During an interview on 5/28/2026 at 4:26 PM with Director of Nursing (DON), the DON stated licensed nurses should always wear new clean gloves before giving any injection medications to any residents. The DON stated this is part of the facility's infection control practices to prevent any contamination to the residents. During a review of the facility's policy and procedure (P&P) titled, Medication Administration, revised 6/01/2017, the P&P indicated, Gloves will be worn to administer medications when contact with blood or potentially infectious body fluid is anticipated. 3. During an observation on 5/29/2026 at the hallway of Nursing Unit 2, the lids of 3 disinfectant wipe containers were open, with the cloth hanging out of the top of the containers mounted in front of Resident Rooms 201, 214 and 226. During an observation on 5/29/2026 at 11:10AM in the hallway of Nursing Unit 8, the lids of 2 disinfectant wipe containers were open, with the cloths hanging out of the top of the container mounted in front of Resident rooms [ROOM NUMBERS]. During an observation on 5/29/2026 at 11:20AM in the hallway of Nursing Unit 9, the lids of 2 disinfectant wipe containers were open, with the cloths hanging out of the top of the container mounted in front of Resident rooms [ROOM NUMBERS]. During an interview on 5/29/2026 at 11:25AM with the Charge Nurse (CN), CN stated that the disinfectant wipes were to be used to clean side rails, bedside tables, and equipment. CN also stated that staff were taught to close disinfectant container lids after each use. During an interview on 5/29/2026 at 11:30AM with Infection Preventionist Nurse (IPN), IPN stated that the disinfectant wipe container lids must be closed to prevent the wipes from drying out, thus not providing the proper disinfecting qualities. IPN also stated that when the disinfectant wipe container lids are left open, it could cause an increased risk of infection in residents. During a review of the facility's disinfectant wipes manufacturer's instructions (undated), the instructions indicated closing the lid after each use to retain moisture. During a review of the facility's policy and procedure titled (P&P), Cleaning & Disinfection of Environmental Surfaces, dated January 2026, the P&P indicated that all disinfectants must be used per the manufacturer's instructions.

Based on observation, interview, and record review, the facility did not provide privacy for one of one sampled resident (Resident 217) reviewed for dignity when Resident 217 was exposed from the waist down during activities of daily living on 5/27/2026.The deficient practice had the potential to result in Resident 217 not being able to enhance the resident's sense of well-being and feeling of self-worth and self-esteem.Findings: During a review of Resident 217's admission Record (AR), the AR indicated Resident 217 was admitted on [DATE] with diagnosis that included Parkinson's disease (progressive neurological disease characterized by a fixed inexpressive face, tremor at rest, slowing of voluntary movements), type 2 Diabetes Mellitus (DM 2, a condition that results in too much sugar circulating in the blood), anxiety disorder (a group of mental disorders characterized by significant feelings of fear that affect with daily activities), and bipolar disorder (a mental illness that causes unusual shifts in mood, energy, and concentration). During a review of Resident 217's [NAME] Data Set (MDS, a resident assessment), dated 5/13/2026, the MDS indicated Resident 217 had an intact cognitive (ability to think, remember, and reason) skills for daily decision making. Resident 217 needed substantial/maximal assistance in toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement).During an observation on 5/27/2026 at 12:50 PM in Resident 217's room, Resident 217 was naked from the waist down while no curtain was drawn.During an interview on 5/27/2026 at 12:52 PM with CNA 2, CNA 2 stated she was in Resident 217's room and was about to help her change but CNA 2 needed to attend to another resident in the next room, so CNA 2 left the room without closing the curtain. CNA 2 stated she should have closed the curtain before she left Resident 217's room. During an interview on 5/27/2026 at 1 PM, LVN 2 stated CNA 2 should have drawn the curtain to provide privacy for Resident 217 before CNA 2 left the resident's room. During an interview on 5/27/2026 at 2 PM with Resident 217, Resident 217 stated she was very angry because of being seen by strangers when she was naked from the waist down. Resident 217 stated, CNA 2 told her that she would come back and did not close the curtain when she left the room. During an interview on 5/28/2026 at 5:17 PM with the Director of Nursing (DON), the DON stated Resident 217 should have privacy at all time and CNA 2 should have closed the curtain before leaving the room to protect Resident 217's privacy. During a review of the facility's policy and procedures (P&P) titled, Privacy and Dignity, revised June 2017, the P&P indicated the facility promotes resident care in a manner and an environment that maintains or enhances dignity and respect, in full recognition of each resident's individuality. During a review of the facility's P&P titled, Resident Rights, revised June 2017, the P&P indicated that the facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment, that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality; and that employees are to treat all residents with kindness, respect, and dignity.

Based on interview and record review, the facility failed to complete the Minimum Data Set (MDS, a standardized assessment and care screening tool) within 14 calendar days of admission for one of seven sampled residents (Resident 336) reviewed for Resident Assessment.This failure had the potential to delay the development of a resident centered care plan which may result in Resident 336 not receiving timely care and services needed for overall wellbeing.Findings:During a review of Resident 336's admission Record, the admission Record indicated Resident 336 was admitted on [DATE], with the following diagnoses but not limited to; malnutrition (imbalance between the nutrients the body needs to function and the nutrients it gets), type two diabetes (where the body either cannot make process sugars in the blood properly), and dementia (a decline in mental abilities severe enough to interfere with daily life).During a review of Resident 336's MDS, dated [DATE], the MDS did not indicate it was completed within 14 days of Resident 336's admission [DATE]). The MDS sections for Mood, Behavior, and Participation in Assessment and Goal Settings were not completed.During a concurrent interview and record review on 5/29/2026 at 11:25 AM with the MDS Nurse (MDSN), Resident 336 MDS was reviewed. The MDS indicated sections for Mood, Behavior, and Participation in Assessment and Goal Settings were completed on 5/28/2026 at 1:04 PM (23 days after admission). MDSN stated this assessment was not completed on time which could affect how Resident 336 is cared for and when the care begins.During a review of the facility's Policy and Procedure (P&P) titled, Resident Assessment Instrument Process, reviewed 6/2017, the P&P indicated that MDS Completion Date for admission is to be on the 14th calendar day of the resident's admission.

Based on interview and record review, the facility failed to complete a Minimum Data Set (MDS-a resident assessment and care-screening tool) discharge tracking assessment (a type of assessment conducted when a resident leaves a nursing home, which includes clinical items for quality monitoring as well as discharge tracking and is transmitted to the Centers for Medicare and Medicaid Services [CMS, a United States government agency that administers healthcare programs]) for one (1) of seven (7) sampled residents (Resident 319) reviewed for Resident Assessment. This deficient practice had the potential to result in the facility's inaccurate quality monitoring data at transition points, such as when residents enter or leave the facility.Findings: During a review of Resident 319's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE] with diagnoses including osteoarthritis of the knee (wear-and-tear joint disease) and hypertension (blood pressure that is higher than normal). During a review of Resident 319's medical records, the Medical Records indicated Resident 319 was discharged to home on 1/30/2026.During a review of resident 319's MDS summary, the MDS Summary indicated a Discharge-return not anticipated MDS, dated [DATE], but was completed on 2/15/2026 (2 days after discharge). During an interview and concurrent record review of Resident 319's Discharge MDS on 5/28/2026 at 12:46 PM with the MDS Nurse (MDSN), the MDSN stated she was responsible to make sure all the residents' MDS assessments were completed and transmitted to CMS system timely. The MDSN stated the facility has 14 days to complete a Discharge MDS from Resident 309's discharge date and another 14 days after completion to transmit to CMS. The MDSN stated Resident 319's discharge MDS was completed late, which was past the 14-day after the resident was discharged from the facility. During a review of the facility's Policy and Procedure (P&P), titled Resident Assessment Instrument (RAI) Process, revised 10/01/2019, the P&P indicated, The facility will transmit MDS assessments in accordance with the transmission dates outlined in the RAI Omnibus Budget Reconciliation Act (OBRA, comprehensive federal law that applies to all nursing homes receiving Medicare and/or Medicaid funding, establishing enforceable standards for resident care and facility operations) required assessment summary and Medicare assessment reporting schedule. During a review of the CMS Long-Term Care Facility MDS 3.0 RAI User's Manual, updated 10/2025, indicated the discharge MDS must be completed within 14 calendar days after the resident's discharge date (i.e., discharge date + 14 days) and once completed, the assessment must then be submitted within 14 calendar days of completion

Based on interview and record review, the facility failed to create a measurable activities care plan for one of 35 sampled residents (Resident 336).This failure has the potential for Resident 336's activity needs not to be met which could result in negatively affecting the resident's psychosocial wellbeing.Findings:During a review of Resident 336's admission Record, the admission Record indicated Resident 336 was admitted on [DATE], with the following diagnoses but not limited to; malnutrition (imbalance between the nutrients the body needs to function and the nutrients it gets), type two diabetes (where the body either cannot make or process sugars in the blood properly), and dementia (a decline in mental abilities severe enough to interfere with daily life).During a review of Resident 336's Minimum Data Set (MDS) dated [DATE], the MDS indicated Resident 336 was severely impaired with cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated that Resident 336 needed some help (partial assistance from another person to complete activities) with activities of daily living such as bathing, dressing, using the toilet, or eating.During a concurrent interview and record review on 5/29/2026 at 12:02 PM with the Activities Director (AD), Resident 336's Activity Care Plan, dated 5/5/2026 was reviewed. The Activity Care Plan indicated Resident 336 was dependent on staff for activities, cognitive stimulation, and social interaction due to cognitive deficits, immobility, and physical limitations. The goal for Resident 336 was to remain involved in cognitive stimulation and social activities as desired, but no measurable objectives (defined quantity or duration) were included. The AD stated that Resident 336's Activities Care Plan did not include measurable objectives for the goal.During an interview on 5/29/2026 at 2:30 PM with the Activities Care Consultant (ACC), the ACC stated that she has noticed the facility's activity care plans' goal are not measurable or quantifiable. The ACC further stated that care plans must be measurable because, if a resident has cognitive impairment, they could experience further decline and be at risk for isolation.During a review of the facility's Policy and Procedure (P&P) titled, Care Planning, revised 10/24/2022, the P&P indicated that the care plan will include measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs.

Based on interview and record review, the facility failed to review and revise all care plans by the target date for one of one sampled resident (Resident 336) reviewed for care planning.This failure had the potential to negatively impact the timeliness and appropriateness of Resident 336's interventions and care needs.Findings:During a review of Resident 336's admission Record, the admission Record indicated Resident 336 was admitted on [DATE], with the following diagnoses but not limited to; malnutrition (imbalance between the nutrients the body needs to function and the nutrients it gets), type two diabetes (where the body either cannot make or process sugars in the blood properly), and dementia (a decline in mental abilities severe enough to interfere with daily life).During a review of Resident 336's Minimum Data Set (MDS) dated [DATE], the MDS indicated Resident 336 was severely impaired with cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated that Resident 336 needed some help (partial assistance from another person) with activities of daily living such as bathing, dressing, using the toilet, or eating.During a concurrent interview and record review on 5/29/2026 at 12:44 PM with the MDS Nurse (MDSN), Resident 336's care plans on the facility's electronic medical records (EMR) system, the page titled, Care Plan Reviews, was reviewed. Resident 336's Dietary, Nursing, Social Services, and Therapy care plans did not indicate they were reviewed and completed by the target date of 5/25/2026. The MDSN stated that Resident 336's care plans were not reviewed and revised by the 5/25/2026 target date. The MDSN stated that when care plans are not reviewed and completed by the target completion date, there is a delay in the resident's care.During a review of the facility's Policy and Procedure (P&P) titled, Care Planning, dated 10/24/2022, the P&P indicated that the care plan must be periodically reviewed and revised by a team of qualified persons after each assessment.

Based on observation, interview, and record review, the facility failed to ensure proper maintenance and position of an indwelling urinary catheter (Foley catheter [FC]- a hollow tube inserted into the bladder to drain or collect urine) for one of two sampled residents (Resident 330) reviewed for catheter care area when staff did not maintain the FC tubing free of dependent loops (a U shaped sag in the drainage tubing that dips below the collection bag, allowing urine to pool and increasing the risk of infection). This deficient practice placed Resident 330 at risk for impaired urine drainage and increased the potential for urinary tract infection (UTI- an infection in the bladder/urinary tract).Findings:During a review of Resident 330's admission Record, the record indicated Resident 330 was admitted to the facility on [DATE] with diagnoses including quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), kidney failure, and urine retention (a condition where the bladder is unable to empty completely). During a review of Resident 330's Minimum Data Set (MDS- a resident assessment tool) dated 5/28/2026, the MDS indicated Resident 330 was cognitively intact (no issues with memory, attention, problem solving, judgement, and planning) and dependent on staff (helper does all of the effort) for all cares such as bathing and toileting. The MDS also indicated Resident 330 used a FC for urinating. During an observation on 5/26/2026 at 10:34 AM, Resident 330's FC was observed. The drainage catheter was observed hanging with a U-shaped sag that dipped below the collection bag with urine pooled in the drainage catheter. During another observation on 5/29/2026 at 11:50 AM, Resident 330's FC was observed with a dependent loop and urine pooled in the looped portion of the drainage catheter. During an interview with Licensed Vocational Nurse (LVN) 19 on 5/26/2026 at 11:02 AM and concurrent observation of Resident 330's FC, LVN 19 stated that FCs should drain continuously without dependent loops or kinks. LVN 19 stated dependent loops, like the one on Resident 330's FC tubing, could cause urine to flow back up into the resident and could cause discomfort, pain, and infection. During an interview with the Director of Nursing (DON) on 5/28/2026 at 4:57 PM, the DON stated foley catheters should not have a dependent loop and the staff was not following the facility's policy when there were dependent loops along Resident 330's FC. During a review of the facility's Policy and Procedure (P&P) titled, Catheter - Care of, revised 6/1/2017, the P&P indicated, An unobstructed flow of urine should be maintained. In order to achieve a free flow of urine. Catheter tubing should be secured to prevent dependent loops.

Based on observation, interview and record review, the facility failed to provide respiratory care services for two (2) of five (5) sampled residents (Residents 16 and 57) reviewed for respiratory care by failing to: 1. Administer continuous oxygen at 2 liters per minute (L/min, Measurement units) to Resident 16 in accordance with the physician's order.This deficient practice had the potential for Resident 16 to experience respiratory distress. 2. Ensure Resident 57 received aerolized inhaled medications (breathing treatment) as indicated on the physician's order.This deficient practice resulted in Resident 57 not receiving breathing treatment as ordered, which increased the risk of shortness of breath, wheezing, and respiratory distress. 1. During a review of Resident 16's admission Record (AR), the AR indicated the facility originally admitted Resident 16 on 9/3/2025 and readmitted on [DATE] with diagnoses that include chronic obstructive pulmonary disease (a progressive, incurable lung disease that blocks airflow and makes it hard to breathe) and dementia (a term for a decline in mental ability severe enough to interfere with daily life). During a review of Resident 16's Minimum Data Set (MDS, an assessment and care planning screening tool), dated 5/6/2026, the MDS indicated Resident 16 had severely impaired cognitive skills (ability to understand and make decisions) for daily decision making. The MDS indicated Resident 16 required substantial/maximal assistance (helper does more than half the effort) with oral hygiene and personal hygiene, and was dependent (helper does all of the effort and resident does none of the effort to complete the activity) on toileting hygiene, shower/bathe self and chair/bed-to-chair transfer. The MDS indicated Resident 16 was on oxygen therapy. During a review Resident 16's Physician Summary Report, dated 527/2026, the report indicated the physician ordered to administer oxygen at 2 L/min via nasal cannula (NC, a flexible tube with two prongs used to deliver supplemental oxygen directly into the nostrils), with a start date of 5/11/2026. During a concurrent observation and interview on 5/26/2026 at 2:16 PM with Licensed Vocational Nurse 7 (LVN 7), Resident 16 was lying in bed with her oxygen NC was on the floor. LVN 7 stated Resident 16 should be receiving oxygen at 2 L/min continuously and the staff are expected to check on the resident to ensure she is receiving oxygen as ordered. During a concurrent observation and interview on 5/27/2026 at 9:50 AM with LVN 8, Resident 16 was lying in bed and was not receiving oxygen. Resident 16's oxygen concentrator (a medical device that filters ambient air to deliver 85-95% pure oxygen to individuals with respiratory conditions) was turned off, and both of the resident's oxygen tubing and concentrator were stored next to the bedside nightstand. LVN 8 stated she did not check Resident 16's physician orders and was not aware that the resident was supposed to receive oxygen continuously. LVN 8 stated when she started her shift at 7 AM, the resident was not on oxygen and her oxygen supplies were stored next to the nightstand, leading her to believe the resident was either no longer on oxygen or receiving it only as needed. LVN 8 further stated the previous shift nurse did not endorse that the resident was on continuous oxygen therapy. During a concurrent interview and record review on 5/28/2026 at 12:38 PM with the MDS Nurse (MDSN), Resident 16's Care Plan was reviewed. The MDSN stated the nurse did not develop a Care Plan to address the use of oxygen therapy for Resident 16. The MDSN stated the nurse should develop the Care Plan for oxygen usage to ensure Resident 16's needs are met, maintain adequate oxygen, and prevent respiratory complications. During an interview on 5/29/2026 at 2:35 PM with the Director of Nursing (DON), the DON stated the nurse should check and follow the physician's order to ensure residents receive oxygen therapy. The DON stated the nurse should develop a Care Plan to address the oxygen usage to ensure residents receive adequate oxygen and prevent respiratory distress and complications. During a review of the facility's Policy and Procedure (P&P) titled, Oxygen Administration, dated 6/1/2017, the P&P indicated for the staff to check the physician's order and turn on the oxygen at the prescribed rate to prevent or reverse hypoxemia (an abnormally low level of oxygen in the blood) and provide oxygen to the tissues. During a review of the facility's P&P titled, Care Planning, dated 10/24/2022, the P&P indicated To ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs. 2. During a review of Resident 57's admission Record, the admission Record indicated the resident was admitted on [DATE] with diagnoses that included aphasia (disorder that affects how you communicate) following cerebral infarction (ischemic stroke, occurs when a blood vessel in the brain is blocked or narrowed), acute and chronic respiratory failure with hypoxia (occurs when the lungs cannot adequately transfer oxygen into the blood stream), and chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty breathing) with acute exacerbation (a sudden, significant worsening of a chronic condition). During a review of Resident 57's History and Physical (H&P), dated 4/29/2026, indicated the resident had poor decision making capacity. During a review of Resident 57's Order Summary Report (OSR) dated 4/27/2026, the OSR indicated a physician order for Ipratropium-Albuterol Inhalation Solution (a combination bronchodilator [type of medication that makes breathing easier by relaxing the muscles in the lungs and widening the airways] used to prevent and treat airway narrowing [bronchospasm] in adults with COPD) 0.5-2.5 milligrams (mg, unit of measure) per three (3) milliliters (ml, unit of measure), 3 ml inhale orally every four (4) hours for shortness of breath (SOB)/wheezing. During a review of Resident 57's Care Plan titled The resident had COPD, dated 4/28/2026, the Care Plan indicated an intervention to give aerosol or bronchodilators (Ipratropium-Albuterol, Albuterol Sulfate) as ordered and to monitor/document any side effects and effectiveness. During an observation in Resident 57's room on 5/26/2026 at 9:50 AM, Resident 57 was observed sleeping and not wearing nebulizer mask (soft, face-covering device that connects to a nebulizer machine to deliver medication as a fine mist directly into the lungs) during breathing treatment. During a concurrent observation and interview in Resident 57's room with Assistant Director of Nursing (ADON) on 5/26/2026 at 10:17 AM, Resident 57 observed sleeping in the same position and not wearing nebulizer mask. ADON confirmed Resident 57's nebulizer mask was not on and stated the mask was used for his breathing treatment. ADON turned off Resident 57's nebulizer machine and stated the purpose of the breathing treatment was for shortness of breath and wheezing. ADON stated if Resident 57 does not receive the breathing treatment he could have shortness of breathing, wheezing, or require additional respiratory services. ADON stated the nebulizer mask should be in place during the duration of the treatment and the mask should be on the resident. During an interview with the Director of Nursing (DON) on 5/28/2026 at 4:45 PM, the DON stated the purpose of wearing the nebulizer mask during a breathing treatment was for better inhalation and delivery of medication. The DON stated if the mask was not worn, the resident did not receive the full dose of the medication and it could cause shortness of breath and respiratory distress. During a review of the facility's policy and procedure (P&P) titled, Aerosolized Medication Therapy- Small Volume Nebulizer, dated 5/1/2024, the P&P indicated the purpose was to deliver inhaled aerosolized medications to the lungs. The P&P indicated to ensure proper set-up and administration of aerosolized inhaled medications. The P&P indicated to administer medication as ordered and to document result of therapy including pre and post vital signs in the electronic health record.

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) was free from sexual abuse (non-consensual [without the person's permission] touching of one person for the sexual gratification of another) on 6/19/2025 by failing to: 1. Protect Resident 1 from Resident 2 by ensuring Resident 2 was provided a one-to-one sitter (1:1, an intervention when a nurse or healthcare professional provides constant observation and support to a resident who is at risk of harm, such as one with cognitive [mental action or process of acquiring knowledge and understanding] impairments, challenging behaviors, or one who may fall or cause harm to himself/herself or to others) in accordance with the physician's order on 6/19/2025 from 11 PM to 11:20 PM. 2. Prevent abuse by ensuring facility licensed staff monitored and documented Resident 2's sexual inappropriate behavior of playing with his private area (a person's external sexual organs or genitals) on 6/12/2025 and developed and implemented interventions to prevent abuse to Resident 1 and other residents in the facility. 3. Notify and inform Resident 2's primary physician (MD) of Resident 2's sexual inappropriate behavior of playing with his private area on 6/12/2025 and obtain orders to protect Resident 1 and other residents residing in the facility from safety and sexual abuse. These deficient practices resulted in Resident 1 experiencing sexual abuse from Resident 2 on 6/19/2025 at around 11:20 PM. Resident 2 who was positive for human immunodeficiency virus (HIV, attacks cells that help the body fight infection, making a person more vulnerable to other infections and diseases) and who should have been supervised with a 1:1 Sitter, was observed by Licensed Vocational Nurse 1 (LVN 1) on top of Resident 1 in Resident 1's room. Resident 1's pants and diaper were pulled down above her knees. Resident 2 stated having sex with Resident 1. Resident 1 was started on HIV prophylaxis (prevention) medication on 6/21/2025 which could result in Resident 1 to suffer adverse side effects such as kidney and liver damage, depression [a mood disorder characterized by persistent feelings of sadness, loss of interest in activities, and a range of other symptoms that interfere with daily life], anxiety [excessive worry, fear, and unease that can interfere with daily life], and suicidal thoughts [thoughts, feelings, or ideas about ending one's own life]). Resident 1 experienced dysphoric (experiencing a state of unease, dissatisfaction, or generalized unhappiness) mood during a consult with psychologist (specializes in the study of mind and behavior or in the treatment of mental, emotional, and behavioral disorders) on 6/25/2025. On 6/24/2025 at 5:38 PM, the California Department of Public Health (CDPH) called an Immediate Jeopardy situation (IJ, a situation in which the facility's noncompliance [not following rules] with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a Resident) due to the facility's failure to protect Resident 1 from sexual abuse from Resident 2. The facility submitted an acceptable IJ Removal Plan (action to correct the deficient practice) to CDPH on 6/26/2025 at 4:50 PM. The IJ was removed on 6/26/2025, after the surveyor verified and confirmed the facility implemented the facility's IJ Removal Plan (a detailed plan to address the IJ findings) while onsite by observation, interview, and record review. The IJ was removed in the presence of the Director of Nurses (DON), Assistant Administrator, Clinical Director Regional, Assistant Administrator, Regional Infection Preventionist Nurse, Regional Director of Staff Development, Quality Assurance (QA), Assistant Director of Nurses (ADON), and Director of Staff Development (DSD). The acceptable IJ Removal Plan included the following information: 1. On 6/19/2025, Resident 2 was observed by the charge nurse on top of Resident 1. Immediately Resident 2 was pulled by the charge nurse to get off Resident 1 and was guided outside of the room. 2. Resident 2 was directed to his room by Licensed Vocational Nurse 1 (LVN 1) and was monitored by LVN 1 and Security guard 1 until the deputies from the local police department arrived at the facility. The deputies interviewed Resident 1. Resident 2 was handcuffed and was taken by the deputies for further investigation. 3. Resident 1 was transferred to the General Acute Care Hospital 1 on 6/20/2025 at 4:45 AM for evaluation by Sexual Assault Response Team (SART a multidisciplinary team that provides medical, legal, and emotional support to survivors of sexual assault) and received appropriate medical treatment. 4. Registered Nurse 1 (RN 1) notified Resident 1's family and physician on 6/20/2025 at 2:26 AM. RN 1 notified Resident 2's physician, family, and responsible party on 6/20/2025 at 12 AM. The Ombudsman (an independent advocate who helps residents navigate concerns, ensuring their rights are protected and their voices are heard), CDPH, and local law enforcement were notified. A thorough investigation was initiated by the Administrator on 6/20/2025. 5. Resident 1 was transferred back to the facility on 6/20/2025 with discharge instructions to provide prophylaxis medication for HIV, monitor for signs of medical deterioration such as fever, pelvic pain, abnormal vaginal/rectal bleeding. Psychosocial support visits by Social Services started on 6/20/2025 and will take place daily for 72 hours and as needed. 6. On 6/24/2025, the DON and Social Services Director completed a facility-wide audit of the wandering elopement assessment and behavior monitoring of all residents with documented sexual inappropriate and wandering behaviors. There were four (4) residents identified with sexually inappropriate behavior. There were also eleven residents identified with wandering and elopement risk. Wandering assessments were updated on 6/24/2025, care plans and orders were revised and updated as needed for 11 residents with wandering monitoring and 4 residents with sexually inappropriate behavior monitoring. 7. The psychologist was informed on 6/24/2025 to reassess the four residents with sexually inappropriate behavior. This will be completed on 6/2025. 11 Care plans were revised and updated for the wandering residents and 4 care plans were revised for the sexually inappropriate care plans. No other residents have been identified as having been sexually abused. 8. The 11 residents that were identified at risk of wandering and elopement were reassessed by the ADON on 6/24/2025. 9. The DON and Designees will in-service all available licensed nurses and certified nursing assistants starting 6/24/2025 and ongoing on recognition and reporting sexual inappropriate behaviors, implementation and documentation of 1:1 supervision; monitoring and documenting wandering behaviors, proper notification to physician of behavioral changes. Staff members who are not currently working will be in-serviced and educated on their first shift back to work. Care plan development and updates for sexually inappropriate behavioral issues, abuse prevention and reporting requirements, change of condition will likewise be initiated as warranted. 10. Outside Resource Consultant 1 was contacted from an outside Behavioral Management Program and will be providing education on sexual and wandering behaviors on 6/2025 and ongoing. 11. Vendor 1 was contacted on 6/24/2025 and will provide further education to licensed and non-licensed staff on 6/25/2025 and ongoing regarding sexual and wandering behaviors. 12. Starting 6/24/2025, residents admitted and readmitted will be assessed to include sexually inappropriate behaviors and wandering and elopement risk. 13. Starting 6/24/2025, residents with sexually inappropriate behavior and wandering behavior will be monitored and logged in newly implemented Resident Visual Check Log daily on every 2-hour basis. The log will be completed by the CNA or the LVN assigned to the resident. The Care plan for the 11 residents identified with wandering behavior and 4 residents identified with sexually inappropriate behavior were updated based on the Behavior Management Policy and Procedure. 14. Starting 6/24/2025, residents who are newly assessed or reassessed and identified with sexually inappropriate behavior or identified at risk for wandering and elopement risk will be referred to psychologist or psychiatrist for evaluation. 4 residents were identified with sexually inappropriate behavior, and 11 residents were identified with wandering behavior. 15. Starting 6/24/2025, the licensed and certified nursing assistant staff on duty will ensure the safety of all residents pertaining to sexually inappropriate behavior and wandering behavior by conducting daily rounds on the unit while they are in the care of facility staff. 16. Starting 6/24/2025 and ongoing, DON/Designee or QA nurse will provide retraining and reeducation to licensed nurses capturing all shifts to identify resident's changes in sexually inappropriate behaviors and to address or intervene, to monitor, protect, prevent serious complications /illness and behavior management. 17. Starting 6/24/2025 and ongoing, Vendor 1 to provide further training to staff will be provided in behavior management. 18. The Staff Development Coordinator/ DON or Designee will provide this in-service by 6/25/2025 and ongoing. This education will include sexually inappropriate behavior and wandering. The training will be included in the hire orientation packet for new hires and rehired employees. 19. The Unit Managers will ensure proper supervision of residents with behavioral issues and will review behavioral documentation monitoring on the electronic medical record (E-mar) each shift, and report concerns to the DON. The Social Services Director revised the facility's abuse prevention policy to include specific interventions for residents with sexual inappropriate behaviors and wandering behaviors. 20. Starting 6/24/2025 and ongoing, the DON and/or Designee is responsible and will audit 100% of residents with documented sexual inappropriate behaviors and wandering behaviors weekly for 4 weeks, then 50% monthly for 2 months to ensure 1:1 supervision is implemented as ordered, behaviors are properly documented, care plans are updated to reflect current behaviors, physician notifications occur as required, and appropriate interventions are in place The Unit Managers will conduct daily rounds on all shifts to ensure proper supervision of residents with behavioral issues. 21. The DON will report monitoring results to the Quality Assurance Performance Improvement (QAPI) committee monthly for three months. 22. The QAPI committee will evaluate the effectiveness of interventions and make changes as needed until substantial compliance is achieved and maintained. Cross reference F689 Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), depression and schizophrenia unspecified (a mental illness that is characterized by disturbances in thought). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 4/26/2025, the MDS indicated Resident 1 had severe impairment with cognitive skills for daily decision making. Resident 1 required supervision or touching assistant (helper provides verbal cues and /or touching/steadying and/or contact guard assistance as resident completes activity) with bed mobility, transfer, walking, upper and lower body dressing, and toilet use. Resident 1 required substantial/ maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs but provides more than half the effort) with shower/ bathing self. During concurrent observation and interview on 6/23/2025 at 4:11 PM, Resident 1 was observed walking in the hallway. During the interview, Resident 1 was asked about the incident on 6/19/2025. Resident 1 stated, There is nothing to talk about. During a review of the General Acute Care Hospital (GACH) Emergency Department History and Physical (ED H&P), dated 6/20/2025, the GACH ED H&P indicated Resident 1 had reported one of the residents (Resident 2) entered her room, lowered his pants, pinned her down, and started having sexual intercourse with her. The GACH ED H&P also indicated the SART nurse, Resident 1 does have positive findings on genitourinary (GU, it refers to the organs and systems involved in the production, storage, and excretion of urine and reproduction) examination evidence of sexual assault (any kind of sexual activity, contact, or experience that happens without one's consent). It also indicated, per SART nurse, there is confirmation that the offender (Resident 2) is HIV positive and Resident 1 was started on Post-Exposure Prophylaxis (PEP, a medication regimen taken after potential exposure to HIV to prevent infection). During a review of Resident 1's Physician's Order, dated 6/20/2025, the Physician's Order, indicated to start Emtricitabine-Tenofovir Disoproxil Fumarate (Truvada, prescription medication used to treat HIV-1 infection, and also to reduce the risk of HIV - 1 infection in high-risk individuals) oral tablet 200 to 300 milligrams (mg, unit of mass) on 6/21/2025. Give one tablet by mouth in the morning for HIV - 1 infection prophylaxis for 28 days. During a review of Resident 1's Physician's order, dated 6/20/2025, the Physician's Order indicated Psychology referral. During a review of Resident 1's Psychology Report, dated 6/25/2025, the Psychology Report indicated Resident 1 was seen following a referral made by the staff on 6/24/2025 due to a report that Resident 1 experienced a suspected sexual assault. The report indicated Resident 1's mood appeared dysphoric and responded to questions with brief, simple answers. The report also indicated Resident 1 became visibly irritable when asked about the incident, expressing frustration with the repetitive nature of the inquiries. Resident 1 declined to provide any specific details and eventually ceased to respond altogether. During a review of the Resident 1's Psychology Report, dated 6/26/2025, the Psychology Report indicated Resident 1 was tearful at one point during evaluation, stating it was caused by the topic of the assault being brought up repeatedly. 2. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] with diagnoses that included paranoid schizophrenia (a mental disorder characterized by psychosis, where individuals experience a disconnect from reality), violent behavior (it is characterized by actions intended to cause physical harm or injury to others, or damage to property), and positive for HIV. During a review of Resident 2's Physician's Order, dated 6/3/2025, the Physician's Order indicated Resident 2 may have 1:1 sitter. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 was moderately impaired with cognitive skills for daily decision making. Resident 2 also required supervision or touching assistance with toileting hygiene, shower/bathe self, change of position, and transfer. Resident 2 was independent for eating, oral hygiene, upper body dressing and personal hygiene. Resident 2 had episodes of wandering daily. During a review of Resident 2's Progress Notes, dated 6/20/2025 timed at 5:30 AM, the Progress Notes indicated at approximately 11:20 PM, charge nurse notified RN supervisor that Resident 2 was allegedly having sexually inappropriate behavior. CN stated that Resident 2 was on top of Resident 1. MD made aware and ordered Resident 1 to be transferred to GACH for further assessment. The facility notified the local police department who arrived at the facility around 1AM. The local police department took custody of Resident 2 and transferred Resident 2 to GACH for further investigation. During an interview on 6/24/2025 at 10 AM with Director of Nurses (DON), the DON stated Licensed Vocational Nurse 1 (LVN 1) called him on the phone on 6/19/2025 around 11:40 PM and notified him that LVN 1 found Resident 2 on top of Resident 1 in Resident 1's room. During an interview on 6/24/2025 at 12:35 PM with Quality Assurance Nurse (QAN), QAN stated the sexual abuse happened during change of shift, between 11 PM to 11:20 PM on 6/19/2025. QAN stated LVN 1 went to Resident 1's room upon hearing a screaming noise from Resident 1's room. QAN stated LVN 1 found Resident 2 on top of Resident 1. QAN stated LVN 1 removed Resident 2 from Resident 1's room right away. LVN1 then notified Registered Nurse Supervisor 1 (RNS 1) and reported to the DON, physicians, families, police, ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and public health. During an interview on 6/24/2025 at 12:37 PM with QAN, QAN stated Resident 2 required a 1:1 sitter in accordance with the physician's order because of the resident's wandering behavior. During an interview on 6/24/2025 at 3:05 PM with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated she had seen Resident 2 playing with his private area sometime this month (6/2025) but does not remember exactly what date. CNA3 stated she did not report the incident to the licensed nurse. During an interview on 6/24/2025 at 3:08 PM with CNA 2, CNA 2 stated she had seen Resident 2 playing with his private area in the restroom area during her shift but does not remember the date when this happened. CNA2 stated she had reported it the charge nurse (LVN 3) a few days after it happened. During an interview on 6/24/2025 at 3:20 PM with Security Guard 1 (SG1), SG 1 stated that on 6/19/2025 at around 11:20 PM, while SG 1 was near the entrance door, he heard LVN 1 scream, Hey get off her. SG 1 stated he followed where the voice was coming from and observed LVN 1 bringing Resident 2 out of Resident 1's room. SG 1 stated, The resident (Resident 2) was holding his pants. It was unbuttoned and unzipped, and I can see his penis. SG 1 stated, The resident (Resident 2) told me that he was having sex with that lady (Resident 1). During an interview on 6/24/2025 at 4:20 PM with RNS 1, RNS 1 stated LVN 1 reported to RNS 1 on 6/19/2025 around 11:20 PM that Resident 2 sexually assaulted Resident 1. RNS 1 stated immediately after receiving the report, she went to Resident 1's room with LVN 1. Resident 1 was observed on her bed with her pants and diaper pulled down above her knees. RNS 1 stated she observed Resident 2 standing with SG 1 in front of his room, across Resident 1's room. RNS 1 stated Resident 2 had an order for a 1:1 sitter but there were no staff assigned to supervise and sit with the resident. RNS 1 added there was no CNA providing 1:1 supervision for Resident 2 for the shift of 11 PM to 7 AM on 6/19/2025. RNS 1 added having a 1:1 sitter could have protected Resident 1 from sexual abuse from Resident 2. During a concurrent interview and record review on 6/24/2025 at 4:30 PM with RNS 1, Resident 2's medical records were reviewed. RNS 1 stated there was a nursing progress note, dated 6/15/2025, which indicated that CNA2 observed and had reported to LVN 3 that Resident 2 was playing with his private area on 6/12/2025. RNS 1 stated Resident 2's sexual inappropriate behavior was a change of condition (COC, any noticeable alteration in a resident's physical or mental status that deviates from their baseline or established pattern, potentially indicating a new illness, worsening condition, or need for intervention) and should have been reported to the MD. RNS1 stated the nurses should have completed a COC report, monitored Resident 2 for 72 hours, and should have notified the MD in accordance with the facility's COC policy. During an interview on 6/24/2025 at 3 PM with the DON, the DON stated the facility did not have a process, such as having a 1:1 sitter log to monitor and ensure the resident requiring a 1:1 sitter was provided with a facility staff to supervise and sit with the resident at all times. The DON stated the facility should have had a 1:1 sitter log, which will be filled out at the beginning of each shift where information such as the name of the resident requiring a sitter, the name of the sitter assigned to the resident, and the date and shift the sitter was assigned will be entered. The DON stated having a 1:1 sitter for Resident 2 could have prevented the sexual assault on 6/19/2025. During an interview on 6/24/2025 at 7 PM with LVN 1, LVN 1 stated that on 6/19/2025 at around 11:20 PM, he found Resident 2 on top of Resident 1 after he heard a screaming noise from Resident 1's room. LVN1 stated he immediately pulled Resident 2 away from Resident 1 while LVN 1 screamed for assistance. LVN 1 stated SG 1 came to assist, and he instructed SG 1 to monitor Resident 2 while LVN 1 went to the nurses' station to report the incident to RNS 1. LVN 1 stated there was an order for Resident 2 to have a 1:1 sitter however Resident 2 was not assigned a sitter on 6/19/2025 for the 11 PM to 7AM shift. During an interview on 6/24/2025 at 7:28 PM with LVN 3, LVN 3 stated one of the CNAs (unnamed) who was assigned as 1:1 sitter to Resident 2 reported on 6/15/2025 that Resident 2 was playing with his private area in his room on 6/12/2025. LVN 3 stated CNA should have reported the incident on 6/12/2025. LVN 3 stated the RN Supervisor (unnamed) also heard Resident 2's sexual inappropriate behavior from the CNA and instructed LVN 3 to document the report on the nursing progress notes. LVN 3 stated a COC report and monitoring for Resident 2's sexual inappropriate behavior should have been done. LVN 3 stated it should have been also reported to MD so proper interventions could have been developed and implemented. During a review of the facility's Policy and Procedure (P&P) titled, Abuse Prevention and Prohibition Program, revised on 8/1/2023, the P&P indicated . each resident has the right to be free from abuse, neglect, mistreatment, and/or misappropriation of property. The Facility has zero tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property .The Administrator is responsible for coordinating and implementing the Facility's abuse prevention policies, procedures, training program, and systems .This policy also identifies Special Considerations regarding the investigation of injuries of unknown origin and criminal sexual abuse. During a review of the facility's P&P titled, Notification of Change of Condition, revised on 6/1/2017, indicated its purpose is to ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner. Definition: An acute change of condition (ACOC) is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains. Clinically important means a deviation that, without intervention, may result in complications or death. (AMOA 2003) Procedure: I. The Licensed Nurse will notify the resident's Attending Physician when there is an: A. Incident/accident involving the resident; B. A significant change in the resident's physical, mental or psychosocial status, e.g., deterioration in health, mental or psychosocial status, life-threatening conditions or clinical complications. II. The Licensed Nurse will assess the resident's change of condition and document the observations and symptoms. Documentation: A. A licensed Nurse will document the following: i. Date, time, and pertinent details of the incident and the subsequent assessment in the Nursing Notes. ii. The time the Attending Physician was contacted, the method by which he was contacted, the response time, and whether or not orders were received. iii. Update the Care Plan to reflect the resident's current status. B. A licensed Nurse will communicate any changes in required interventions to the IDT members involved in the resident's care. C. A licensed Nurse will document each shift for at least seventy-two (72) hours. D. Documentation pertaining to a change in the resident's condition will be maintained in the resident's medical record and on the 24-Hour Report.

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 2) who had episodes of wandering (moving aimlessly from place to place without a specific destination or purpose) was supervised by failing to provide a one to one sitter (1:1, an intervention when a nurse or healthcare professional provides constant observation and support to a resident who is at risk of harm, such as one with cognitive [mental action or process of acquiring knowledge and understanding] impairments, challenging behaviors, or one who may fall or cause harm to himself/herself or to others) in accordance with the physician's order on 6/19/2025. This deficient practice resulted in Resident 2 wandering into Resident 1's room on 6/19/2025 around 11:20 PM. Resident 2 was observed by Licensed Vocational Nurse 1 (LVN 1) on top of Resident 1 in Resident 1's room. Resident 1's pants and diaper were pulled down above her knees. Resident 2 stated having sex with Resident 1. Cross reference F600 Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), depression and schizophrenia unspecified (a mental illness that is characterized by disturbances in thought). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 4/26/2025, the MDS indicated Resident 1 had severe impairment with cognitive skills for daily decision making. Resident 1 required supervision or touching assistant (helper provides verbal cues and /or touching/steadying and/or contact guard assistance as resident completes activity) with bed mobility, transfer, walking, upper and lower body dressing, and toilet use. Resident 1 required substantial/ maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs but provides more than half the effort) with shower/ bathing self. 2. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] with diagnoses that included paranoid schizophrenia (a mental disorder characterized by psychosis, where individuals experience a disconnect from reality), violent behavior (it is characterized by actions intended to cause physical harm or injury to others, or damage to property), and positive for HIV. During a review of Resident 2's Wandering and Elopement (a person leaving a safe area or a responsible caregiver without permission or supervision) Risk Assessment, dated 6/3/2025, the Wandering and Elopement Risk Assessment indicated Resident 2 had a significant actual risk. During a review of Resident 2's Physician's Order, dated 6/3/2025, the Physician's Order indicated Resident 2 may have 1:1 sitter. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 was moderately impaired with cognitive skills for daily decision making. Resident 2 also required supervision or touching assistance with toileting hygiene, shower/bathe self, change of position, and transfer. Resident 2 was independent for eating, oral hygiene, upper body dressing and personal hygiene. Resident 2 had episodes of wandering daily. During a review of Resident 2's Progress Notes, dated 6/20/2025 timed at 5:30 AM, the Progress Notes indicated at approximately 11:20 PM, charge nurse notified RN supervisor that Resident 2 was allegedly having sexually inappropriate behavior. CN stated that Resident 2 was on top or Resident 1. During an interview on 6/24/2025 at 10 AM with Director of Nurses (DON), the DON stated Licensed Vocational Nurse 1 (LVN 1) called him on the phone on 6/19/2025 around 11:40 PM and notified him that LVN 1 found Resident 2 on top of Resident 1 in Resident 1's room. During an interview on 6/24/2025 at 12:35 PM with Quality Assurance Nurse (QAN), QAN stated the sexual abuse happened during change of shift, between 11 PM to 11:20 PM on 6/19/2025. QAN stated LVN 1 went to Resident 1's room upon hearing a screaming noise from Resident 1's room. QAN stated LVN 1 found Resident 2 on top of Resident 1. QAN stated LVN 1 removed Resident 2 from Resident 1's room right away. LVN1 then notified Registered Nurse Supervisor 1 (RNS 1) and reported to the DON, physicians, families, police, ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and public health. During an interview on 6/24/2025 at 12:37 PM with QAN, QAN stated Resident 2 required a 1:1 sitter in accordance with the physician's order because of the resident's wandering behavior. During an interview on 6/24/2025 at 3 PM with the DON, the DON stated the facility did not have a process, such as having a 1:1 sitter log to monitor and ensure the resident requiring a 1:1 sitter was provided with a facility staff to supervise and sit with the resident at all times. The DON stated the facility should have had a 1:1 sitter log, which will be filled out at the beginning of each shift where information such as the name of the resident requiring a sitter, the name of the sitter assigned to the resident, and the date and shift the sitter was assigned will be entered. The DON stated having a 1:1 sitter for Resident 2 could have prevented the sexual assault on 6/19/2025. During an interview on 6/24/2025 at 3:20 PM with Security Guard 1 (SG1), SG 1 stated that on 6/19/2025 at around 11:20 PM, while SG 1 was near the entrance door, he heard LVN 1 scream, Hey get off her. SG 1 stated he followed where the voice was coming from and observed LVN 1 bringing Resident 2 out of Resident 1's room. SG 1 stated, The resident (Resident 2) was holding his pants. It was unbuttoned and unzipped, and I can see his penis. SG 1 stated, The resident (Resident 2) told me that he was having sex with that lady (Resident 1). During an interview on 6/24/2025 at 7 PM with LVN 1, LVN 1 stated that on 6/19/2025 at around 11:20 PM, he found Resident 2 on top of Resident 1 after he heard a screaming noise from Resident 1's room. LVN1 stated he immediately pulled Resident 2 away from Resident 1 while LVN 1 screamed for assistance. LVN 1 stated SG 1 came to assist, and he instructed SG 1 to monitor Resident 2 while LVN 1 went to the nurses' station to report the incident to RNS 1. LVN 1 stated there was an order for Resident 2 to have a 1:1 sitter however Resident 2 was not assigned a sitter on 6/19/2025 for the 11 PM to 7AM shift. During a review of the facility's Policy and Procedure (P&P) titled, Physician Orders, revised on 5/1/2024, the P&P indicated orders will be carried out completely and noted in a timely manner. During a review of the facility's P&P titled, Abuse Prevention and Prohibition Program, revised on 8/1/2023, the P&P indicated . each resident has the right to be free from abuse, neglect, mistreatment, and/or misappropriation of property. The Facility has zero tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property . The Facility is committed to protecting residents from abuse by anyone, including but not limited to facility staff, other residents, consultants, volunteers, staff from other agencies providing services under arrangement, family members, legal guardians, surrogates, sponsors, friends, and visitors. Prevention: The Facility maintains adequate staffing on all shifts to ensure that the needs of each resident are met.

Based on observation, interview, and record review, the facility failed to prevent accidents for two (2) of 2 sampled residents (Resident 1 and 3) by: 1. Failing to ensure Resident 1 who had history of fall was free from falls and injury in accordance with the resident's care plan intervention to supervise Resident 1 while the resident is sitting in the wheelchair. On 1/3/2025, Certified Nursing Assistant 1 (CNA 1) left Resident 1 sitting in a wheelchair without staff supervision. This deficient practice resulted in Resident 1 being found outside of Building 1 on 1/3/2025 at around 1:45 PM. Resident 1 was found holding his left arm while lying on the ground with a laceration (a deep cut or tear in the skin) on the resident's left eyebrow measuring one (1) centimeter (cm- unit of measurement). Resident 1 complained of breakthrough pain (a sudden increase in pain in residents who are taking medicines that usually keep their pain under control) rated at 3 out of 10 (level of 10 as the most painful) on his left eyebrow laceration site. On 1/3/2025 at around 2:12 PM, Resident 1 was sent to General Acute Care Hospital (GACH) by the paramedics (a person trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital) where Resident 1 was found to have an acute (sudden) displaced fracture (a broken bone where the pieces have moved out of alignment, creating a gap between them) deformity in the left neck of the humerus (the short, narrow area that connects the head to the body of the upper arm bone). 2. Failing to identify the environment for potential safety hazard (something that is dangerous or likely to cause damage) and failing to ensure there was no sharp pointed knife with black handle on top of the Resident 3's shelf (a flat length of wood or other rigid material, attached to a wall or forming part of a piece of furniture, that provides a surface for the storage or display of objects). Theis deficient practice placed Resident 3 at risk for potential accidents and which can lead to serious harm or injury. Findings: 1. During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included unspecified dislocation of left hip (when the ball portion of the hip joint is dislodged from its socket), unspecified dementia (a progressive state of decline in mental abilities), and history of falling. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 11/13/2024, the MDS indicated Resident 1 was assessed having severely impaired (never/rarely made decisions) cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 1 was assessed to require partial/moderate assistance (helper does less than half the effort) with sit to stand, sit to lying, and lying to sitting on side of bed. The MDS indicated, Resident 1 was assessed to be dependent (helper does all of the effort) with walking 10 feet (ft- unit of measurement) and that the resident used a manual wheelchair and required partial/moderate assistance with wheeling 50 ft with two turns and substantial/maximal assistance (helper does more than half the effort) with wheeling 150 ft. Resident 1 was assessed having fall incident with no injury since admission/entry or prior assessment. During a review of Resident 1's Fall Risk (Morse) Assessment (a widely used assessment tool that helps healthcare professionals predict a resident's risk of falling in healthcare settings like hospitals and long-term care facilities), dated 9/23/2024, the Fall Risk Assessment indicated Resident 1 was high risk for falls. During a review of Resident 1's Care Plan, dated 9/23/2024, the Care Plan indicated Resident 1 had an actual fall with no injury due to impaired sensory perception, confusion, impaired safety awareness, and muscle weakness initiated on 9/23/2024. The care plan indicated intervention to keep resident up in wheelchair in a supervised area and to provide frequent visual checks several times per shift. During a review of Resident 1's PT Evaluation and Treatment Plan, with a certification period of 10/7/2024 to 11/17/2024, the PT Evaluation and Treatment Plan's Functional/Mobility Assessment indicated Resident 1 required substantial/maximal assistance with sit to stand. The Functional/Mobility Assessment further indicated walking 10 feet was not attempted due to medical conditions or safety concerns. During a review of Resident 1's Progress Note, dated 1/3/2025, at 1:50 PM, the Progress Note indicated, report to Medical Doctor (MD) for Resident 1 was found on the floor with a 1 cm laceration on left eyebrow and the resident complained of unable to move left arm. The progress note indicated MD ordered to transfer the resident to GACH by paramedic. During a review of Resident 1's Pain Assessment, dated 1/3/2025, the Pain Assessment indicated Resident 1 complained of breakthrough pain rated at 3 out of 10 on his left eyebrow laceration site. Resident 1 received Tylenol (a medication used for pain) 325 milligrams (mg- unit of measurement) 2 tablets by mouth. During a review of Resident 1's Skin Observation Check, dated 1/3/2025, the Skin Observation Check indicated Resident 1 had a laceration measuring 1 cm by 0.1 cm on his left eyebrow. During a review of Resident 1's GACH X-ray (pictures of the inside of the body) of the left shoulder, dated 1/3/2025 entered time at 8:16 PM, the X-ray result indicated an acute displaced fracture deformity in the left neck of the humerus. During a review of Resident 1's Progress Note, dated 1/5/2025 entered at 6:38 AM, the Progress Note indicated, Resident 1 was monitored for unwitnessed fall and readmission (date and time not specified). During a review of Resident 1's Multidisciplinary Progress Record signed by Resident 1's MD, dated 1/6/2025, the Multidisciplinary Progress Record indicated Resident 1 had a left humerus fracture after the fall on 1/3/2025. During a review of GACH's Orthopedic (relating to the branch of medicine dealing with correction of deformities of bones or muscles) Notes dated on 1/7/2025, it indicated, Resident 1 had a fall from the resident's wheelchair on 1/3/2025 and fractured his left arm and family opted not to do surgery (branch of medicine treats injuries, diseases, and deformities by the physical removal, repair or readjustment of organs, bones and tissues often involving cutting into the body). The orthopedic notes also indicated, Resident 1 reported sharp pain with level of seven (7) out of 10 (pain level of 10 is the most painful). During an observation in Resident 1's room on 1/8/2025 at 9:09 AM, Resident 1 was observed lying in bed with left arm in a sling (a device used to limit movement of the shoulder or elbow while it heals). Resident 1 had a dry scab (a dry, rough protective crust that forms over a cut or wound during healing) on the resident's left elbow. Resident 1 stated he fell but did not remember when, how or why he fell . During an interview with Licensed Vocational Nurse 3 (LVN 3), on 1/8/2025, at 9:50 AM, LVN 3 stated Resident 1 is unable to stand without assistance. LVN 3 stated Resident 1 uses the wheelchair and can wheel his wheelchair in the hallway. LVN 3 stated on 1/3/2025 at around 1 PM, Resident 1 was sitting on his wheelchair in the dining room while CNA 1 was feeding another resident (not sure if in the dining room or into another resident's room). LVN 3 stated on 1/3/2025 Speech Therapist 1 (SPT 1) found Resident 1 on the ground outside Building 1's back door (unknown how the resident was able to get outside). LVN 3 stated SPT1 found resident lying on the resident's right side with blood coming from the resident's left eyebrow. LVN 3 stated Resident 1 complained of left shoulder pain after the fall. LVN 3 stated 911 (a phone number used to contact emergency services) was called and Resident 1 was transferred to GACH. LVN 3 stated Resident 1 should not have been left unsupervised in the dining room. During an interview with LVN 3 on 1/8/2025, at 9:55 AM, LVN 3 stated Resident 1 returned from GACH on the same day sometime in the evening of 1/3/2025. During an interview with CNA 1 on 1/8/2025, at 10:21 AM, CNA 1 stated she was assigned to care for Resident 1 on 1/3/2025. CNA 1 stated Resident 1 eats his meal in the dining room while sitting on his wheelchair. CNA 1 stated Resident 1 was able to wheel around in his wheelchair. CNA 1 stated on 1/3/2025, Resident 1 was sitting in the dining room when CNA 1 left the dining room to feed another resident (Resident 9). CNA 1 stated could not remember if there were other facility staff in the dining area to supervise the residents. CNA 1 stated she did not notify other staff that she was leaving Resident 1 in the dining room on 1/3/2025 and that she did not ask another staff to supervise Resident 1 before leaving the dining room to attend to another resident. During an interview with SPT 1, on 1/8/2025 at 10:57 AM, SPT 1 stated he was in another building when he heard someone crying outside. SPT 1 stated he went outside and saw Resident 1 on the ground, lying on his right side next to the resident's wheelchair outside Building 1's back door. SPT 1 stated Resident 1 was asking for help, and no staff was present when SPT 1 found the resident on the floor. SPT 1 stated Resident 1 was bleeding from his left eyebrow. During an interview and record review with LVN 2, on 1/8/2025, at 12:33 PM, Resident 1's Care Plan for fall dated 9/23/2024, was reviewed. The Care Plan indicated intervention to keep the resident in a supervised area. LVN 2 also stated Resident 1 fell outside Building 1 on 1/3/2025 and that the Care Plan intervention to keep Resident 1 in a supervised area was not followed. LVN 2 stated Resident 1's fall could have been prevented if the Care Plan was followed and a facility staff stayed in the dining room to supervise Resident 1. LVN 2 stated CNA 1 should have informed another staff that she was leaving the dining room so that Resident 1 can be supervised by another staff. LVN 2 stated the facility's policy to prevent falls and to provide a safe environment for residents was not followed. During a review of the facility's policy and procedure (P&P), titled, Fall Management Program, revised on 6/1/2017, the P&P indicated the facility will prevent resident falls and minimize complications associated with falls. The P&P further indicated, it is the policy of this facility to provide the highest quality of care in the safest environment for the residents residing in the facility and to prevent resident falls through meaningful assessments, interventions, education, and reevaluation. 47362 2. During a review of Resident 3's admission record indicated the facility admitted Resident 1 on 6/12/2023 with diagnoses which includes muscle weakness, lack of coordination and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 3's History and Physical (H&P) dated 9/16 /2024 indicated Resident 1 has the capacity to understand make decisions. During a review of Resident 3's Minimum Data Set (MDS, standardized care and screening tool), dated 9/11/2024, indicated Resident 3 was moderately impaired with cognition (processes of thinking and reasoning) skills for daily decision making. During an observation on 1/7/2025 at 9:50 AM in Resident 3's room. Observed a sharp pointed knife with black handle about four (4) inches (unit of measurement) long located on top of the shelf. During concurrent observation and interview on 1/7/2025 at 10:05 AM with the treatment nurse (TN1), TN 1 stated there was a sharp pointed knife with black handle on top of the Resident 3's shelf. TN1 also stated all residents are not supposed to have sharp pointed objects like knife in their possession or in the resident's room, it can cause accident that can harm Resident 1 and other residents. During interview on 1/7/2025 at 10:39 AM with the Unit Manager (UM) stated a knife was not allowed at the facility. UM stated the facility have confused, and residents that are wandering (when a person roams around and becomes lost or confused about their location. It is a common behavior that can cause great risk for the person and was often the major priority [and concern] for caregivers) in the facility. During concurrent interview and record review on 1/8/2025 at 4:33 PM with LVN 2, the facility's Policy and Procedure (P&P) titled Safety of Resident revised date 5/1/2023 was reviewed. LVN 2 stated the P&P indicated purpose: to provide a safe environment for resident and facility staff. During the same concurrent interview and record review on 1/8/2025 at 4:33 PM with LVN 2, the facility's P&P titled Weapons revised date 6/1/2017 was reviewed. The P&P indicated Purpose: To provide a safe environment for residents, visitors, and facility staff. The facility prohibits residents, visitors and staff form possessing any type of weapon while on the facility premises. All items designed to cause bodily harm are considered weapons including but not limited to knives, firearms, and blades longer than 3 inches. LVN 2 stated the knife on Resident 3's shelf top was more than 3 inches long and that after the facility investigated, the facility found out that it was Resident 3's family brought the knife with black handle last 1/5/2025 unknown time. LVN 2 stated, if that is the case the knife was at Resident 3's room since 1/5/2025 until 1/7/2025. LVN 2 stated the facility failed to provide safe environment to Resident 3 and other residents in the facility and the staff should have checked the environment for any safety hazards that needs to be removed especially they have confused residents and residents that were wandering around.

Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent accidents for four (4) out of seven (7) residents (Resident 216, 217, 300, 179, and 277) by failing to: 1. Provide a 1:1 sitter for Resident 216, who was assessed as high risk for falls. 2. a. Ensure the licensed nurses developed a care plan with interventions to prevent Resident 300 from falls before the resident had a fall on 4/11/2024. b. Ensure the nursing staff developed a care plan for Resident 300's fall prevention after the resident's fall on 4/11/24 to prevent the resident from future falls including a fall on 5/1/2024. c. Ensure Resident 300 was provided with partial/moderate assistance (helper does less than half the effort) while walking on 5/1/2024 to prevent the resident from falling and sustaining an injury. d. Ensure an Interdisciplinary Team ([IDT]a group of healthcare professionals from diverse fields who work in a coordinated manner toward a common goal for the resident) Falls Committee was conducted with after Resident 300's fall on 4/11/2024 to evaluate a root cause analysis (a wide range of approaches, tools, and techniques used to uncover causes of problems) and provide interventions to prevent future falls in accordance with the fall management facility policy. 3. Facility did not ensure Resident 179 will have multiple falls. The facility did not revise Resident 179's care plans on each actual fall incident. 4. Visually (relating to seeing or sight) monitor Resident 277's whereabouts in accordance with the physician order dated 3/9/2024 and the care plan for the risk for falls dated 12/19/2023. Resident 277 was assessed as high risk for falls, had an episode of fall on 4/23/2024, and had a wandering (moving from place to place without a fixed plan) behavior. These deficient practices resulted in: 1. Multiple falls for Resident 216 on 4/28/2024 and 5/9/2024. 2. Resident 300 to fall on 5/1/2024 and sustained a right femur (thigh bone) fracture. On 5/1/2024 Resident 300 was transferred to the General Acute Care Hospital (GACH) where the resident underwent a right hip hemiarthroplasty (a surgical procedure that involves replacing half of the hip joint). 3. Resident 179 suffered ten actual fall (suddenly go down onto the ground or towards the ground unintentionally or accidentally) incidents in the facility which may lead to serious injury to the Resident. 4. Resident 277 to have an unwitnessed fall on 5/8/2024 in the patio and sustained a right eyebrow laceration (a deep cut or tear in skin), fracture (broken bone) of the right zygomatic arch (a bone surrounding the eyeball is broken), and a fracture of the right orbital (surrounding the eyeball) floor anterior (in front of) wall and posterior (toward the back) wall of the maxillary sinus (located to the side of the nasal [relating to the nose]cavity, and below the orbit). Resident 277 was transferred to the GACH on 5/8/2024. Findings: Cross Reference F657 1. A review of Resident 216 Admission Record indicated resident was originally admitted on [DATE] and was readmitted on [DATE] with the following diagnoses of dementia (a condition characterized by memory loss and judgment) and schizophrenia (mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to inappropriate actions and feelings). A review of Resident 216 History and Physical (H&P), dated 4/28/2024, indicated resident does not have the capacity to understand and make decisions. A review of Resident 216 Minimum Data Set (MDS; a standardized care screening and assessment tool), dated 4/23/2024, indicated resident was severely impaired in cognitive skills for daily decision making. MDS also indicated resident is dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity.) with oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing and putting on/taking off footwear. MDS indicated resident has a history of falls in the past 2-6 months of admission. A review of Resident 216 Fall Risk Assessment, dated 12/16/2023, indicated resident was at high risk for falling. A review of Resident 216 Care Plan, initiated on 2/6/2024, indicated actual fall on 2/6/2024, actual fall on 4/28/2024, actual fall on 5/9/2024 at 12:15 PM, and unwitnessed fall on 5/9/2024 at 4:40 PM. A review of Resident 216 Progress Notes, dated 4/28/2024 at 12 AM, indicated resident tried to get out of right side of the bed, slipped and hit his head with slight bleeding on the forehead. A review of Resident 216 clinical record indicated that on 5/9/2024 at 12:15 PM resident had a fall. Resident did not hit his head and did not have any signs or symptoms of pain. A review of Resident 216 Progress Notes, dated 5/9/2024 at 4:50 PM, indicated resident was found by the bedside, inside his room. Medical Doctor (MD) was notified and gave an order for a 1:1 sitter. During an interview on 5/23/2024 at 10:32 AM, Licensed Vocational Nurse 10 (LVN 10) stated Resident 216 fell 4 (four) times. LVN 10 also stated Resident 216 required 1:1 after the first incident of the falls (2/6/2024). During a concurrent record review of Resident 216 clinical recorded, dated 5/9/2024 at 12:15 PM, and interview on 5/9/2024 at 10:34 AM, LVN 10 stated according to the record resident had a 1:1 sitter; however, LVN 10 clarified that sitter was also supervising nine other residents. LVN 10 also stated Resident 216 fell while in the hallway when he tried to stand from his wheelchair. LVN 10 stated resident should have a 1:1 sitter supervising Resident 216 and no other residents. During an interview on 5/24/2024 at 8:52 AM, Director of Nursing (DON) stated Resident 216's behavior of physical aggression and getting up on his own both from bed and wheelchair required for a 1:1 sitter in accordance with the policy. DON stated having a 1:1 sitter could have prevented Resident 216 from having further falls. A review of the facility's Policy and Procedure titled Safety of Residents, revised 5/1/2023, indicated if a resident's behavior becomes unmanageable in a way that compromises his or her safety the Charge Nurse and the Director of Nursing (DON) are notified immediately. Policy also indicated charge nurse/ DON will maintain one on one supervision of the resident until the behavior has subsided. A review of the facility's Policy and Procedure titled Fall Management Program, dated 6/1/2017, indicated the policy is to prevent resident falls and minimize complications. Policy also indicated to provide the highest quality care in the safest environment for the residents residing in the facility. 44636 Cross Reference F656 2. During a review of Resident 300's Admission Record, the Admission Record indicated Resident 300 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including fracture of a right femur, presence of right artificial hip joint, history of falling, and syncope (fainting or passing out). During a review of Resident 300's History and Physical (H&P), dated 5/7/2024, the H&P indicated Resident 300 did not have the capacity to understand and make decisions. The H&P indicated Resident 300 was status post ([S/P] a term used to refer to after the experienced event) right hip hemiarthroplasty. During a review of Resident 300's Minimum Data Set ([MDS] a standardized assessment and care-screening tool), dated 3/17/2024, the MDS indicated Resident 300's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making were moderately impaired. Resident 300 required partial/moderate assistance for walking ten feet (the ability to walk at least 10 feet in a room, corridor, or similar space). The MDS indicated walking 50 and 150 feet was not attempted due to the resident's medical condition or safety concerns. The MDS indicated Resident 300 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as the resident completes the activity) for roll left and right, sitting to lying and lying to sitting on side of bed. The MDS indicated Resident 300 required partial/moderate assistance for sit to stand and transfer between surfaces. During a review of Resident 300's Fall Risk Assessment, dated 4/11/2024, the Fall Risk assessment indicated Resident 300 was at moderate risk for falls. During a review of Resident 300's Nurses' Note, dated 4/11/2024, the Nurses' note indicated Resident 300 was placed on monitoring for an unwitnessed fall. There was no other information documented regarding the details of Resident 300's fall incident, including the resident's assessment after the fall. During a review of Resident 300's Physician's Order, dated 4/11/2024, the Physician's Order indicated an X-Ray (photographic or digital image of the internal composition of something, especially a part of the body) on the sacrum (the large, triangle-shaped bone at the base of the spine)/ coccyx (the small bone at the bottom of the spine) and left and right knee to rule out injury due to fall. During a review of Resident 300's X-Ray Report, dated 4/12/2024, the X-ray report indicated Resident 300 did not have an acute fracture or dislocation in the left knee, right knee, sacrum, and coccyx. During a concurrent review of Resident 300's IDT Fall Committee meeting (not done after fall on 4/11/2024) and fall care plan (not done after fall on 4/11/2024) and interview on 5/24/2024 at 10:51 PM with the Director of Nursing (DON), the DON stated, an IDT Fall Committee meeting was not conducted and should have been conducted after Resident 300's first fall on 4/11/2024. The DON also stated a fall care plan was not developed and should have been completed after Resident 300's first fall on 4/11/2024. The DON stated Resident 300's Fall Risk Assessment, dated 4/11/2024, indicated Resident 300 was at moderate risk for falls. The DON stated there was no fall risk assessment prior to Resident's fall on 4/11/2024. During a review of Resident 300's Nurses Notes, dated 5/1/2024, the Nurse's notes indicated during room rounds on 5/1/2024 at 10 AM, Resident 300 was found lying on the floor. The Nurses notes indicated Resident 300 claimed he slipped while walking in the hallway and complained of pain and discomfort on the back of his head and right shoulder. The Nurses note indicated the doctor ordered for Resident 300 to be transferred to a GACH. The Nurses Notes dated 5/1/2024 at 10:26 AM, indicated the paramedics arrived and transferred the resident. During a review of Resident 300's GACH's computed tomography ([CT] a diagnostic test noninvasive medical examination or procedure that is uses specialized X-ray {an imaging study that takes pictures of bones and soft tissues} equipment to produce cross-sectional images of the body) result, dated 5/1/2024, the CT indicated Resident 300 had a right hip fracture. During a review of Resident 300's GACH's H&P record, dated 5/2/2024, the GACH's H&P indicated a Medical Doctor (MD) discussed Resident 300's case with the Orthopedic Surgeon ([OS], doctor who specialize in surgery of bones, joints, and muscles) who ordered for Resident 300 to have an urgent right hip hemiarthroplasty surgery. During a review of Resident 300's GACH's Progress Note, dated 5/3/2024, the GACH's Progress Note indicated Resident 300 was brought in by Emergency Medical Service (EMS) for an unwitnessed fall at the facility. Resident 300 was found to have a right hip fracture and admitted for further management. Resident 300 was S/P right hip hemiarthroplasty on 5/2/2024. During a review of the IDT Falls Committee Meeting Notes, dated 5/8/2024 (seven days after the Resident 300's fall incident on 5/1/2024), the IDT Falls Committee Meeting Notes indicated Resident 300 had an unwitnessed fall. It also indicated Resident 300 was observed on the floor in the hallway, transferred to the hospital on 5/1/2024, and was readmitted back to the facility on [DATE] after a right hip hemiarthroplasty surgery due to a fracture of the right hip. During a concurrent observation and interview on 5/23/2024 at 10:35 AM in Resident 300's room, Resident 300 was lying in bed awake and stated he does not know about his fall incidents. During an interview on 5/23/2024 at 10:46 AM, Certified Nursing Assistant (CNA 6) stated before Resident 300's hip surgery on 5/2/2024, the resident was able to walk around the unit, but now he cannot walk. During an interview on 5/23/2024 at 10:53 AM, Licensed Vocational Nurse (LVN 2) stated, prior to the fall on 5/1/2024, Resident 300 would always try to get up from the bed or a wheelchair unassisted. LVN 2 stated Resident 300 would walk around the hallway and to the nursing station by himself. LVN 2 stated Resident 300 walked short distances and his gait was unsteady. LVN 2 stated on 5/1/2024, LVN 2 heard a noise around the corner of the hallway while he was passing medication. LVN 2 stated Resident 300 was walking in the hallway by himself, possibly tried to grab onto the sidebar, and fell . LVN 2 stated Resident 300 was lying on the floor in the hallway and could not move his leg when assessed. LVN 2 stated Resident 300 complained of pain level rated 10 out of 10 on a pain scale from aero to ten where a zero represents no pain and 10 represents the worse pain possible. During an interview on 5/24/2024 at 9:09 PM LVN 8 stated Resident 300 was able to walk prior to his fall on 5/1/2024, however his gait was very unsteady, and he could not bear weight (support body weight through the bones, muscles, and joints during various activities, such as standing, walking, or exercising). LVN 8 stated Resident 300 would get up unassisted and he was very unbalanced. During a concurrent record review of Resident 300's current care plans with LVN 8, LVN 8 stated there was no care plan developed for Resident 300 getting up unassisted. During a concurrent record review of Resident 300's current care plans with LVN 8, LVN 8 stated, there were no interventions in place to ensure Resident 300 would not get up unassisted. LVN 8 stated Resident 300 wanted to walk by himself and did not want to use his wheelchair. LVN 8 stated Resident 300 needed someone to assist him when he walked. LVN 8 stated Resident 300 had fall risk factors which included his unsteady gait, balance, behavior disturbance, epilepsy (a brain disorder that causes unprovoked, recurrent seizures), cerebrovascular accident (CVA [stroke], damage to the brain from interruption of its blood supply) and medications. During a concurrent review of Resident 300's MDS, dated [DATE], and an interview on 5/24/2024 at 9:09 PM with LVN 8, LVN 8 stated prior to Resident 300's first fall on 4/11/2024, the resident required partial/moderate assistance for walking at least 10 feet. LVN 8 stated Resident 300 should be assisted with walking in accordance with the MDS. During a concurrent record review of Resident 300's Nurses Notes, for the month of April, SBAR (an acronym for Situation-Background-Assessment-Recommendation is a technique used to provide a framework for communication between members of the health care team), dated 4/11/2024, and IDT notes from 4/11/2024 to 5/24/2024, and interview with the DON on 5/24/2024 at 10:44 PM, the DON stated Resident 300 had a fall on 4/11/2024, however, the records only indicated Resident 300 had an unwitnessed fall. The DON stated Resident 300's documentation should have included a narrative or a summary of the fall event on 4/11/2024. The DON stated a care plan for fall prevention was not developed and should have been developed before Resident 300's fall on 4/11/2024. The DON stated if the care plan was developed then it should have been revised after Resident 300's fall on 4/11/2024, in accordance with the facility policy. The DON stated Resident 300's care plan for the fall prevention was not initiated until 5/7/2024. The DON also stated an IDT meeting was not conducted for Resident 300's first fall on 4/11/2024 from 4/11/2024 to 5/24/2024 and should have been conducted after Resident 300 fell on [DATE], in accordance with the facility policy. During an interview on 5/24/2024 at 10:48 PM, the DON stated when a resident fall occurs, the initial intervention would be to ensure the resident was safe. The DON stated, the physician will be notified, and a post fall assessment (guide for staff in the assessment of resident for potential injury after a fall occurred) and neuro-check (consists of physical examination to identify signs of disorders affecting the brain, spinal cord [long, tube-like band connecting the brain to the lower back], and nerves) would be completed. The DON added an IDT meeting would be conducted to ensure revision of the resident's care plan to include interventions to keep the resident safe and prevent further falls. The DON stated IDT meetings were done within 72 hours after a resident fall in accordance with the facility policy. The DON stated the care plan for preventions of falls should be created or updated at the time of the fall or during the IDT meeting to include any interventions needed to prevent further falls. During a concurrent record review of Resident 300's Nurses Notes, dated 5/1/2024, and interview with the DON on 5/24/2024 at 10:56 PM, the DON stated Resident 300 had another fall on 5/1/2024. The DON stated Resident 300 was walking in the hallway and slipped and was found lying on the floor in the hallway. The DON stated according to the nursing documentation, there was no staff assisting Resident 300 while walking on 5/1/2024. The DON stated Resident 300 had to walk with partial or moderate assistance as indicated on the MDS, which meant Resident 300 needed someone to assist him while walking. The DON stated Resident 300 could not ambulate (to move from place to place: walk) 100 % on his own. The DON stated Resident 300 returned from the hospital on 5/7/2024 with a right hip fracture from the fall which required a surgical intervention. The DON stated a fall risk assessment was not completed for Resident 300 not until the resident had his first fall on 4/11/2024. The DON stated the fall risk assessment dated [DATE] indicated Resident 300 was assessed as at moderate risk for falls due to diagnoses such as CVA, and syncope. The DON stated a fall risk assessment should have been completed prior to Resident 300's first fall to help establish resident's fall risk and interventions to help prevent the resident's fall including the fall on 4/11/2024. The DON stated a care plan was not initiated until 5/7/2024, which was after the Resident 300 had two falls one on 4/11/2024 and the second on 5/1/2024. The DON stated Resident 300's fall could have been prevented if an IDT meeting was conducted and care plan for the prevention of falls was put in place before the resident first fall on 4/11/2024. During a review of facility's Policy and Procedure (P&P) titled, Fall Management Program, revised on 6/1/2017, the P&P indicated to prevent resident falls and minimize complications associated with falls through the development of a Fall Management Program. Following a resident's fall, the licensed nurse will review the circumstances of the fall, review the plan of care, implement new interventions as appropriate, and revise the plan as indicated. The IDT-Falls Committee will meet within 72 hours of a fall. The IDT-Falls Committee will review and document the summary of event following a fall, root cause analysis, referrals, as necessary; and interventions to prevent future falls. The Fall Management Program strives to prevent resident falls through meaningful assessments, interventions, education, and reevaluation. 45456 3. A review of Resident 179's Admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), history of traumatic related fracture (a serious injury that occurs when extreme force is applied to the bone) and muscle weakness. A review of Resident 179's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 2/16/2024, indicated Resident 179 had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 179 required partial/moderate assistance (helper does less than half the effort, helper lifts, holds, or supports trunks or limbs, but provides less than half the effort) in toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, roll left and right, sit to lying, and lying to sitting on side of the bed, sit to stand, chair /bed-to-chair transfer, toilet transfer and tub/shower transfer. A review of Resident 179's Care Plan (CP) initiated on 9/3/2022 and revised on 5/20/2024, indicated Resident 179 was at risk for falls and/or injuries related to balance deficit, cognitive, impairment, decreased strength and endurance, poor safety, awareness/judgement, unsteady gait, anti-hypertensive, and psychotropic medications. It indicated resident had multiple falls with interventions that included frequent visual checks, functional mobility training if indicated, keep adjustable bed in low position for safe transfers, monitor medications for side effects that may increase risk for falls, notify physician as appropriate, provide assistance with transferring and locomotion as needed, Physical therapy (PT, is a medical treatment used to restore functional movements, such as standing, walking, and moving different body parts) / Occupational therapy (OT, use of self-care and work and play activities to promote and maintain health, prevent disability, increase independent function, and enhance development) assessment and training as indicated. A review of Resident 179's Interdisciplinary Team (IDT, a group of professional and direct care staff that have primary responsibility for the development of a plan for the care and treatment of a resident) Meeting for the actual Falls incidents indicated, there were no IDT records for the following dates: - Actual fall on 1/9/2024, with injury. - Actual fall on 1/13/2024, no injury. - Actual fall on 2/12/2024, with injury. A review of Resident 179's Nurses Notes on 5/22/2024 at 3:26 PM indicated, Licensed Vocational Nurse 12 (LVN 12) stated, around 2PM, LVN 12 heard indicated a thump noise while charting at nursing station. LVN 12 went to the common bathroom, Resident 179 was being assisted to wheelchair. Licensed Nurse reported to charge nurse she found Resident 179 on floor on her left side and helped assist resident to wheelchair. There was hematoma noted on Resident 179's left cheek. During an observation in the residents' communal restroom on 5/22/2024 at 2:35 PM, observed Resident 179 with her face down on the floor. Multiple facility staff assisted Resident 179 back to her wheelchair and rolled her back to her room. During a concurrent record review of Resident 179's Fall Care plan and interview with the Director of Nursing (DON) on 5/24/2024 at 5:12 PM, the DON stated, Resident 179's care plan was generalized, it is not patient centered and needed areas for improvement. Resident 179 was a fall risk and interventions should include the need for a sitter and an IDT update. During a concurrent review of facility's policy for Fall Management Program and interview with the DON on 5/24/2024 at 10:06 PM, DON stated, The most effective intervention was having 1:1 sitter for the resident. It should have been done to supervise Resident 179. During a concurrent review of facility's policy for Fall Management Program and interview with the DON on 5/24/2024 at 10:28 PM, DON stated, In the post fall policy, IDT Team should review the fall incident and customize the care plan to the resident's needs and should try different approach or interventions. During a concurrent review of facility's policy for Fall Management Program and interview with the RCD on 5/24/2024 at 10:54 PM, RCD stated, Policy indicated on Post fall - Interventions to prevent future falls, it means 1:1 supervision should have been included in the care plan immediately. A review of facility's policy and procedure titled, Fall Management Program revised on 6/1/2017, indicated to provide the highest quality of care in the safest environment for the residents residing in the facility. The facility has developed a Fall Management program that strives to prevent resident falls through meaningful assessment, interventions, education, and reevaluation. 50012 4. A review of Resident 277's Admission Record (Face Sheet), indicated Resident 277 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included history of fall, muscle weakness, and dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). A review of Resident 277's care plan for at risk for fall dated 12/19/2023 indicated Resident 277 was at risk for falls related to antihypertensive (medicines that bring blood pressure down) medications, balance deficit, bladder dysfunction (leaking of urine that you cannot control), cognitive impairment, decreased strength or endurance, history of falls, inappropriate use of assistance device with ambulation, poor safety awareness or judgment, psychotherapeutic medications (any drug that affects brain activities associated with mental processes and behavior), unsteady gait (manner of walking), visual deficit. The care plan goal indicated Resident 277 would be free of falls. The care plan interventions which included reviewing past information on past falls and attempts to determine cause of falls, anticipating for contributing factors for falls, placing the bed in low position, and to frequently providing visual monitoring. A review of Resident 277's History and Physical (H&P) dated 5/24/2023, indicated Resident 277 did not have the capacity to understand and make decisions. A review of Resident 277's Minimum Data Set (MDS - a comprehensive assessment and screening tool), dated 2/23/2024, indicated Resident 277's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making was severely impaired. The MDS also indicated Resident 277 required supervision or touching assistance (helper provides verbal cues and/or touching, steadying and/or contact guard assistance as resident completes activity. Assistance maybe provided throughout the activity or intermittently.) for sit to stand, walking 10 feet, walking 50 feet with two turns, walking 150 feet. A review of Resident 277's Change in Condition (COC) Evaluation form, dated 4/23/2024 indicated Resident 277 had a fall on 4/23/2024 12:10 AM without injury sustained. The COC Evaluation form indicated the resident was found sitting on the floor next to the bed in an upright position. The resident complained of pain to the left forearm and there was a scrape and swelling noted. A review of Resident 277's Morse Fall Scale (MFS tool that predicts the likelihood that a resident will fall), dated 4/23/2024, indicated Resident 277 had a total score of 65, which meant the resident was a high risk for fall. A review of Resident 277's COC Evaluation form dated 5/8/2024 indicated Resident 277 had a fall on 5/8/2024 with injury. Resident 277 had an unwitnessed fall in the patio of Unit 300 and was found with a laceration on her right upper eyelid approximately three (3) centimeters (cm, a unit of measurement). The COC Evaluation form indicated Resident 277 was transferred to GACH via 911 (an emergency service). A review of the interdisciplinary team (IDT, a team of professionals from different fields) conference record, dated 5/9/2024, indicated Resident 277 had an unwitnessed fall on 5/8/2024 in the patio of Unit 300 with injury sustained. The IDT conference record indicated Resident 277's care plan was updated. A review of the Computer Tomography (an imaging test that helps healthcare providers detect injuries and diseases) from the GACH, dated 5/8/2024, at 12:27 PM, indicated Resident 277 had a fracture of the right zygomatic arch and a fracture of the right orbital floor anterior wall and posterior wall of the maxillary sinus. A review of Resident 277's Order Summary Report dated 5/24/2024 indicated a physician order, dated 3/9/2024, to monitor resident's whereabouts due to wandering and an order, dated 5/8/2024 to transfer Resident 277 to the GACH for laceration (a deep cut or tear in the skin) on right upper eyelid post fall. During a concurrent observation and interview on 5/23/2024 at 2:30 PM, Resident 277 was observed wandering in hallway without staff supervision or assistance. Resident 277 was observed to have a laceration on the right upper eyelid (the folds of the skin which cover the eye). Resident 277 was mumbling words and did not respond to questions appropriately. Resident 277 stated that she did not recall falling or what led to her fall. During an interview on 5/24/2024 at 9 AM, Licensed Vocational Nurse (LVN) 9 stated Resident 277 liked to walk up and down the hallway. LVN 9 stated Resident 277 had an unwitnessed fall on 5/8/2024 and was found outside the smoking patio by a resident (unidentified) and that resident (unidentified) notified him (LVN 9). LVN 9 stated that he could not recall who was the resident that notified him of the fall. During the interview on 5/24/2024 at 9 AM, LVN 9 stated on 5/8/2024 he performed a head-to-toe assessment on Resident 277. LVN 9 stated the resident had a laceration to the right upper eyelid, which was bleeding. LVN 9 stated he notified the charge nurse (unidentified), and the paramedics (healthcare professionals trained to respond to emergency calls) were called. LVN 9 stated Resident 277 was transferred to the hospital for further evaluation. During the interview on 5/24/2024 at 9 AM, LVN 9 stated that he only supervised residents that went outside to smoke in the patio and the activity coordinator was the one who watched residents in the patio. LVN 9 stated Resident 277 shuffled (walking pattern that occurs when a person drags their feet while walking. The length of each step is typically shorter than normal) when she walked, which increased her chances for falls. During the interview on 5/24/2024 at 9 AM, LVN 9 stated Resident 277 was on frequent visual checks which just required us (the staff) to watch her (the resident) from a distance. LVN 9 stated it was a bit hard to keep track on her (the resident) because the resident liked to wander around the unit. LVN 9 stated the resident was on wandering monitoring as well. During a review of facility's Policy and Procedure (P&P) titled, Fall Management Program, revised on 6/1/2017, the P&P indicated to prevent resident falls and minimize complications associated with falls through the development of a Fall Management Program.

Based on observation, interview, and record review, the facility failed to ensure the resident, who was complaining of having new onset of severe (that which is disabling, preventing performing normal activities during the day or night) pain to the right underarm area that was radiating to right shoulder had the pain under control for one of one sampled resident (Resident 88) by failing to: 1. Ensure Resident 88's pain was accurately assessed and re-assessed when the Tylenol (a pain reliever used to treat mild and moderate pain) was not effective in resolving Resident 88's pain. 2. Call the physician when Registered Nurse (RN) 2 and Licensed Vocational Nurse (LVN) 15 were unable to access the automated medication dispenser (a computer-controlled system that automates the dispensing of medications in hospitals) to obtain the Tramadol (a strong narcotic pain killer used to treat moderate to severe pain) in order to administer to Resident 88 for severe pain. 3. Ensure to implement Resident 88's care plan for actual pain on the right chest related to a fracture (broken bone) of the ninth (9th) and tenth (10th) ribs, to administer pain medication as ordered, and notify the physician Resident 88 was experiencing unmanageable, intolerable, and severe pain on 5/21/2024. These failures resulted in Resident 88 to experience unresolved severe pain for 13 hours from 10:10 AM to 11:09 PM on 5/21/2024. Findings: During a concurrent observation and interview on 5/21/2024 at 10:18 AM, at Resident 88 Room, Resident 88 was moaning and grimacing in pain. Resident 88 stated she was having unusual severe pain to the right underarm area that was radiating to her right shoulder. Resident 88 stated her pain level was nine (9) over 10 on a numeric pain scale (zero meaning no pain and 10 meaning the worst pain imaginable. A pain level of 9 meant severe pain). Resident 88 stated that the pain started on 5/21/2024 after she was transferred from the dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) chair to the wheelchair while at the dialysis center. Resident 88 stated that the pain had not stopped since she returned to the facility from the dialysis center at around 9:30 AM. Resident 88 stated she notified LVN 15 about her pain. Resident 88 stated she was given Tylenol by LVN 15 at approximately 10 AM (on 5/21/2024). Resident 88 stated the Tylenol still had not kicked in (had not taken into effect). During an interview on 5/21/2024 at 10:29 AM, LVN 15 stated that she had just given Resident 88 Tylenol 325 milligram (mg, unit of measurement. Tylenol is used to relieve mild pain or a pain level of 1 to 3 over 10) two tablets by mouth at 10:10 AM. LVN 15 stated Resident 88 complained of pain in right axilla (the area of the human body directly under the shoulder joint) and shoulder pain. LVN 15 stated Resident 88 had a pain level of three (3) over 10 (a pain level of 3 meant mild pain). LVN 15 stated she assessed Resident 88 and noted some bruising (happens when blood pools under your skin after an injury) and swelling around Resident 88's right ribcage area (surrounds the lungs and the heart, serving as an important means of bony protection for these vital organs). LVN 15 stated she notified RN 2 about the residents' pain, bruising, and swelling to the right ribcage area. During a concurrent observation and interview on 5/21/2024, at 1:27 PM, at Resident 88 Room, Resident 88 was grimacing and restless. Resident 88 stated she was uncomfortable and still in a lot of pain and the resident rated her pain level at an eight (8) over 10 on a numeric pain scale (a pain level of 8 meant severe pain). Resident 88 stated that she notified LVN 15, and she was informed that RN 2 had notified the Primary Care Physician (PCP) 1 and were waiting for orders. During an interview on 5/22/2024 at 10:41 AM, LVN 15 stated Resident 88 continued to have persistent pain to the right ribcage area. LVN 15 stated that on 5/22/2024, at 12:37 AM Resident 88 became hypotensive (low blood pressure) and lethargic (drowsy, not alert, or decrease in consciousness), PCP 1 was notified, and Resident 88 was transferred to the general acute care hospital (GACH) via paramedics (emergency medical response). During an interview on 5/22/2024 at 1:25 PM, LVN 15 stated RN 2 reported Resident 88's change of condition (COC- a sudden clinically important deviation from baseline) to PCP 1 on 5/21/2024, at noon. LVN 15 stated that the PCP 1 ordered Tramadol, and a chest x-ray (a device that produces images of internal tissues, bones, and organs) to rule out fracture, bruising, and pain. LVN 15 stated the licensed nurses were unable to access the automated medication dispenser because they (the licensed nurses) did not have the authorization access code from the pharmacy to retrieve the narcotic. LVN 15 stated that newly ordered medication (Tramadol) could take several hours to be delivered from the pharmacy. LVN 15 stated that the PCP 1 or Medical Director (MD) 1 should have been notified about the inability to retrieve the Tramadol from the automated medication dispenser as this (not having the access code) delay care and could have potentially affected Resident 88's physiologic (according to the normal way of functioning of the body) and psychologic (mental or emotional rather than physical) well-being. During a phone interview on 5/23/2024 at 2 PM, Resident 88 stated she had excruciating pain (causing great pain or anguish) on 5/21/2024 at her right underarm area that was radiating to her right shoulder. Resident 88 stated the pain started at the dialysis center after she was transferred from the dialysis chair to the wheelchair. Resident 88 stated the pain was constant and was never alleviated, causing her to feel restless and anxious from continuous pain. Resident 88 stated taking Tylenol, the morning she returned from dialysis (on 5/21/2021 at 10:10 a.m.), hardly felt any relief. Resident 88 stated that the pain became worse throughout the day, and she notified numerous staff members. Resident 88 stated she could only recall telling LVN 15 and RN 2 about her pain but could not recall the rest of the staff members she notified throughout the day. Resident 88 stated the pain progressively getting worse throughout the day. During an interview on 5/24/2024 at 9:17 AM, RN 5, who worked on 5/21/2024 morning shift (7 AM to 3 PM), stated Resident 88 returned from the dialysis center on 5/21/2024 at around 9:30 AM and reported pain to her right underarm. RN 5 stated LVN 15 and RN 2 assessed Resident 88 and identified bruising and swelling to the right ribcage area. RN 5 stated Resident 88 reported the pain started after she was transferred from the dialysis chair to the wheelchair. RN 5 stated that bruising and swelling could be an indication of internal bleeding and could have been a life-threatening matter. During a concurrent interview and record review on 5/24/2024 at 11AM, with RN 5, Resident 88's Medication Administration Record (MAR), for the month of May 2024 was reviewed and the MAR indicated the following: - On 5/21/2024 at 10:10 AM, Resident 88 pain level was three (3) of 10 and was given Tylenol. - On 5/21/2024 at 11:10 AM, the Tylenol was documented ineffective, Resident 88's pain level remained three (3) of 10. - On 5/21/2024 at 11:09 PM Resident 88 pain level was documented with pain level of seven (7) of 10 and Tramadol 25 mg was given. - On 5/22/2024 at 12:20 AM Resident 88's pain level increased to 10 over 10. RN 5 stated that there was no document indicating Resident 88 was reassessed for pain on 5/21/2024 after 11:10 AM when the Tylenol did not relieve Resident 88 from pain. RN 5 stated the next documented pain assessment and pain intervention was on 11:09 P.M. when Resident 88 was given Tramadol 25 mg. During an interview on 5/24/2024 at 11 AM, RN 5 stated that Resident 88 was not given the Tramadol timely due to a delay of getting authorization access code for the automated medication dispenser. RN 5 stated that waiting for a newly ordered medication (Tramadol) from the pharmacy could take several hours. RN 5 stated the MAR indicated that Resident 88 went approximately 13 hours without effective pain management to treat moderate to severe pain. RN 5 stated that the paramedics should have been called much sooner when the licensed nurses were unable to access the Tramadol from the automated medication dispenser and unable to alleviate Resident 88's pain from the rib fractures. RN 5 stated that there was no other pain medication or pain relief method documented and that if it was not documented, it was not done. During a concurrent observation and interview on 5/24/2024 at 11:24 AM, with RN 5, the automated medication dispenser showed Tramadol was available in the automated dispensing system. RN 5 stated that the primary physician or medical director should be notified if there was a delay of getting authorization to retrieve narcotics (a drug that is given to people in small amounts to make them sleep or feel less pain) from the automated medication dispenser especially when a resident was experiencing unrelieved pain. During an interview on 5/24/2024 at 1:09 PM, Minimum Data Set Nurse (MDSN) 1, stated that licensed nurses should be able to access the automated medication dispenser for urgent and emergency cases. MDSN 1 stated that she was aware that staff have had issues accessing the automated medication dispenser to pull medication due to authorization issues. MDSN 1 stated if they cannot contact the primary physician to expediate the authorization, they can reach out to the medical director who was available 24 hours seven (7) days a week who can help get the authorization. During the interview on 5/24/2024 at 1:09 PM, MDSN 1 stated unrelieved pain for a long period of time can cause physical, mental, and psychosocial (describing the intersection and interaction of social, cultural, and environmental influences on the mind and behavior) harm. MDSN 1 stated that Resident 88 should have not endured pain for such a long time. MDSN 1 stated that if staff member were having issues with accessing the automated medication dispenser due to authorization, then they should have called the paramedics and transfer the resident to GACH right away for further evaluation. During a concurrent interview and record review on 5/24/2024 at 2:15 PM, with the Director of Nursing (DON), Resident 88's progress notes, dated 5/21/2024 through 5/23/2024, and Resident 88's MAR dated 5/1/2024 through 5/31/2024 were reviewed. The DON stated the progress notes and MAR indicated, Resident 88 went several hours without pain medication, no pain assessments, and progress notes related to pain was documented in the charting system after 11:10 AM and before 11PM on 5/21/2024. During the interview on 5/25/2024 at 2:15 PM, the DON stated that he was aware that the process to use the automated medication dispenser was difficult to access. The DON stated that licensed nurse should not wait for primary doctor and pharmacy authorization while the resident was enduring severe pain. The DON stated the licensed nurse should reached out to MD 1 who was available 24 hours seven (7) days a week to expedite the authorization process. The DON stated that if all else fails then residents should be sent out via 911 for further evaluation and patient safety. The DON stated that possible complications of rib fractures could result in internal bleeding, organ injuries or respiratory failure (a serious condition that makes it difficult to breathe on your own). During a phone interview on 5/24/2024 at 2:35 PM, the Pharmacist (Pharm) 1 stated that Resident 88's Tramadol was delivered to the facility no later than 6:44 PM on 5/21/2024. During a phone interview on 5/24/2024 at 4:30 PM, Medical Director (MD) 1 stated that pain management was of vital importance. MD 1 stated that he expected staff to effectively manage residents' pain and residents should not be enduring pain for a long period of time. MD 1 stated that staff should be communicating with the medical (physician's) team if current treatment measures were ineffective. MD 1 stated that in a scenario where licensed nurses were unable to access the emergency kit to retrieve the necessary pain medication, licensed nurses should reach out to MD 1 to get the pharmacy to release the authorization code for the automated medication dispenser. MD 1 stated that the medical director was available 24 hours seven (7) days a week, but if staff are unable to get the authorization code from pharmacy, then staff should be transferring resident to the hospital for moderate to severe unrelieved pain for further evaluation. A review of Resident 88's Admission Record (Face Sheet), indicated the facility admitted Resident 88 to the facility on [DATE], and readmitted the resident on 5/10/2024, with diagnoses including but not limited to, chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), end stage renal disease (the permanent stage where kidney function has declined to the point that the kidneys can no longer function on their own), chronic obstructive pulmonary disease (a common lung disease causing restricted airflow and breathing problems), renal dialysis, and type 2 diabetes mellitus (condition that affects the way the body processes blood sugar). A review of Resident 88's Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool), dated 2/3/2024, indicated the resident's cognitive (the ability to think and process information) skills for daily decisions making was intact, and required partial or moderate assistance with activities of daily living (ADLs) and partial or moderate assistance with mobility. A review of Resident 88's COC form, dated 5/21/2024 at 10:10 AM, indicated Resident 88 came back from dialysis and had new swelling, bruising on the right armpit. The resident was complaining of pain to that area (right armpit), and that Resident 88 stated it (the swelling and bruising on the right armpit) occurred during transfer from dialysis chair to wheelchair in the dialysis center. The COC indicated Resident 88 had a respiratory rate (the number of breaths a person takes per minute) of 26 and had acute (sudden) right armpit pain level three (3) on a numeric pain scale. The COC indicated PCP 1 was notified at 10:15 AM and PCP 1 ordered to monitor the area and obtain an x-ray of the right ribs. A review of Resident 88's Final X-ray Report, dated 5/21/2024, indicated Resident 88 had an acute (sudden) hairline fractures (a small crack or severe bruise within a bone) to the ninth (9th) and tenth (10th) ribs. A review of Resident 88's progress notes, dated 5/21/2024 at 10:20 AM, indicated RN 2 called the dialysis center and spoke with the dialysis RN that took care of Resident 88 during dialysis. The dialysis RN stated that the staff at the dialysis center had difficulty transferring Resident 88 and the resident required four (4) people to transfer Resident 88 from dialysis chair to the wheelchair. A review of Resident 88's physician order dated 5/21/2024 at 12:54 PM indicated to give the resident Tramadol 25 mg give one tablet by mouth every six (6) hours as needed for moderate to severe pain. A review of Resident 88's plan of care for actual pain on the right chest related to a fracture of the 9th and 10th ribs, initiated on 5/21/2024, indicated an intervention to administer pain medications as ordered, monitor for effectiveness and side effects, monitor and assess for verbal and non-verbal cues of pain and discomfort: verbalization of pain, moaning, grimacing, guarded posture, restlessness, confusion, hallucinations (an experience involving the apparent perception of something not present), dysphoria (a state of feeling very unhappy, uneasy or dissatisfied), nausea, vomiting, dizziness, and falls. The care plan indicated to report occurrences to the physician. Resident 88's care plan indicated a goal to relieved Resident 88's pain within 30 minutes to an hour post intervention. A review of Resident 88's progress notes dated 5/22/2024 at 12:20 AM, indicated that the follow-up medication assessment for Resident 88 had a pain level of 9 or severe pain and the Tylenol was ineffective. A review of Resident 88's COC, dated 5/22/2024 at 12:37 AM, indicated Resident 88 was noted with hypotension (when blood pressure [the amount of force your blood uses to get through your arteries] is lower than normal) and decreased level of consciousness and PCP 1 was notified with an order to transfer Resident 88 to GACH for further evaluation via paramedics. The COC indicated Resident 88 had acute right armpit pain level nine (9) over 10 on a numeric pain scale and a blood pressure of 79/37 mmHg (millimeters of mercury-unit of measurement- normal reference range120/80). A review of Resident 88's Progress Notes, dated 5/23/2024, indicated LVN 18 called GACH to follow-up on Resident 88. LVN 18 spoke with GACH RN and was told Resident 88 was being treated for hairline fractures on the right ribs ninth (9th) and tenth (10th). GACH RN reported that resident was in stable condition. GACH RN reported that Resident 88 would be transferred to a lower level of care within the hospital and no discharge orders yet to return to skilled nursing facility. A review of the facility's policy & procedures (P&P) titled, Pain Management, dated 6/1/2017, indicated: - Facility staff is responsible for helping the resident attain or maintain their highest level of well-being while working to prevent or manage the resident's pain. - The licensed nurse will administer pain medication as ordered and document all medication as ordered and document all medication administered on the MAR. - After medications or interventions are implemented, re-evaluate the resident's level of pain within one hour. - The licensed nurse will assess the residents for pain and document results on the MAR each shift using the 1-10 pain scale. The shift pain score will indicate the highest pain level that occurred on that shift. - If there is a new onset of pain, if the pain changed in nature, or the pain has not been relieved with current medications, the licensed nurse will notify the attending physician for a review of medications and the IDT-pain committee. - Nursing staff will implement timely interventions to reduce the increase in severity of pain.

Based on interview and record review the facility failed to provide treatment and services to attain the highest practicable mental and psychosocial wellbeing for one of two sampled resident (Resident 1) who was diagnosed with depression (a constant feeling of sadness and loss of interest, which stops you doing your normal activities) and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) by facility staff failing to: 1. Monitor and acknowledge Resident 1's expressions of feeling depressed. Resident 1 verbalized his, ups and down with depression and continually expressing depressive symptoms due to external social and familial factors. 2. Review, revise, and implement care plan that can assist in the resident's existing needs and potential risks related to Resident 1's verbalization of being depressed. 3. Review, revise, and implement a resident- centered care plan that addressed Resident 1's emotional and psychological needs due to the resident's history of suicidal ideation (thoughts of killing oneself) and verbalization of loneliness. On 3/25/2024, Resident 1 verbalized, it is hard to live with this loneliness, tired of living this way. 4. Consistently implement the plan (resident to work on cognitive reframing [therapy that aims to improve patient's cognitive function] of relational dynamics. Resident to work on increasing social engagement and interaction, as well as daily activities. Resident to work on concrete problem solving and solution focused steps to move on and function in life) delineated in the progress notes conducted by the Psychologist (MD 3, a professional who practices psychology [study of mind and behavior]) on 3/4/2024, 3/18/2024 and on 3/25/2024 the plan for Resident 1 to work on ensuring safety and alleviating depressive signs and symptoms. 5. Address Resident 1's use of Fluoxetine (antidepressant, medication to treat depression) and Olanzapine (medication for bipolar disorder) when resident was admitted to the facility on [DATE] from General Acute Care Hospital (GACH) 2 and not continued while residing in the facility from 12/6/2023 to 4/8/2024. This deficient practice led Resident 1 to be missing on 4/8/2024 at 7:20 AM. On 4/12/24, around 6:30 AM (four days later), Resident 1's body was found in the facility premises with the resident's head wrapped in a clear plastic material with a black cord tied around the resident's neck. Resident 1 was pronounced dead by Paramedic on 4/12/2024 at 7:01 AM and cause of death was suicide according to Los Angeles County Medical Examiner case report. On 4/12/2024 at 8:33 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 facility's failure to provide treatment and services to attain the highest practicable mental and psychosocial wellbeing of Resident 1 who was diagnosed with depression and bipolar disorder. The survey team notified the Director of Nursing (DON), Assistant Director of Nursing (ADON 2), Infection Preventionist Nurse (IPN), Quality Assurance Nurse (QAN) and Director of Staff Development (DSD) of the IJ situation due to: facility failing to acknowledge and monitor Resident 1's expressions of feeling depressed and failed to review, revise, and implement care plan that addressed this depression on 12/6/2023, 3/4/2024 and 3/18/2024; Facility failed to review, revise, and implement a resident- centered care plan that addressed the assessed Resident 1's emotional and psychological needs of verbalization of loneliness and having history of suicidal ideation. On 3/25/2024, Resident 1 verbalized it is hard to live with this loneliness, tired of living this way, and having a history of suicidal ideation; Facility failed to assure facility staff consistently implement the plan (resident to work on cognitive reframing of relational dynamics. Resident to work on increasing social engagement and interaction, as well as daily activities. Resident to work on concrete problem solving and solution focused steps to move on and function in life, delineated in the progress notes conducted by MD 3 on 3/4/2024, 3/18/2024 and on 3/25/2024 the plan for Resident 1 to work on ensuring safety and alleviating depressive signs and symptoms; and facility failed to address the need to continue Resident 1's Fluoxetine (antidepressant, medication to treat depression) and Olanzapine (medication for bipolar disorder) when resident was admitted to the facility on [DATE] from GACH 2. On 4/14/2024 at 6:56 PM, the IJ was removed in the presence of the Assistant Administrator (AADM), Regional Clinical Director (RCD) and MDS coordinator 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 4/12/2024, included the following: a. An immediate search was conducted by all available staff in and around the interior (including bathrooms, shower areas, storage areas) and exterior premises (including RTC 1) grounds and parking lot) when Resident 1 was found missing on 4/8/2024. Administrator (ADM), AADM and DON, Medical Doctor (MD/ PCP) and Responsible party (RP) were informed. The facility called code green (alert to all staff when a resident is missing or cannot be found in the facility) immediately, all common areas were searched, the resident was not found, the ADM / designee, DON, PCP and RP were notified. ADM / designee contacted law enforcement gave the following information: residents name, description (hair color, eye color, skin complexion, clothing, distinguishing marks) and recent photo of resident and addressed and telephone number and worked with the responsible party while the resident was being located. Charge nurse (Licensed Vocational Nurse [LVN] 1) documented in the resident's medical record how the elopement occurred. b. On 4/8/2024, Temple Sheriff Station was notified by the RN Supervisor and Deputy 1 arrived at the facility while facility staff continued to search for the resident. c. On 4/8/2024, surrounding hospitals ER including GACH 3, GACH 4, GACH 5, GACH 6 and also Metro Link (ML) customer service was called by Social Service Director (SSD) to find out if this resident was picked up by someone and brought to the hospital. The response was negative (no knowledge of Resident 1's whereabouts). Deputy 1 gave verbal report from Sheriff's Department K9 unit that a scent was picked up at a local bus stop on [NAME] Ave. d. On 4/8/2024, Temple City Sheriff and acute hospitals around the area were called daily from 04/08/2024 to 04/11/2024 by SSD and Assistant Administrator to verify if resident happened to show up for the next three days, the Social Service also informed local hospitals to call the facility if the resident shows up. The response was still negative (no knowledge of Resident 1's whereabouts). e. From 04/08/2024 the nursing staff conducted head count of all residents in the facility and a search if Resident 1 was found. f. On 4/12/2024, Resident 1's body was found (by the gardener) behind unit 600 at around 6:30 AM with head wrapped in a plastic (clear plastic) and with a black cord tied around the resident's neck. g. The DON and Medical Records reviewed clinical records on 04/12/2024 to 04/13/2024 for residents with diagnoses of depression with suicidal ideation and bipolar disorder with suicidal ideation and there were eighty- seven (87) residents potentially affected by this deficient practice. These identified residents were reassessed; care plans reviewed, revised, and updated ensuring care plans are individualized addressing the emotional and psychosocial needs of residents with interventions implemented. There were Five (5) residents identified with history of verbalizing signs and symptoms of suicidal ideation. h. An in-service was initiated on 04/13/2024 by the ADON and Social Service Director to licensed nurses, including the Interdisciplinary Team (IDT, team of different specialty that brings together knowledge from different departments to help ensure the resident received the care she/ he needs - Social Service, Nursing, MDS, Activities, Dietary) and CNA's regarding the facility's policy and procedure titled, Management of Patients with Depression and Bipolar Disorder including checking if medications are appropriate for patients with depression with suicidal ideation and bi-polar disorder with suicidal ideation. Residents upon admission, readmission, quarterly and upon identification of significant change of condition to determine signs and symptoms of depression and bipolar disorder. This included preventative interventions that will be documented in the resident's care plan, behavior monitoring in the medication administration record (MAR), clinical records, reviewed and re-evaluated by the IDT (Nursing, Social Services, MDS, DON / designee). Also, on 04/13/2024 an in-service by RCD, ADON, Social Services included education on social support and psychological therapy to improve coping skills to better equip and deal with life's stresses and conflicts. i. On 04/12/2024 Medical Records Director conducted an audit for residents that are identified to have depression with suicidal ideation and bi-polar with suicidal ideation if they are on anti-depressant medication. One (1) resident was identified having no anti-depressants. The care plan for depression with suicidal ideation was updated to include monitoring with behavior, Psychology consult was recommended on 04/13/2024 per health practitioner's order. j. On 04/13/2024, the AADM and RCD shall schedule the [NAME] President (VP) of Behavioral Health to provide education regarding behavioral management specific to residents with depression with suicidal ideation and bi-polar with suicidal ideation (date to be determined). k. Starting 4/13/2024, under the supervision of the ADM, Social Service Director, and social service staff will ensure to assess residents upon admission, readmission, quarterly and change of condition or as needed to determine resident's risk for depression, bipolar disorder and suicidal ideation signs and symptoms. l. Starting 4/13/2024, once identified, the IDT including SSD, Nursing, MDS, Activities and Dietary will ensure care plans are developed to address depression with suicidal ideations and bipolar disorder with suicidal ideation to include preventative interventions addressing the emotional and psychosocial needs of residents. m. Starting 4/13/2024, the IDT including SSD, Nursing, MDS, Activities and Dietary during daily reviews of residents' clinical records will ensure care plans are individualized and in place to include preventative interventions of residents that have diagnosis of depression with suicidal ideation and bipolar disorder with suicidal ideation. The SSD will ensure this is documented in the residents' clinical records and re-evaluated by the IDT upon admission, readmission, quarterly and change of condition or as needed. n. Starting 4/13/2024, the care plan for depression with suicidal ideation and bi-polar disorder with suicidal ideation were developed with approaches delineated in the progress notes by the Psychologist to be consistently implemented by social service staff and nursing staff. The social service staff and nursing staff will ensure that the approaches are meeting the emotional and psychosocial needs of the resident. During weekly behavioral management meeting, the psychologist and psychiatrist (a medical practitioner that specializes in diagnosis and treatment of mental illness) provide additional recommendations and approaches. o. Starting 4/13/2024, ongoing behavioral and psychotropic (relating to drugs that affect a persons' mental state) assessment for patients with suicidal ideation will be in place upon admission and readmission as to whether care approaches addressed in the psychiatry / psychology progress notes are completed. This will be verified by the DON and ADON. This will be done upon admission, quarterly at a minimum and as needed for any changes of condition. p. Starting 4/13/2024, the DON will ensure to review the clinical records of residents receiving antidepressant and will ensure that their interventions are carried out. The attending physician and psychiatrist will be notified for any recommendations on behavioral management and medication management for residents who are receiving antidepressants. q. Starting 4/13/2024, non-compliance of depression with suicidal ideation and bipolar disorder with suicidal ideation management will be discussed by the IDT (Social Services, Nursing, DON / ADON, MDS, including Psychologist or Psychiatrist) during the daily stand-up meeting and clinical rounds to ensure timely resolution and corrective action is sustained. r. On 04/13/2024 the RCD reached out to the Social Services consultant to provide ongoing facility level support and provide education on behavioral management on residents with depression with suicidal ideation and bipolar with suicidal ideation (schedule to be determined). s. On 04/13/2024 the AADM and RCD shall schedule the VP of Behavioral Health to provide education regarding behavioral management specific to residents with depression with suicidal ideation and bipolar with suicidal ideation (scheduled on 4/16/2024 at 2:30PM). t. Starting 4/13/2024, the Social Service Director is responsible for monitoring corrective actions through an on-going compliance ensuring care plans for depression with suicidal ideation and bipolar disorder with suicidal ideation are in place to include preventative interventions such as: address the emotional and psychosocial needs, implement care approaches, on-going behavioral and psychotropic assessments as to whether care approaches are addressed in the progress notes on new admissions, readmission and change of condition. u. Starting 4/13/2024, the DON and ADON likewise responsible for monitoring the need for the continued administration of antidepressant in collaboration with the attending physician and psychiatrist or psychologist. The DON and Social Service Director will ensure the deficient practice will not be repeated. The RN supervisor shall monitor the MAR administration of anti-depressants every shift daily. The Medical Records department shall audit the medication administration record daily, 7 days a week. v. Starting 4/13/2024, the results of the RN audit of the MAR and the Medical Records daily MAR audit will be submitted and discussed during the monthly quality assurance meeting for its compliance. This will again be submitted to the Quarterly Performance Improvement Committee for review and recommendations follow up ensuring compliance. w. Starting 4/13/2024, the Performance Improvement Committee will monitor the process weekly for the next two weeks then monthly for the next three months until compliance is achieved. Findings: A review of Resident 1's Admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included seizure (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain), depression and bipolar disorder. A review of Resident 1's History and Physical Examination (H&P), dated 3/16/2024, indicated Resident 1 had the capacity to make decision or make needs known. A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care planning tool) dated 1/17/2024, indicated Resident 1's cognition (mental action or process of acquiring knowledge and understanding) was intact. The MDS also indicated Resident 1 needed partial moderate assistance (helper does less than half of the effort. Helper lifts, holds, or supports trunk limb, but provides less than half of the effort) with toileting hygiene, shower, bath self and lower body dressing. The MDS also indicated Resident 1 needed supervision or touching assistance (helper provides verbal ques and or touching/ steadying and or contact guard assistance as resident completes activity) when walking. The MDS also indicated Resident 1 has depression, and bipolar disorder. During a review of Resident 1's active medications at time of discharge reconciliation (updated list of resident's medication list to reflect the resident's medication upon discharge which is continued at home or in the facility) dated 12/6/2023 at 1:03 PM from GACH 2, it indicated the resident was receiving Fluoxetine 20 milligram (mg, unit of measurement). A review of Resident 1's Progress Notes by social services dated 2/21/2024 signed at 10:03 AM indicated, Resident 1 expressed having depression due to his divorce. A review of Resident 1's Progress Notes by MD 4 dated 12/13/2023 indicated Resident 1 has history of depression, unspecified bipolar disorder, and unspecified suicide attempt 10 months ago. A review of Resident 1's Progress Notes by MD 3 dated 3/4/2024, indicated Resident 1 stated that he has his ups and down with depression. The progress notes also indicated the following objectives: a. Resident will learn and implement positive coping skills to decrease depressive and anxiety symptoms from zero (0) to one (1) time per day. b. Resident will increase behavioral activation (behavior therapy of treating mood disorders. Examples are engaging in fulfilling or healthy activities can make someone feel good, which then makes them more likely to keep participating in those activities) to decrease depressive and anxiety symptoms from 0 to 1 time per day. c. Resident will learn to identify and replace automatic thoughts reflecting depressing and anxiety with reality- based thoughts from 0 to 1 time per day. The progress notes by MD 3 also indicated the following plan: a. Resident to work on cognitive reframing of relational dynamics. b. Resident to work on increasing social engagement and interaction, as well as daily activities. c. Resident to work on concrete problem solving and solution focused steps to move on and function in life. A review of Resident 1's Progress Notes by the MD 3 dated 3/18/2024, indicated, Resident 1 continually expressing depressive symptoms due to external social and familial factors. The progress notes also indicated the same objectives and plan mentioned on the progress notes dated 3/4/2024. A review of Resident 1's Progress Notes by the MD 3 dated 3/25/2024, indicated, Resident 1 at times was tearful as Resident 1 shared about current interfamilial dynamics. The progress notes indicated Resident 1 expressed sense of loneliness and the resident stated, I feel alone in this world, it is really hard to live in this loneliness. The progress notes also indicated, Resident 1 stated that his history of suicidal ideation(S/I) and situational awareness (S/A) keeps him from every one thing to do anything to himself, but he does feel tired of living this way. The progress notes indicated the objectives were the same as the objectives from 3/4/2024 and 3/18/2024 progress notes by MD 3. In addition, the progress notes by the MD 3 dated 3/25/2024 indicated the plan for Resident 1 to work on ensuring safety and alleviating depressive signs and symptoms. During concurrent interview and record review on 4/10/2024 at 1:15 PM with the QAN, Resident 1's Progress Notes from psychologists dated from 3/4/2024 to 4/8/2024 was reviewed. QAN stated the 3/4/2024 progress notes by MD 4 indicated, the frequency of treatment was weekly or as needed. QAN stated, there was no documented evidence that Resident 1 was seen by a psychologist on 3/11/2024 and 4/1/2024. During concurrent interview and record review on 4/9/2024 at 10:03 AM, with the License Vocational Nurse (LVN 2), Resident 1's progress notes dated 4/8/2024 signed at 10:48 AM by LVN 1 was reviewed. LVN 2 stated the progress notes indicated LVN 1 last saw Resident 1 around 5:30 AM brushing his teeth. The progress notes also indicated, at approximately 7:20 AM, Resident 1 was missing. During an interview on 4/9/2024 at 2:03 PM with the Social Service Director (SSD 1), SSD 1 stated Resident 1 told SSD (unable to recall exact date) the resident was very lonely from his divorce. SSD 1 further stated, SSD 1 was wondering why Resident 1 left his eyeglasses, cellphone, and all belongings when Resident 1 cannot be found in the facility on 4/8/2024. SSD 1 stated, there was no follow up action and intervention done when resident expressed feeling lonely from his divorce. During concurrent interview and record review on 4/12/2024 at 12:50 PM with the Minimum Data Set Coordinator (MDSC), Resident 1's MDS dated [DATE] was reviewed, MDSC stated according to Resident 1's MDS, the resident has major depressive disorder, and resident was admitted from GACH 2 on 12/6/2024 with diagnosis of depression and bipolar disorder. MDSC also stated Resident 1 has no medication for depression since admitted to the facility on [DATE]. The MDSC also stated, there was no documented evidence of the care plan was reviewed, revised, and implemented for behavioral monitoring for depression and bipolar disorder since Resident 1 was admitted in the facility on 12/6/2023. MDSC was unable to answer why the medication for depression (Flouxetine) was not continued or ordered when Resident 1 was admitted back to the facility on [DATE]. A concurrent interview and record review on 4/12/2024 at 6:45 PM with the DON, Resident 1's care plan for behavioral problem initiated on 10/10/2023 was reviewed. The care plan indicated the resident has a behavior problem related to history of having suicidal thoughts. The care plan indicated goal was for Resident 1 to have fewer episodes of history of having suicidal thoughts and interventions included: to monitor behavior episodes and attempt to determine underlying causes, consider location, time of day, persons involved and situations and document behavior and potential causes. The DON stated, there was no documented evidence that the care plan was reviewed, revised, and implemented when Resident 1 verbalized feeling lonely and hard to live with his loneliness on 3/25/2024. During the same interview on 4/12/2024 at 6:45 PM with the DON, Resident 1's care plan for depression initiated on 10/26/2024 was reviewed, indicated Resident 1 has depression manifested by lack of interest leaving room. The care plan indicated intervention to monitor/ document/report any signs and symptoms of depression, document per facility protocol. The DON stated, there was no documented evidence of the care plan was reviewed, revised, and implemented when Resident 1 verbalized he has ups and downs with depression on 3/4/2024 and when Resident 1 was noted to have continued to experience depressive signs and symptoms due to external social and familial factors 3/18/2024. During concurrent interview and record review on 4/12/2024 at 6:53 PM with the DON, the Resident 1's Order Summary Report for April 2024 was reviewed, the DON stated Fluoxetine was not seen in the order summary report of Resident 1. During concurrent interview and record review on 4/12/2024 at 6:54 PM with the DON, Resident 1's electronic health record (eHR) was reviewed, the DON stated the eHR indicated Resident 1's Fluoxetine 20 milligram (mg, unit of measurement) capsule was started from initial admission at the facility on 10/11/23 and was discontinued on 12/5/2023 by Primary Physician (MD 1). The DON stated, the medication should have been reordered when the Resident was admitted back to the facility from GACH 2 on 12/6/2023. The DON further stated there was no Flouxetine ordered, and the resident is not receiving any antidepressant medication from 12/6/2023 to present (4/12/2024). During concurrent interview and record review on 4/12/2024 at 7:03 PM, Resident 1's Order Summary Report for April 2024 was reviewed. The DON stated Olanzapine was not included in the order summary report because it was not ordered. The DON stated, there was no documented evidence as to why Olanzapine and Fluoxetine were not ordered and continued when the resident was admitted to the facility on [DATE] from GACH 2. During the same interview with the DON on 4/12/2024 at 7:03 PM, the DON stated there was no documented evidence of Resident 1's behavior monitoring for depression, bipolar disorder, and suicidal ideation from Resident 1 admission on 12/6/2023 to 4/8/2024 as indicated in the care plan initiated on 10/10/2023 and 10/26/2023. The DON also stated, there should be an order to monitor Resident 1's depression, bipolar disorder, and suicidal ideation. The DON added Resident 1's care plan was not reviewed and revised when the resident verbalized feeling of depression on 3/4/2024 and 3/18/2024 during visit from MD 4 and it should have been reviewed and revised. A review of the County of Los Angeles Sheriff's Department Incident Report dated 4/12/2024 indicated the following: a. Resident 1 was reported missing on 4/8/2024 by the facility's nursing staff and when the report was made Resident 1 left a message on an envelope detailing the passcode to his cellphone and the message, Burn up, dump me in the S.F Bay by Oakland. b. Deputy 2 responded to the facility's call and the call stated an adult male was behind the unit 600 not breathing. c. On 4/12/2024 (4 days later from when Resident 1 was missing), upon the Deputy 2's arrival (time not indicated), the deputy approached the pair of feet and observed the body of Resident 1, and the body was lying on the ground on his right side with a large clear plastic bag wrapped around Resident 1's head and there was a black cable wrapped around the resident's head over the plastic bag. d. Resident 1 was pronounced dead by Paramedic 1 on 4/12/2024 at 7:01 AM. During a review of Resident 1's case information from Los Angeles County Medical Examiner website, indicated the following: a. date of death : 4/12/2024 b. Place of death: Convalescent Hospital c. Manner: Suicide d. Cause A: Asphyxia (a condition arising when the body is deprived of oxygen, causing unconsciousness or death) e. Cause B: Suffocation (process of dying from being deprived of air or unable to breathe) A review of facility's Policies and Procedure (P&P) titled Behavior Management revised date 11/1/2017, indicated purpose was to ensure that facility staff performs an appropriate assessment of the resident's behavioral symptoms and implement appropriate interventions before and after the resident begins taking psychotherapeutic medications (medications to treat a group of mental disorders). The P&P also indicated the facility is responsible for providing behavioral health care and services that creates an environment that promotes emotional and psychosocial well-being meet each resident's needs and include individualize approach to care. A review of facility's P&P titled Behavior Treats to Harm Self date revised 6/1/2021, indicated the purpose of the policy is to respond appropriately to residents who are verbalizing suicidal thoughts and / or comments about self-harm. The P&P also indicated documenting behaviors interventions and notifications in the medical records.

Based on interview and records review, the facility failed to call and notify primary physician for one of fifteen (15) sampled residents (Resident 1), when the Resident 1 experienced shortness of breath (SOB, difficult or labored breathing) and had an oxygen saturation (measures the percentage of oxygen in the blood) of 76% and 88% (levels between 95% to 100% are considered normal for both adults and children) on [DATE] at 5 PM. In addition, the facility licensed staff administered oxygen via non-rebreather mask (a device used to assist in the delivery of oxygen therapy, which is a treatment that provides extra oxygen to breathe in) at 8 liters per minute (LPM) to the resident without prior notification and obtaining a physician's order. These deficient practices resulted in Resident 1 being found noncoherent (lacking normal clarity or intelligibility in speech or thought) on [DATE] at 5:18 PM. At 5:23 PM, Resident 1 became unresponsive with a fading pulse (a weak or absent pulse rate which is a medical emergency). At 5:25 PM, cardiopulmonary resuscitation (CPR - an emergency lifesaving procedure performed when the heart stops beating) was initiated by the facility staff. At 6:08 PM, Resident 1 was pronounced dead by paramedics. On [DATE] at 11:44 AM an Immediate Jeopardy (IJ: a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's Administrator (ADM), Director of Nursing (DON), Assistant Administrator (AADM), and the Quality Assurance Nurse (QA) regarding the facility's failure to call and notify the primary physician when Resident 1 experienced SOB and had an oxygen saturation of 76% and 88% on [DATE] at 5 PM, and to obtain a physician's order before administering oxygen via a non-rebreather mask at 8 LMP on [DATE] at 5 PM. On [DATE] at 7:31 PM the IJ was removed after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practices). The surveyors verified and confirmed the implementation of the Plan of Action (POA) while onsite by observation, interview, and record review. The IJ was removed in the presence of the ADM, AADM, and DON. The acceptable IJ Removal Plan included the following: a. On [DATE], an investigation was initiated by the Director of Nursing (DON) after he was informed of the incident regarding Resident 1. b. On [DATE] an in-service was provided by the DON to Registered Nurse (RN) 1, RN 2, RN 3, and Licensed Vocational Nurse (LVN) 2 regarding contacting physician as soon as possible after initiation or adjustment of oxygen therapy in emergency situations (an illness, injury, symptom, or condition so serious that needs care right away to avoid severe harm), for verification and documentation (the record of nursing care) of the order for oxygen therapy consultation, and further orders. Any adjustment of resident's oxygen to maintain the resident's baseline (the initial measurement of a condition that is taken at an early time point and used for comparison over time to look for changes) requires a notification to medical doctor (MD/ primary physician) and change of condition assessment completed. Beginning [DATE], all licensed nurses were in-serviced. c. On [DATE], RN 2 was placed on immediate suspension for practicing outside of her scope of practice, for failing to call and notify primary physician (get an order to administer 8 LPM of oxygen via non- rebreather mask) regarding Resident 1 's SOB and low oxygen saturations. Before returning RN 2 will be re-evaluated for extended probation or termination. d. The DON reviewed residents' clinical records and identified 14 other residents with diagnosis of chronic obstructive pulmonary disease COPD receiving oxygen therapy. e. The above 14 residents having diagnosis of COPD receiving oxygen therapy were assessed for: Oxygen saturation while on oxygen, Lung sounds (the noises a person makes as they breath in and out) (clear, congested, rhonchi [coarse, loud sounds], wheezes [whistling or rattling sound], rales [rattling sound], crackles [discontinuous, interrupted explosive sounds], rubs [creaking, grating, and rubbing sound], diminished lung sounds), pulse, respiration rate, liters of oxygen applied, PRN (Latin term pro re nata means as needed) oxygen order using audit tool starting [DATE] by the DON/Assistant Director of Nursing (ADON) for MD orders and review of care plans. No shortness of breath was evident of the above 14 identified residents. f. On [DATE] ADON's review of oxygen orders were reviewed for accuracy. Special instruction added If resident is not able to maintain adequate oxygen saturation equal to or above 93% with current oxygen order, notify MD/complete change of condition, update order and care plan (a form that summarize a person's health conditions, specific care needs, and current treatments.). g. An in-service (Topic: oxygen and scope of practice) on oxygen (O2) therapy was provided by the DON on [DATE] and on-going to include all licensed nurses for the 7 AM- 3 PM, 3 PM- 11 PM, and 11 PM- 7 AM shifts. The in-service emphasized on calling and notifying primary physicians, ensuring getting an order before administering oxygen above 2 LPM. h. On [DATE], the facility Regional Clinical Consultant contacted and arranged a Respiratory Therapist (RT, work under the direction of doctors and treat a range of patients, from premature infants whose lungs are not fully developed to elderly people with lung disease) 1 from an outside Respiratory Therapy center (RTC) for further training education to be provided to facility licensed staff covering respiratory compromised patients including COPD. On [DATE] discussion held with Medical Director (MD) 1 and RT 1 for future standard order recommendations for new and existing COPD patients. The facility came to an agreement for COPD standard order recommendations as follows: Oxygen at 2 to 5 LPM via nasal cannula (NC - a medical device used to provide supplemental oxygen therapy to people who have lower oxygen levels) continuous inhalation (the process by which other gases or air enter the lungs) with humidifier (a device used to humidify supplemental oxygen) for SOB secondary to COPD and may titrate (to continuously measure and adjust the balance) to keep oxygen saturation equal to or above 93%. In addition, it indicated to monitor and record oxygen saturation every shift on room air and notify the primary physician if resident's oxygen saturation is less than (<) 92%. i. Beginning [DATE], residents admitted and readmitted with diagnosis of COPD and any change of condition will be assessed to include shortness of breath, document in resident's record date and time oxygen is being used, oxygen flow rate (the percent or concentration of oxygen that a person inhales) and device being used, and oxygen saturation. PRN high concentration oxygen orders will be obtained in case desaturation (when the amount of oxygen bound to hemoglobin drops below the normal level) noted in resident. j. Beginning [DATE], attending physicians will be notified to initiate oxygen therapy for COPD patients for parameters (measurement set to determine if normal or abnormal and how many liters of oxygen to administer) for PRN oxygen orders in emergency situations. Fourteen (14) out of the 14 residents have already obtained orders for PRN oxygen in case of emergency. k. Beginning [DATE], DON/Designee or Quality Assurance (QA) Nurse will continue to retrain licensed nurses capturing all three shifts to identify resident's changes in condition every month for three months and then ongoing quarterly afterwards. l. Beginning [DATE], licensed department heads, Minimum Data Set (MDS, a standardized assessment tool that measures health status in nursing home residents) nurses (MDS nurse and/or MDS assistant nurse) and RN supervisors on all shifts will be responsible for monitoring Monday through Friday residents randomly receiving oxygen therapy ensuring when a resident is experiencing shortness of breath the primary physician will be notified right away and to prevent further occurrence of serious harm, serious impairment and death of residents with change of condition requiring immediate intervention. m. Beginning [DATE], the DON or Designee will provide the results of audits monthly to the Quality Assurance Committee for recommendations and follow up and ensure compliance. n. The Performance Improvement Committee will monitor the process weekly for the next two weeks, then monthly for three months until compliance is achieved. Findings: A review of Resident 1's Admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of acute respiratory failure with hypoxia (lack of oxygen in the tissues to sustain bodily function), COPD, and chronic congestive heart failure (a long-term condition when the heart cannot pump well enough to give the body a normal supply). A review of Resident 1's MDS, dated [DATE], indicated Resident 1 was cognitively (related to being or involving conscious intellectual activity such as thinking, reasoning, or remembering) intact for daily decision making. The MDS indicated extensive assistance for bed mobility (ability to move easily), transfer (how resident moves between surfaces), dressing, toilet use, personal hygiene (practices conducive to maintaining health and preventing disease, especially through cleanliness), and bathing. The MDS indicated Resident 1 was receiving respiratory treatment that consisted of oxygen therapy (a treatment that provide with extra oxygen to breath in, also called supplemental oxygen). A review of Resident 1's History and Physical, (H&P, the initial clinical evaluation and examination of the patient) dated [DATE], indicated the resident was alert (a state in which a person is awake and appropriately answer all questions) and oriented (a person's level of awareness of self, place, time, and situation). A review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR, a technique that can be used to facilitated prompt and appropriate communication) form, dated [DATE], indicated a change of condition in Resident 1 who presented altered mental status (a change in mental function that stems from illnesses, disorders and injuries affecting the brain) and was unresponsive (no reacting or able to react in a normal way when touched, spoken to, etc.). The SBAR indicated resident's pulse rate was 50 beats per minute (normal range is 60 to 100), respiration rate was 12 breaths per minute, and oxygen saturation was 76% (normal range is 95% to 100%) on O2 via nasal cannula. The SBAR also indicated, at 5 PM, the resident's oxygen saturation was assessed at 76% on 4 LPM via nasal cannula, and O2 was increased at 8 LPM on non-rebreather mask, O2 saturation was noted to go up to 88%. At 5:10 PM, the resident was observed on the floor next to her bed, verbally responsive however incoherent not expressed in a way that can be understood, not able to talk clearly). The SBAR also indicated at 5:23 PM, the resident was noted with a fading pulse and became unresponsive. CPR was then initiated, and the primary physician was called at 5:30 PM (30 minutes after the resident's change of condition [COC]). The SBAR did not indicate documented evidence that the licensed nurse obtained a physician's order to increase the resident's oxygen level from 4 to 8 LPM and to place a non-breather mask on the resident to administer oxygen. During a review of Resident's 1 Nurse Progress Note, dated [DATE] at 11:25 PM, indicated CPR was performed for 42 minutes. At 6:08 PM the resident was pronounced dead. During an interview on [DATE] at 11:23 AM with LVN 1 stated on [DATE] at 5 PM Resident 1 had an oxygen saturation of 76% on 4 LPM via nasal cannula. LVN 1 stated, RN 2 increased Resident 1's oxygen to 8 LPM via nonrebreather mask. LVN 1 stated, the resident still had SOB, so the LVN 1 administered Duoneb (a sterile inhalation solution that relaxes muscles in the airways and increase airflow to the lungs), and the resident's oxygen saturation went up to 88%. LVN 1 also stated, at 5:15 PM, LVN 1 left the room while the resident was still in the same position sitting on the edge of the bed on the right side and then RN 2 also stepped out after. During the same interview with LVN 1, LVN 1 stated on [DATE] at 5:18 PM, LVN 1 did a visual check and observed the resident lying on the floor beside the resident's bed. LVN 1 also stated, LVN 1 called the resident by name, and the resident was moaning or groaning incoherent, but no words spoken. LVN 1 also stated, the RN 2 arrived in Resident 2's room, LVN 1 called 911 and prepared the paperwork for the paramedics (911 personnel), but LVN 1 did not call the doctor. LVN 1 stated, I think somebody else called the doctor, maybe another RN supervisor called at 6:15 PM. During an interview with RN 2 on [DATE] at 4:37 PM, RN 2 stated Resident 1 was sitting on the edge of the bed, with the resident's feet on the floor, and upper body bent forward. RN 2 stated Resident 1 said she cannot breathe. RN 2 stated she went to get an oxygen tank, then placed Resident 1 on 8 LPM via non-rebreather mask. RN 2 stated Resident 1's oxygen saturation was 88% after receiving the 8 LPM of oxygen. RN 2 stated she left the room to attend to a call from another supervisor. RN 2 stated she returned to Resident 1's room (unable to recall exact time) and Resident 1's oxygen saturation was 88%. RN 2 stated Resident 1 was still sitting on the edge of the bed with both hands on her thighs with feet on the floor, and upper body bent forward. RN 2 stated she felt Resident 1 was better and left the room to go to another unit in the facility. RN 2 stated LVN 1 called her to report Resident 1 was lying on the floor (unable to recall specific time) and the resident was able to open her eyes and only made groaning sounds. During the same interview with RN 2, RN 2 stated she did not notify the doctor of Resident 1's oxygen saturation of 76% on [DATE] at 5 PM. RN 2 stated the primary physician should have been notified right away to get a physician orders. RN 2 stated she administered 8 LPM via non-rebreather mask to Resident 1 on [DATE] at 5 PM because she thought there was a physician's order. RN 2 stated an oxygen saturation of 76% could lead to decreased oxygen to the brain and impaired circulation to the heart which could lead to dizziness and falls. RN 2 stated Resident 1 should not had been left alone sitting on the edge of the bed on [DATE] since the resident was experiencing SOB at the time. During an interview with the DON on [DATE] at 5:40 PM, the DON stated if Resident 1's oxygen saturation was below 86% nurses should have notified the attending physician so they can get physician's order to address Resident 1's SOB and low oxygen saturation. The DON stated Resident 1 had a physician's order to monitor oxygen saturation to maintain oxygen saturation levels between a certain range (unable to recall exact percentages). During an interview with the DON on [DATE] at 5:45 PM, the DON stated after Resident 1's COC on [DATE], RN (unidentified) notified DON. The DON stated he informed RN (unidentified) to obtain an order for 8 LPM of oxygen from the doctor but the RN contacted the resident's physician to obtain an order after the nurses already placed the non-rebreather mask on the resident. During a concurrent interview and review of Resident 1's medical records dated from [DATE] to [DATE] with the ADON 1 on [DATE] at 11:06 AM, ADON 1 was unable to provide documented evidence of a physician's order for the 8 LPM of oxygen via a non-rebreather mask prior to resident's COC on [DATE] at 5 PM. During an interview with RN 1 on [DATE] at 3:19 PM, RN 1 stated he arrived in the resident's room and Resident 1 was receiving 8 LPM of oxygen a via non-rebreather mask. RN 1 stated RN 2 administered oxygen to Resident 1, but he did not see a physician's order for the 8 LPM oxygen via a non-rebreather mask. RN 1 stated if he saw Resident 1's saturation at 76% he would have called the doctor to get orders to address the resident's low oxygen saturation. During a telephone interview with the Medical Director (MD) 1 on [DATE] at 7:44 PM, MD 1 stated an increase of 8 LPM of oxygen is too much for a resident. MD 1 stated nurses should slowly increase oxygen three to four liters and see if the resident will improve or not. MD 1 stated, the nurses could then increase to four to five liters slowly, give breathing treatment and should have called 911 a few minutes later. MD 1 stated the increase of oxygen should be done slowly allowing the patient to utilize the benefit of the oxygen and going up to 8 LPM does shut off the breathing drive (the intensity of the output of the respiratory centers and determines the mechanical output of the respiratory muscles also known as the breathing effort). During an interview with ADON 1 on [DATE] at 12:38 PM, ADON 1 stated he went to Resident 1's room around 5:20 PM. ADON 1 stated Resident 1 was found unresponsive, lying in bed, and was connected to 8 LPM of oxygen via a non-rebreather mask. ADON 1 stated Resident 1 had agonal breathing (agonal respiration, the gasping that people do when they're struggling to breathe because of cardiac arrest or another serious medical emergency) and was very pale. ADON 1 stated at 5:25 PM, he initiated compressions and RN 1 assisted with the ambubag (a bag valve mask, a handheld tool used to delivery positive pressure ventilation [to supply oxygen to a person's lungs] to any person with insufficient or ineffective breaths). ADON 1 stated he continued with compressions until paramedics arrived at 5:32 PM. ADON 1 stated he was informed by the paramedics chief Resident 1 was pronounced deceased (dead) at 6:08 PM. ADON 1 stated he did not contact the Resident 1's primary physician during the incident (SOB and CPR of Resident 1) nor after the incident. During an interview with the DON on [DATE] at 6:58 PM, the DON stated Resident 1's primary physician should be notified when Resident 1's had a COC of SOB, oxygen saturation of 76%, and to get an order to change and/ or increase the oxygen the resident received. The DON stated the nurses should have notified the doctor for a possible need to transfer to a higher level of care (GACH) based on the physician's order. The DON stated there was no order at the moment when Resident 1's oxygen was increased to 8 LPM and given via non-rebreather mask. The DON stated without a physician's order for oxygen (including how many liters and type of oxygen delivery), licensed nurses were not supposed to administer oxygen above two (2) LPM. A review of the facility's policy and procedure titled, Change of Condition revised [DATE], indicated notifying the attending physician: a. The Attending Physician will be notified timely with a resident's change in condition. b. Notification to the Attending Physician will include a summary of the condition change and an assessment of the resident's vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) and system review focusing on the condition and/or signs and symptoms for which the notification is required. A review of facility's policy and procedure titled, Medication - Administration, revised [DATE], indicated medication will be administered by a licensed nurse per order of an attending physician or licensed independent practitioner. A review of facility's policy and procedure titled, Oxygen Administration, revised [DATE], indicated a physician's order is required to initiate oxygen therapy. The order should include oxygen flow rate, method of administration (e.g., nasal cannula), usage of therapy (continuous or prn), titration instruction (if indicated) and indication for use.

Based on interview and record review the facility failed to provide respiratory care for one of 15 sampled residents (Resident 1) by ensuring the resident's oxygen saturation (measures the percentage of oxygen in the blood) was monitored every two hours in accordance with the resident's physician's order. In addition, the facility staff failed to notify the resident's the primary physician when the resident was experiencing shortness of breath (SOB, difficult or labored breathing) with desaturation (blood oxygen levels drop below a normal range [usually 95% to 100%]) and administered oxygen via non-rebreather mask (a special medical device that helps provide you with oxygen in emergencies) at eight (8) liters per minute (LPM - the measure of the volume of oxygen supplied over a period) to the resident without prior notification and obtaining a physician's order. These deficient practices resulted in Resident 1 being found noncoherent (lacking normal clarity or intelligibility in speech or thought) on [DATE] at 5:18 PM. At 5:23 PM, Resident 1 became unresponsive with a fading pulse (a weak or absent pulse rate which is a medical emergency). At 5:25 PM, cardiopulmonary resuscitation (CPR - an emergency lifesaving procedure performed when the heart stops beating) was initiated by the facility staff. At 6:08 PM, Resident 1 was pronounced dead by paramedics. On [DATE] at 11:44 AM an Immediate Jeopardy (IJ: a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's Administrator (ADM), Director of Nursing (DON), Assistant Administrator (AADM), and the Quality Assurance Nurse (QA) regarding the facility's failure to monitor Resident 1's oxygen saturation, and to call and notify the primary physician when Resident 1 experienced SOB and had an oxygen saturation of 76% and 88% on [DATE] at 5 PM, and to obtain a physician's order before administering oxygen via a non-rebreather mask at 8 LMP on [DATE] at 5 PM. On [DATE] at 7:31 PM the IJ was removed after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practices). The surveyors verified and confirmed the implementation of the Plan of Action (POA) while onsite by observation, interview, and record review. The IJ was removed in the presence of the ADM, AADM, and DON. The acceptable IJ Removal Plan included the following: a. On [DATE], the DON identified 14 other residents with diagnosis of chronic obstructive pulmonary disease (COPD) and receiving oxygen therapy. b. On [DATE] an in-service was provided by the DON to Registered Nurse (RN) 1, RN 2, RN 3, and Licensed Vocational Nurse (LVN) 2 regarding contacting physician as soon as possible after initiation or adjustment of oxygen therapy in emergency situations (an illness, injury, symptom, or condition so serious that needs care right away to avoid severe harm), for verification and documentation (the record of nursing care) of the order for oxygen therapy consultation, and further orders. Any adjustment of resident's oxygen to maintain the resident's baseline (the initial measurement of a condition that is taken at an early time point and used for comparison over time to look for changes) requires a notification to MD and change of condition assessment completed. Beginning [DATE] all licensed nurses were in-serviced. c. On [DATE], RN 2 was placed on immediate suspension for practicing outside of her scope of practice (describes the procedures, actions, and process that a healthcare practitioner is permitted to undertake under their professional license), for failing to call and notify primary physician (to get an order to administer 8 LPM of oxygen via non- rebreather mask) regarding Resident 1 's SOB and low oxygen saturations. Before returning RN 2 will be re-evaluated for extended probation or termination. d. The DON reviewed residents' clinical records and identified 14 other residents with diagnosis of COPD receiving oxygen therapy. e. The above 14 residents having diagnosis of COPD receiving oxygen therapy were assessed for: Oxygen saturation while on oxygen, Lung sounds (the noises a person makes as they breath in and out) (clear, congested, rhonchi [coarse, loud sounds], wheezes [whistling or rattling sound], rales [rattling sound], crackles [discontinuous, interrupted explosive sounds], rubs [creaking, grating, and rubbing sound], diminished lung sounds), pulse, respiration rate, liters of oxygen applied, PRN (Latin term pro re nata means as needed) oxygen order using audit tool starting [DATE] by the DON/Assistant Director of Nursing (ADON) for MD orders and review of care plans. No shortness of breath was evident of the above 14 identified residents. f. On [DATE] ADON's review of oxygen orders were reviewed for accuracy. Special Instruction added, If resident is not able to maintain adequate oxygen saturation equal to or above 93% with current oxygen order, notify MD/complete a Change of Condition (COC - tool used by health care professionals when communicating about critical changes in a patient's status) assessment and update order. g. The above 14 residents are being monitored every shift for shortness of breath. Oxygen saturation to be recorded in every shift and documented in the Medication Administration Record (MAR). h. An in-service (Topic: Oxygen administration/adjustment/oxygen monitoring) on oxygen therapy was provided by the DON on [DATE] and on-going to include all licensed nurses for the 7 AM to 3 PM, 3 PM to 11 PM, and 11 PM to 7 AM shifts. The in-service emphasized on monitoring oxygen saturation every shift continuously and as needed documented in MAR in accordance with the physician's order to maintain oxygen saturation equal to or above 93% and include additional information average oxygen saturation of COPD residents is 88% to 92% (as referenced from the Emergency Medicine Journal, published [DATE]). It also included to call the primary physician when a resident is experiencing shortness of breath/desaturation. i. On [DATE], the facility Regional Clinical Consultant contacted and arranged a Respiratory Therapist (RT) 1 from an outside Respiratory Therapy center (RTC) for further training education to be provided to facility licensed staff covering respiratory compromised patients including COPD. On [DATE] discussion held with Medical Director (MD) 1 and RT 1 for future standard order recommendations for new and existing COPD patients. The facility came to agreement for COPD standard order recommendations as follows: Oxygen at 2 to 5 LPM via nasal cannula (NC - a medical device used to provide supplemental oxygen therapy to people who have lower oxygen levels) continuous inhalation (the process by which other gases or air enter the lungs) with humidifier (a device used to humidify supplemental oxygen) for SOB secondary to COPD and may titrate (to continuously measure and adjust the balance) to keep oxygen saturation equal to or above 93%. In addition, it indicated to monitor and record oxygen saturation every shift on room air and notify the primary physician if resident's oxygen saturation is less than (<) 92%. j. Beginning [DATE], residents admitted and readmitted with diagnosis of COPD and any change of condition will be assessed to include shortness of breath, document in resident's record date and time oxygen is being used, oxygen flow rate and device being used, and oxygen saturation. PRN high concentration oxygen orders will be obtained in case desaturation noted in resident. k. Beginning [DATE], DON/Designee or QA Nurse will retrain licensed nurses capturing all three shifts to identify resident's changes in condition/experiencing shortness of breath, to call the and notify primary physician, to monitor oxygen saturation every shift continuously documented in the MAR in accordance with physician's order to maintain oxygen saturation equal to or above 93%. Licensed department heads, MDS nurses and RN supervisors on all shifts will be responsible Monday through Friday for monitoring residents' occurrence of serious harm, serious impairment, and death of residents with change of condition requiring immediate intervention. l. Beginning [DATE], licensed department heads, Minimum Data Set (MDS) nurses (MDS nurse and/or MDS assistant nurse) and RN supervisors on all shifts will be responsible for monitoring Monday through Friday residents randomly receiving oxygen therapy ensuring when a resident is experiencing shortness of breath the primary physician will be notified right away and to prevent further occurrence of serious harm, serious impairment and death of residents with change of condition requiring immediate intervention. m. Beginning [DATE], the DON or Designee will provide the results of audits to the Quality Assurance Committee for recommendations and follow up and ensure compliance. n. The Performance Improvement Committee will monitor the process weekly for the next two weeks, and then monthly for three months until compliance is achieved. Cross reference F580. Findings: A review of Resident 1's Admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of acute respiratory failure with hypoxia (lack of oxygen in the tissues to sustain bodily function), COPD, and chronic congestive heart failure (a long-term condition when the heart cannot pump well enough to give the body a normal supply). A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care planning tool) dated [DATE], indicated Resident 1 was cognitively intact (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 1 was assessed requiring extensive assistance (resident involved in activity, staff provided weight-bearing support) for bed mobility (ability to move easily), transfer (how resident moves between surfaces), dressing, toilet use, personal hygiene (practices conducive to maintaining health and preventing disease, especially through cleanliness), and bathing. The MDS also indicated Resident 1 was receiving respiratory treatment that consisted of oxygen therapy. A review of Resident 1's History and Physical (H&P, the initial clinical evaluation and examination of the patient) dated [DATE], indicated Resident 1 was alert and oriented (assessment of a person's level of alertness to person, place, time, and situation). A review of Resident 1's SBAR (an acronym for Situation-Background-Assessment-Recommendation is a technique used to provide a framework for communication between members of the health care team) dated [DATE], indicated Resident 1 was observed on the floor and was placed in bed for further assessment. The SBAR also indicated, at 5:23 PM RN (not specified) continued to assess Resident 1 and noted the resident with a fading pulse. The resident became unresponsive. At 5:25 PM, CPR was initiated. A review of Resident 1's COC dated [DATE], indicated at 5 PM Resident 1's oxygen saturation was assessed at 76% on 4 LPM via NC. The COC indicated, the licensed nurse (not specified) increased Resident 1's oxygen to 8 LPM on non-rebreather mask and resident's oxygen saturation was noted at 88%. The COC also indicated, LVN 1 notified RN 2 regarding Resident 1 lying on the floor. The COC indicated, Resident 1 was verbally responsive but incoherent (not expressed in a way that can be understood, not able to talk clearly) and that the primary medical doctor (PMD) was notified on [DATE] at 5:30 PM. A review of Resident 1's Nurses Notes dated [DATE], indicated at 5 PM Resident 1 was noted with SOB. The resident was sitting at the edge of the bed in an orthopneic position (used when experiencing SOB, a sitting position where an individual leans slightly forward with arms propped in front on over-bed table, pillows, or knees). The Resident 1's oxygen saturation was assessed at 76% with four (4) LPM via NC. The licensed nurse (not specified) increased Resident 1's oxygen via NC to 8 LPM on a non-rebreather mask and oxygen saturation noted at 88%. The Nurses Notes further indicated at 5:15 PM, Resident 1 was re-evaluated with no SOB and was left sitting at the edge of the bed. At 5:18 PM, the resident was seen lying on the floor next to the resident's bed. The resident was verbally responsive but was incoherent. At 5:23 PM, the resident was noted with fading pulse and became unresponsive. At 5:25 PM CPR was initiated. At 5:32 PM, 911 paramedics arrived on scene (in the facility) and continued with resuscitation efforts (CPR). At 6:08 PM (after 42 minutes of CPR), Resident 1 was pronounced dead by paramedics. A review of Resident 1's Physician's Order Summary Report for [DATE], indicated on [DATE] the PMD ordered to monitor Resident 1's oxygen saturation/pulse oximetry (a test used to measure the saturation of oxygen carried in an individuals' red blood cells) every two hours continuously to maintain an oxygen saturation between 95% and 100%. The physician's order indicated Resident 1 to have oxygen at three (3) LPM via NC or to maintain oxygen saturation at 95 continuously. The physician's order indicated to change oxygen to 4 LPM via nasal cannula for desaturation and shortness of breath. A record review of Resident 1's oxygen saturation summary for [DATE], indicated Resident 1's oxygen saturation on [DATE] at 9:50 AM was 78% while the resident receiving oxygen (level not indicated) via nasal cannula. The oxygen saturation summary did not indicate Resident 1's oxygen saturation was monitored and documented every two hours from [DATE] to [DATE] in accordance with the physician's order. A review of Resident 1's Care Plan did not have any care plans related to Resident 1's respiratory failure or COPD management upon readmission to the facility on [DATE] to [DATE]. A review of Resident 1's clinical record indicated a care plan for oxygen therapy dated [DATE] with goals for the resident to have no signs and symptoms of poor oxygen absorption. Interventions included for licensed nurse to monitor for signs and symptoms of respiratory distress (a serious lung condition that causes low blood oxygen) and to report to physician; monitor the resident's respirations (breathing), pulse oximetry, increase heart rate restless and skin color. Additional interventions included for oxygen and to promote lung expansion and improve lung exchange. This care plan was canceled on the same date, [DATE]. There is no documented evidence in the resident's clinical record that indicates a care plan was developed for the use of oxygen therapy. During an interview with LVN 1 on [DATE] at 3:20 PM, LVN 1 stated on [DATE] at 5 PM Resident 1 had SOB and was sitting at the edge of the bed. LVN 1 stated Resident 1 was sitting in an orthopneic position and Resident 1's oxygen saturation was 76% while connected to 4 LPM via nasal cannula. LVN 1 stated Resident 1 was wheezing and gasping (to breathe loudly and with difficulty, trying to get more air) for air. LVN 1 stated Resident 1 continued to have SOB, therefore LVN 1 gave Resident 1 DuoNeb (a sterile inhalation solution that relaxes muscles in the airways and increase airflow to the lungs). LVN 1 stated Resident 1's oxygen saturation was at 88% after the DuoNeb treatment. LVN 1 stated she and RN 2 had stepped out of the room while Resident 1 was sitting on the edge of the bed. LVN 1 stated at 5:18 PM, she came back to Resident 1's room and saw the resident lying on the floor on the right side of the resident's bed. LVN 1 stated Resident 1 was not able to speak any words after the fall. LVN 1 stated Resident 1 was moaning or groaning and was incoherent. LVN 1 stated each time Resident 1's oxygen saturation was checked, nurses needed to document Resident 1's oxygen saturation in the computer and if it was not in Resident 1's medical records, then it was not done. LVN 1 stated, oxygen saturation should be monitored and documented in accordance with the physician's order so the facility could address the desaturation right away. LVN 1 stated she could not recall how often Resident 1's oxygen saturation needed to be monitored and documented. During the same interview with LVN 1 on [DATE] at 3:20 PM, LVN 1 stated the doctor should had been contacted when Resident 1's oxygen saturation decreased to 76%. LVN 1 stated Resident 1's was at risk for death due to her decrease in oxygen supply in the blood. LVN 1 stated she did not contact Resident 1'sprimay physician when resident experienced SOB and desaturation on [DATE] at 5 PM. LVN 1 also stated she was sure if there was a physician's order to increase the oxygen to 8 LPM via a non-rebreather mask. LVN 1 stated she would normally increase Resident 1's oxygen to 8 LPM via non-rebreather mask when Resident 1's oxygen saturation decreased. LVN 1 stated it was not the first time LVN 1 increased Resident 1's oxygen to 8 LPM via a non-rebreather mask. LVN 1 stated she had experience with increasing Resident 1's oxygen levels many times but she never checked if there was a physician's order nor if it was in the facility's policy and procedure for administering oxygen. During an interview with RN 2 on [DATE] at 4:37 PM, RN 2 stated Resident 1 was sitting on the edge of the bed, with resident's feet on the floor, and upper body bent forward. RN 2 stated Resident 1 said she could not breathe. RN 2 stated she went to get an oxygen tank, then placed Resident 1 on 8 LPM via non-rebreather mask. RN 2 stated Resident 1's oxygen saturation was 88% after receiving the 8 LPM of oxygen. RN 2 stated she left the room to attend to a page from another supervisor. RN 2 stated she returned to Resident 1's room (unable to recall exact time) and Resident 1's oxygen saturation was 88%. RN 2 stated Resident 1 was still sitting on the edge of the bed with both hands on her thighs with feet on the floor, and upper body bent forward. RN 2 stated she felt Resident 1 was better and left the room to go to another unit in the facility. RN 2 stated LVN 1 called her to report Resident 1 was lying on the floor (unable to recall specific time) and the resident was able to open her eyes and only made groaning sounds. During the same interview with RN 2 on [DATE] at 4:37 PM, RN 2 stated she did not notify the doctor of Resident 1's oxygen saturation of 76% on [DATE] at 5 PM. RN 2 stated the primary physician should have been notified right away to get a physician orders. RN 2 stated she administered 8 LPM via non-rebreather mask to Resident 1 on [DATE] at 5 PM because she thought there was a physician's order. RN 2 stated an oxygen saturation of 76% could lead to decreased oxygen to the brain and impaired circulation to the heart which could lead to dizziness and falls. RN 2 stated Resident 1 should not had been left alone sitting on the edge of the bed on [DATE] since the resident was experiencing SOB at the time. During an interview with the DON on [DATE] at 5:40 PM, the DON stated if Resident 1's oxygen saturation was below 86% nurses should had notified the attending physician. The DON stated Resident 1 had a physician's order to monitor oxygen saturation to maintain oxygen saturation levels between a certain range (unable to recall exact percentages). During the same interview and concurrent record review with the DON on [DATE] at 5:40 PM, of Resident 1's physician order dated [DATE], indicated oxygen saturation was to be monitored every two hours continuous to maintain oxygen level at 95% to100%, every shift. The DON stated the nurses did not monitor and document Resident 1's oxygen saturation every two hours, instead nurses were only documenting the oxygen saturation every shift. The DON stated the nurses should had been putting the oxygen saturation percentage obtained every two hours in accordance with the physician's order. During concurrent interview and record review with the DON on [DATE] at 5:45 PM, of Resident 1's oxygen saturation summary for [DATE] indicated there was 17 days from [DATE] to [DATE] that oxygen saturation was not monitored every shift. The DON confirmed the oxygen saturation for Resident 1 was not monitored and documented every shift nor every two hours monitoring in accordance with the physician's order. During the same interview with the DON on [DATE] at 5:45 PM, the DON stated after Resident 1's COC on [DATE], RN (unidentified) notified DON. The DON stated he informed RN (unidentified) to obtain an order for 8 LPM of oxygen from the doctor. The DON validated the nurses did not have an order to administer the 8 LPM of oxygen via a non-rebreather mask but contacted the resident's physician to obtain an order after the nurses already placed the non-rebreather mask on the resident. During a concurrent interview and review of Resident 1's medical records dated from [DATE] to [DATE] with the ADON 1 on [DATE] at 11:06 AM, ADON 1 was unable to provide documented evidence for the physician's order for the 8 LPM of oxygen via a non-rebreather mask prior to resident's COC on [DATE] at 5 PM. During a concurrent interview and record review of Resident 1's care plans dated from [DATE] to [DATE], with Minimum Data Set Assistant (MDS Asst) on [DATE] at 2:14 PM, MDS Asst verified and confirmed there were no care plans developed specific to Resident 1's COPD diagnosis and for oxygen therapy. The MDS Asst stated it is important to have a resident centered care plan to guide interventions on a specific problem for the resident. The MDS Asst stated the charge nurses should had developed a care plan for Resident 1's to ensure the facility addressed and had the correct interventions in place for the resident's COPD and oxygen use. During an interview with RN 1 on [DATE] at 3:19 PM, RN 1 stated he arrived at Resident 1's room and Resident 1 was receiving 8 LPM of oxygen a via non-rebreather mask. RN 1 stated RN 2 administered oxygen to Resident 1, but he did not see a physician's order for the 8 LPM oxygen via a non-rebreather mask. RN 1 stated if he saw Resident 1's saturation at 76% he would have called the doctor and 911 right away. During a telephone interview with the Medical Director (MD) 1 on [DATE] at 7:44 PM, MD 1 stated an increase of 8 LPM of oxygen is too much for a resident. MD 1 stated nurses should slowly increase oxygen three to four liters and see what happens. MD 1 stated, the nurses could then increase to four to five liters slowly, give breathing treatment and should have called 911 a few minutes later. MD 1 stated the increase of oxygen should be done slowly allowing the patient to utilize the benefit of the oxygen and going up to 8 LPM does shut off the breathing drive (the intensity of the output of the respiratory centers and determines the mechanical output of the respiratory muscles also known as the breathing effort). During an interview with ADON 1 on [DATE] at 12:38 PM, ADON 1 stated he went to Resident 1's room around 5:20 PM. ADON 1 stated Resident 1 was found unresponsive, lying in bed, and was connected to 8 LPM of oxygen via a non-rebreather mask. ADON 1 stated Resident 1 had agonal breathing (agonal respiration, the gasping that people do when they're struggling to breathe because of cardiac arrest or another serious medical emergency) and was very pale. ADON 1 stated at 5:25 PM, he initiated compressions and RN 1 assisted with the ambubag (a bag valve mask, a handheld tool used to delivery positive pressure ventilation [to supply oxygen to a person's lungs] to any person with insufficient or ineffective breaths). ADON 1 stated he continued with compressions until paramedics arrived at 5:32 PM. ADON 1 stated he was informed by the paramedics chief Resident 1 was pronounced deceased (dead) at 6:08 PM. ADON 1 stated he did not contact the Resident 1's primary physician during the incident (SOB and CPR of Resident 1) nor after the incident. During an interview with the DON on [DATE] at 6:58 PM, the DON stated Resident 1's primary physician should be notified when Resident 1's had a COC of SOB, oxygen saturation of 76%, and to get an order to change and/ or increase the oxygen the resident received. The DON stated the nurses should had notified the doctor for a possible need to transfer to a higher level of care (GACH) based on the physician's order. The DON stated there was no order at the moment when Resident 1's oxygen was increased to 8 LPM and given via non-rebreather mask. The DON stated it was not safe to leave Resident 1 alone and sitting on the edge of the bed due to risk for accidents and/ or fall. The DON stated proper assessment was not done to reassess the patient such as assessing the lung sounds, accessory muscles, and respiratory rate. The DON stated without a physician's order for oxygen (including how many liters and type of oxygen delivery), licensed nurses were not supposed to administer oxygen above two LPM. A review of the facility's policy and procedure titled, Change of Condition revised [DATE], indicated notifying the attending physician: a. The Attending Physician will be notified timely with a resident's change in condition. b. Notification to the Attending Physician will include a summary of the condition change and an assessment of the resident's vital signs and system review focusing on the condition and/or signs and symptoms for which the notification is required. A review of the facility's policy and procedure titled, Oxygen Administration revised [DATE], indicated a physician's order is required to initiate oxygen therapy. The order shall include oxygen flow rate, method of administration (e.g. nasal cannula), usage of therapy (continuous or prn), titration instructions (if indicated), and indication for use. A review of the facility's policy and procedure titled, Pulse Oximetry (Assessing Oxygen Saturation) revised [DATE], indicated the following information will be recorded in the resident's medical record: date and time the procedure was performed, oxygen saturation level, and any unusual findings and action taken. A review of the facility's policy and procedure titled, Physician Order revised [DATE], indicated the Licensed Nurse receiving the order will be responsible for documenting and implementing the order. The policy and procedure indicated documentation pertaining to physician orders will be maintained in the resident's medical record. A review of the facility's policy and procedure titled, Care Planning revised [DATE], indicated a licensed nurse will initiate the care plan, and the plan will be finalized and updated as indicated for change in condition, onset of new problems, resolution of current problems, and as deemed appropriate by clinical assessment and judgement on an as needed bases. The facility will develop a person-centered baseline care plan for each resident within 48 hours of admission. The baseline care plan will include initial goals based on admission orders and physician orders.

Based on interview and record review, the facility failed to provide the necessary care and services for one of three sample resident (Resident 1), who was assessed at being at risk for developing pressure ulcers, to prevent development of new pressure ulcers (localized injury to the skin and or underlying tissue usually over a bony prominence as result of pressure or pressure in combination with shear [a horizontal force that causes the bony prominence to move across the tissue as the skin is held in place, and results from patient movement, nurse movement of the patient, and bed movement] and/or friction [rubbing together] ) by: 1. Facility licensed staff failing to continually assess for wound progress, monitor, and document weekly wound assessment for Resident 3's noted skin breakdown on [DATE], [DATE] and [DATE] in accordance with the facility's policies and procedure. 2. Facility licensed staff failing to assess, identify, monitor, inform the physician and provide treatment for Resident 1's identified skin breakdowns that were observed and reported by certified nurse assistant (CNA) to licensed nurses on ten (10) different dates from [DATE] to [DATE] in accordance with the facility's policies and procedure. 3. Facility staff failing to reposition Resident 1 every two (2) hours for the month of [DATE] on 11 different dates in accordance with the resident's care plan. These deficient practices resulted in Resident 1 developing ten (10) pressure ulcer of different stages (to determine extent of damage of the pressure ulcer) on multiple body sites, and one (1) moisture associated skin damage (MASD, caused by prolonged exposure to urine or stool, perspiration, mucus, saliva) without treatment provided. Resident 1 was sent to general acute care hospital (GACH) 1 on [DATE] due to decrease level of consciousness, labored and rapid breathing and resident's skin was cold and clammy (skin is cold and sweaty to touch). Resident 1 was diagnosed in GACH 1 with sepsis 2 (a serious condition from the presence of harmful microorganism in the blood or other tissues potentially leading to the malfunction of various organs, shock, and death) and cellulitis (a common and potentially serious bacterial skin infection with warmth/redness). Resident 1 was then sent to GACH 2 (from GACH 1) on [DATE] at 12 AM and was admitted and stayed in GACH 2 for 16 days with final diagnosis of cellulitis of the buttocks and infected multiple pressure ulcers of different stages in the buttocks. Resident 1 was discharged placed under hospice care (type of health care that focuses on the palliation [relief of symptoms and suffering] of a terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) on [DATE] and died on [DATE]. Findings: 1. A review of Admission Record indicated Resident 1 was readmitted to the facility on [DATE], Resident 1 was readmitted to the facility with diagnoses of urinary tract infection (UTI, an infection in any part of the urinary system, the kidneys, bladder, or urethra [tubular structure that conducts urine]) and Parkinson's disease (mental disorder of the central nervous system that affects movement, often including tremors). A review of Resident 1's Nursing Admission Assessment, dated [DATE], indicated the resident's skin was highly exposed to moist, resident was bedridden, and had a potential risk for friction and shear. A review of Resident 1's Care Plan (CP) for resident has malnutrition related to at risk for skin breakdown, initiated on [DATE], indicated facility will notify physician and family of skin breakdown. A review of Resident 1's Skin Observation Checks, dated [DATE], indicated the resident had a MASD on coccyx (small triangular bone at the base of the spinal column). A review of Resident 1's CP for actual impairment of skin integrity MASD on coccyx initiated on [DATE], indicated follow facility protocols for treatment of injury. A review of Resident 1's CP for resident has potential impairment to skin integrity related to fragile skin initiated on [DATE], indicated the goal was resident will not develop further skin breakdown. A review of Resident 1's CP for potential for pressure injury (pressure ulcer) development related to history of pressure ulcer initiated on [DATE], indicated interventions to follow facility's policy or protocols for the prevention or treatment of skin breakdown and the resident needs to turn or reposition at least every 2 hours or more often as needed and as tolerated. A review of Resident 1's Skin observation check, dated [DATE], indicated the resident has pressure ulcer on right gluteal fold (the horizontal skin crease that forms below the buttocks, separating the upper thigh from the buttocks) which measured 3 cm by 1cm. A review of Resident 1's quarterly Minimum Data Set (MDS, a standardized assessment and care screening tool), dated [DATE], indicated Resident 1 was moderately impaired with her cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 1 needed extensive assistance with two persons for bed mobility (ability to move easily), transfer (how resident moves between surfaces), dressing, toilet use, personal hygiene (practices conducive to maintaining health and preventing disease, especially through cleanliness) and bathing. The MDS indicated Resident 1 was frequently incontinent (insufficient voluntary control) of urine and bowel movement. The MDS indicated Resident 1 was at risk of developing pressure ulcers and had the following unhealed pressure ulcers and had one (1) Stage 2 (partial thickness loss of dermis [the thick layer of tissue containing blood capillaries, nerve endings, sweat glands, hair follicles , and other structure]) pressure ulcer which was presenting as a shallow open ulcer (an open sore on an external or internal surface of the body, caused by a break in the skin) with a red or pink wound bed, without slough (dead tissue separating from living tissue) body site not indicated. The MDS also indicated Resident 1 had MASD (location not indicated). The MDS also indicated one of the skin and ulcer treatment was turning or repositioning program. A review of Resident 1's Skin Risk (Braden Scale, purpose of the scale is to help health professionals, especially nurses, assess a patient's risk of developing a pressure ulcer, a score of 18 or less indicated at risk for developing pressure ulcers and interventions should be in place) assessment dated [DATE], indicated Resident 1's Braden Scale score was 13 (moderate risk). A review of Resident 1's CP for resident has healed wound on right gluteal fold initiated on [DATE], indicated monitor for worsening of skin integrity and reposition resident every 2 hours. A review of Resident 1's medical records dated from [DATE] to [DATE], there was no documented evidence in Resident 1's medical records that the weekly wound assessment was done for Resident 1's MASD on coccyx area after it was noted on [DATE]. In addition, there was no documented evidence of Resident 1's weekly wound assessment (to monitor progress of wound if healing or not) for the resident's right gluteal pressure (3 cm x 1 cm) ulcer after it was noted on [DATE]. Resident 1's medical records did not have documented evidence that the weekly wound monitoring and treatment administration was done for the resident's stage 1 (unspecified in the MDS), stage 2 (unspecified in the MDS) and MASD (unspecified in the MDS) after it was noted on [DATE] during quarterly MDS assessment. A review of Resident 1's Activities of Daily Living Flowsheet (ADL flowsheet, care guide and where certified nurse assistant [CNA] documents the care they provide for the residents) dated [DATE], for skin observation indicated the resident was noted to have the following skin concerns (location not indicated) on the following dates: a. On [DATE] Resident 1 was observed with scratched and red areas, discoloration, and skin tear. b. On [DATE] with scratched and red areas; skin tear. c. On [DATE] with discoloration and skin tear. d. On [DATE] with red area, skin tear, and open area. e. On [DATE] with red area and skin tear. f. On [DATE] with scratched and red areas. g. On [DATE] with scratched and red areas, and open area. h. On [DATE] with red area, skin tear and open area. i. On [DATE] with discoloration, skin tear, and open area. j. On [DATE] with red area and skin tear. The ADL Flowsheet indicated skin observations on [DATE] to [DATE] were reported to the licensed nurse by the certified nurse assistant (CNA) who signed the ADL flowsheet for that date and shift. The ADL flowsheet was not signed or filled out on [DATE] and did not indicate if there was any skin observation was done. A review of Resident 1's Care Plans (CP) dated [DATE] to [DATE], did not indicate any care plan initiated to address Resident 1's change of condition about the skin scratches, redness, skin tear and/ or open area noted by the CNAs on 8 different dates from [DATE] to [DATE]. During a concurrent interview and record review on [DATE] at 9:21 AM with the treatment nurse 2 (TXN 2), Resident 1's medical records dated from [DATE] to [DATE] were reviewed. Resident 1's medical records did not indicate any documentation the licensed nurse assessed, monitored, or that the physician was notified, to obtain orders for treatment on Resident 1's skin condition/ issues noted on from [DATE] to [DATE]. TXN 2 stated she unaware the resident had any pressure ulcers or wounds. The TXN 2 stated, the licensed nurses and CNAs did not report that Resident 1 had skin scratches, tears, redness and/ or open area from [DATE] to [DATE] and TXN2 only found out about Resident 1's multiple pressure ulcers and MASD the day the resident was transferred to the GACH 1 on [DATE]. A review of Resident 1's change of condition (COC, form used by licensed nurses when there is a new concern noted with resident's health condition such as new wound or skin breakdown) Evaluation, dated [DATE] entered at 6:51 PM, indicated Resident 1 had skin changes and noted to have the following 11 wounds: a. Left buttock (outer) pressure ulcer measured 6 centimeters (cm, unit of measurement) by 3 cm suspected deep tissue injury (DTI, purple or maroon localized area of discolored intact skin or blood- filled blister due to damage of underlying soft tissue from pressure and/ or shear). b. Left buttock outer pressure ulcer measured 7 cm by 5.5 cm suspected DTI c. Left buttock (Inner) pressure ulcer measured 13 cm by 7 cm stage 3 (full thickness tissue loss. Subcutaneous (situated under the skin) fat may be visible, but bone, tendon, or muscle is not exposed) d. Right buttock (Inner) pressure ulcer measured 8 cm by 5 cm unstageable (UTD, unable to determine stage of pressure ulcer by visual examination) e. Sacrum (a triangular bone in the lower back) pressure ulcer measured 3.5 cm by 2 cm UTD f. Sacrum pressure ulcer measured 3 cm by 1.5 cm UTD g. Sacrum pressure ulcer measured 2 cm by 1.5 cm UTD h. Vertebrae (each of the series of small bones forming the backbone) (upper middle) moisture associated skin damage (MASD, caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate [drainage], mucus, saliva, and their contents). i. Left lower abdomen pressure ulcer measured 10 cm by 1 cm suspected DTI j. Right lower abdomen pressure ulcer measured 5 cm by 0.5 cm suspected DTI k. Left iliac crest (a curved area at the top of the ilium bone, the largest of three bones that make up the pelvis) (front) pressure ulcer measured 3 cm by 1 cm suspected DTI A review of Resident 1's Nurse Notes dated [DATE] entered at 12:44 AM, indicated the following: a. At 6:30 PM resident was noted to have redness on entire backside, inner and outer left thigh, and right side of abdomen. b. At 8 PM, noted there were no order for the resident's sacrococcyx (an connection between the top of the sacrum and the base of the coccyx [tailbone]) wound treatment. Noted skin tears on back. A review of Resident 1's COC Evaluation, dated [DATE] entered at 1:13 AM, indicated new onset of the following skin changes (4 wounds noted): a) Lower back site #1 - pressure ulcer Stage 4 (a large wound in which the skin is significantly damaged. Muscle, bone, and tendons may be visible through a hole in the skin). The COC did not indicate wound measurement. b) Lower back site #2 - pressure ulcer Stage 4 c) Right and left buttock - redness d) Sacrogluteal (triangular bone at the base of the vertebrae and near buttocks) external right and left buttocks- unstageable A review of Resident 1's Weekly Nursing Summary dated from [DATE] to [DATE], indicated the following: a. On [DATE] at 1:58 AM, during the skin assessment, the licensed nurse did not document any wounds and/ or any skin breakdown (inconsistent with the COC dated on [DATE] entered at 6:51 PM and COC dated on [DATE] entered at 1:13 AM). b. On [DATE] at 1:46 AM during the skin assessment, the licensed nurse did not document wounds and/or skin conditions (ADL flowsheet indicated on [DATE] and [DATE] Resident 1 noted with skin redness, skin tear and open area). c. On [DATE] at 4 AM during the skin assessment, the Licensed nurse did not document wounds and/or skin conditions (ADL flowsheet indicated on [DATE] Resident 1 noted with scratch on her skin). d. On [DATE] at 3:09 AM during the skin assessment, the licensed nurse did not document wounds and/or skin conditions (ADL flowsheet indicated on [DATE] Resident 1 noted with scratch on her skin. A review of Resident 1's Skin Weekly assessment dated [DATE] indicated the following pressure ulcers were acquired and observed: a. Unstageable pressure injury on lower back site # 1. Size about 1.0 cm by 2.0 cm by 0.2 cm. No odor noted, moderate exudate, periwound (surrounding skin of wound) intact, attached wound edge. b. Unstageable pressure injury on sacrogluteal. Size about 22.5 cm by 12.0 cm. No odor noted. periwound intact and attached wound edges. c. Unstageable pressure ulcer on lower back site #2. Measured 1.5 cm by 2.0 cm by 0.2 cm. 100% slough (dead tissue in wound, usually cream or yellow in color), moderate exudate (wound drainage), periwound intact, attached edges, and no odor noted. d. Resident 1 also acquired and first observed on [DATE] with redness on right and left buttocks. No odor, no exudate, no infection noted. A review of Resident 1's COC Evaluation, dated [DATE] at 2:38 PM indicated Resident 1 had decreased level of consciousness. The COC indicated the resident had labored breathing and rapid respirations with rate of 28 breaths per minute. The COC evaluation also indicated Resident 1's oxygen saturation (measurement of how much hemoglobin [a protein responsible for transporting oxygen in the blood] is currently bound to oxygen compared to how hemoglobin remains unbound. For adults, the normal range is 95 -100%) was at 80% and resident's skin was cool and clammy. The COC also indicated the following skin issues were noted: 1) Vertebrae (upper-mid) skin tear (measurement not indicated) 2) Coccyx: MASD, and Pressure ulcer (stage not indicated) 3) Discoloration on abdomen 4) Redness to back, legs, and buttocks 5) Suspected deep pressure injury to left buttocks A review of Resident 1's Nurse Notes dated [DATE] entered at 6:38 PM, indicated Resident 1 was sent to GACH 1 via 911 (emergency transport services) at 2:15 PM. A review of Resident 1's GACH 1 record (undated), indicated Resident 1 presented to the emergency room (ER) with altered mental status on [DATE] at 2:34 PM. The GACH 1 records indicated, Resident 1 was drowsy and not responding to voice, left lower leg cellulitis. Acute (characterized by sharpness or severity of sudden onset) diagnosis made during the emergency room (ER) visit was sepsis ,d+[DATE] and cellulitis. The GACH 1 records also indicated laboratory test results of the following: a. On [DATE] at 3:50 PM lactate (measure of the amount of lactic acid [a chemical that the body produces during the process of breaking down sugar] in the blood]. High levels of lactate are associated with increased risk of death independent of organ failure and shock) was critical high 7.5 millimoles per liter (mmol/L, unit of measurements) b. On [DATE] at 5:50 PM, lactate critical high at 6.9 mmol/L c. On [DATE] at 4 PM blood culture (test conducted to determine bacterial growth in the blood) collected and results on [DATE] at 11:37 PM indicated positive for staphylococcus epidermidis (bacteria that lives in the skin and prefers sweaty places,) and on [DATE] at 5:20 PM indicated positive for staphylococcus hominis (presumed pathogen in few reported skin and soft tissue infection cases). The GACH 1 record indicated the resident was discharged to GACH 2 on [DATE] at 12 AM (total of 9 hours and 30 minutes stay in GACH 1 emergency department) with final diagnosis of sepsis. A review of Resident 1's GACH 2 records indicated Resident 1 admitted to the GACH's telemetry unit (unit where patients are under continuous cardiac monitoring and/ or on close observation usually patients who have experienced heart attack or stroke) from [DATE] and discharged on [DATE] to a nursing home (not indicated) under hospice care services. The GACH 2 records also indicated resident was admitted with pressure ulcer stage 3 and DTI on bilateral buttocks, with skin breakdown and mild odor, and pressure ulcer redness on resident's back. The GACH 2 records indicated Resident 2's final diagnosis was cellulitis of the buttocks and infected multiple stage 2 and stage 3 pressure ulcer of the buttocks. In addition, the GACH 2 records indicated the following pressure injury was present during admission of the resident: a. Pressure ulcers stage 3 and DTI on middle back, lower back, bilateral buttocks, and sacrum area. b. Pressure ulcers stage 1 on bilateral heel. c. Erythema (redness) on bilateral side of the abdomen and bilateral upper thigh. d. Skin breakdown (unspecified) on the back and buttocks. A review of Resident 1's Death Certificate indicated the resident died on [DATE] due to cardiorespiratory (sudden loss of heart function, breathing and consciousness) arrest. During an interview with treatment nurse 3 (TXN 3) on [DATE] at 3:40 PM, TXN 3 stated the wound management protocol was: CNAs are the initial first eye to view the patient's skin. If they notice anything different or incorrect, they should report it to the charge nurse. The TXN 3 also stated, the CNA performs a skin assessment each shift, signs off and reports to the charge nurse (CN) if there was any changes with the skin condition such as redness, skin tear, scratches and/ or open wound. The CN reviews, assess and reports to the treatment nurses. TXN 3 stated, It is an agreement that if they have found changes in the patient, they should report it. TXN 3 stated, the CN should have completed the COC, skin and pain assessment, progress note, initiated a care plan, and called the physician to get a treatment order. During an interview with Family 1 on [DATE] at 4:42 PM, Family 1 stated, Resident 1 was discharged from GACH 2 to an assisted living home under hospice care services. Family 1 stated, Resident 1 eventually died on [DATE] in the assisted living home. Family 1 stated, the facility never informed her of Resident 1's pressure ulcers from [DATE] to [DATE]. Family 1 stated, Resident 1 did not have any wound care treatment provided by the facility since [DATE]. Family 1 stated, in GACH 2 she remembered the GACH 2 nurses told her Resident 1 has pressure ulcers at the buttocks with one measured 6 inches with 2 inches deep and the one in the coccyx area was debrided (remove damaged tissue to promote healing of wound) in the hospital. 2. During an interview with CNA 3 on [DATE] at 8:48 AM, CNA 3 stated Resident 1 was bed ridden and was totally dependent, with ADLS. CNA 3 stated, when CNA finds something different on a resident's skin, CNAs go and tell the nurse and document on the ADL flowsheet and CNAs sign it and give it to the licensed nurse. CNA 3 also stated, it was important to make sure turning or repositioning the resident every 2 hours to avoid development of pressure ulcers. During a concurrent interview and record review on [DATE] at 1:15 PM with the Director of Nursing (DON), Resident 1's Activities of Daily Living (ADL) Flowsheet dated [DATE] was reviewed. The ADL flowsheet did not indicate signature on the following dates and time for turn and reposition every 2 hours (total of 11 days): a. ,d+[DATE] from 8 AM to 2 PM b. ,d+[DATE] from 12 AM to 6 AM c. ,d+[DATE] from 12 AM to 6 AM d. ,d+[DATE] from 8 PM to 10 PM e. ,d+[DATE] from 12 AM to 10 PM f. ,d+[DATE] from 12 AM to 6 AM g. ,d+[DATE] from 4 PM to 10 PM h. ,d+[DATE] from 12 AM to 2 PM i. ,d+[DATE] from 4 PM to 10 PM j. ,d+[DATE] from 4 PM to 10 PM k. ,d+[DATE] from 4 PM to 10 PM The DON stated, the ADL flowsheet did not have the staff's signature, or it was left blank meaning it was not done. A concurrent interview and record review of Resident 1's medical records, with the DON on [DATE] at 1:15 PM with the presence of Assistant Administrator, Quality Assurance (QA) Nurse, and Lead Treatment Nurse, indicated: a. The DON stated that Resident 1's Weekly Nursing Summary dated [DATE] entered at 1:58 AM indicated Resident 1's skin is intact whereas Skin Weekly assessment dated [DATE] entered at 1:13 AM indicated Resident 1 had pressure ulcers on her buttocks. The DON stated there was inconsistency with the licensed nurse assessment and documentation and that it was because the nurses overlooked skin assessments. b. A review of Resident 1's Skin Weekly assessment dated [DATE] indicated that the pressure injures were acquired in the facility and was observed on [DATE]. The DON stated a wound noted on [DATE] that measures 22.5 cm by 12.0 cm does not develop overnight and this wound could have been present even days prior to [DATE]. During the same interview and record review of Resident 1's medical records, with the DON on [DATE] at 1:15 PM with the presence of Assistant Administrator, QA Nurse, and Lead Treatment Nurse, the DON, stated there was no documentation of wound assessment, monitoring, care plan was initiated, or physician was notified and treatment for the skin breakdown for Resident 1's skin breakdowns noted by the CNAs from the ADL flowsheet from [DATE] to [DATE]. The DON stated, it was important to assess, identify, monitor, and provide treatment in preventing new wound and treatment for wound to avoid complications such as infections on the wound. During an interview with TXN 1 on [DATE] at 11:25 AM stated the resident did not have any wound at the beginning of April. TXN 1 stated the sudden discovery of Resident 1's multiple pressure ulcers located at the buttocks and lower abdomen were considered a neglect as skin conditions were not assessed, monitored, was not reported to the physician and no treatment was done. A review of facility's policy Pressure Ulcer Prevention, updated [DATE], indicated the purpose of the policy is that residents at risk for skin breakdown, implement measures to prevent and/ or manage pressure ulcers and minimize complications. The policy also indicated the following: a. Licensed nurses will complete a skin assessment and document in the resident's medical record upon admission, readmission, weekly and as needed. b. If the resident is identified as having a wound at any time other than admission, wound monitoring record will be implemented for each identified wound. c. Nursing staff will develop a CP specific to the resident, monitor interventions for effectiveness and revised as indicated. d. CNAs will inspect the resident's skin during ADL care and report unusual findings to the licensed nurse e. The licensed nurse will document effectiveness of pressure ulcer prevention techniques in the resident's medical record on a weekly basis. A review of facility's policy Wound Management, updated [DATE], indicated the resident who has a wound will receive necessary treatments to promote healing, prevent infection and prevent new pressure ulcers from developing. The Licensed nurse will perform a weekly skin assessment and as needed for each resident. The Licensed nurse will assess the care needs for the pressure ulcer and wound management. The License nurse will evaluate and modify interventions for a resident with an existing PU/PI. The policy indicated managing the wound requires documentation at a minimum of weekly until the wound is healed, and the resident 's care plan update as necessary. The policy indicated the documentation will include location of wound, length, width, and depth measurements records recorded in centimeters. In addition, the policy indicated documentation should include direction, length of tunneling (chronic wound that has progressed to form an opening underneath the surface of the skin) and undermining (a separation of the wound edges from the surrounding healthy tissue, often creating a pocket under the wound surface), appearance of the wound base, if there is a drainage amount and characteristics including color, consistency, and odor. In addition, the policy indicated documentation should include appearance of wound edges, evaluation of the skin adjacent to the wound and presence of new epithelium (thin layer of tissue that covers organs, glands, and other structures within the body).

Based on interview and record review, the facility failed to ensure residents who receive dialysis treatment (procedure to remove wastes or toxins from the blood and adjust fluid and electrolyte [substance that breaks up into ions {particles with electrical charges} when it is dissolved in water or body fluids] imbalances) are provided services consistent with professional standards of practice for one of 18 sampled residents (Resident 159). (Professional standards of practice is an ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments. The nursing home staff must be aware and identify changes in resident's behavior, especially for a cognitively [mental action or process of acquiring knowledge and understanding] impaired resident, that may impact the safe administration of dialysis, including, resistance to care, and pulling on tubes/access sites and inform the attending practitioner and dialysis facility of the changes.) Resident 159, who had tendencies of picking on his skin and arteriovenous (AV) shunt (a vascular access that is surgically created vein used to remove and return blood during dialysis) site, for approximately four (4) months from [DATE] to [DATE], was not reevaluated, continually monitored, and managed for his behaviors. There was no revised nursing care plan (a formal process that correctly identifies existing needs and recognizes a resident's potential needs or risks to achieve healthcare outcomes) to prevent Resident 159 from continually picking and touching his AV shunt site. As a result of Resident 159's behaviors, the resident was found in bed bleeding at the AV shunt site on [DATE] at 2:10 AM. The facility staff called 911 (emergency services) and initiated cardiopulmonary pulmonary resuscitation (CPR). At 2:55 AM the resident was pronounced dead by paramedics (person trained to give emergency medical care to people who are injured or ill). These deficient practices placed additional 17 identified residents receiving dialysis treatment at risk for injury or death. On [DATE] at 4:23 PM, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's Administrator (ADM), Administrator Assistant (AADM), and the Director of Nursing (DON) regarding the facility's failure to: 1. Monitor and document Resident 159's behavior of picking on skin especially the AV shunt site on the upper left arm as identified by the facility since [DATE] in accordance with the resident's care plan. 2. Formulate care plans with resident-specific interventions to include evaluation of effectiveness of interventions, and the need to revise/add interventions to address Resident 159's behavior of picking on skin especially the AV shunt site from [DATE] to [DATE]. 3. Intervene and address when Resident 159 was observed with behaviors of attempting to pick on his skin especially the AV shunt site, and resident's history of pulling out his Quinton catheter (a flexible tube placed into a large vein for short term hemodialysis [treatment to filter wastes and water from the blood] treatment), from [DATE] to [DATE]. These deficient practices placed 18 residents who are on dialysis at risk for getting complications such as bleeding or infection from the dialysis site. Resident 159 was found in bed bleeding at the AV shunt site on his left upper arm on [DATE] at 2:10 AM. Facility staff attempted to perform Cardiopulmonary resuscitation (CPR, lifesaving technique useful in emergencies such as when someone's breathing, or heartbeat has stopped). Resident 159 expired on [DATE] at 2:55 AM. On [DATE] at 6:38 PM, the IJ was removed after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practices). The surveyor verified and confirmed the implementation of the Plan of Action (POA) while onsite by observation, interview, and record review. The IJ was removed in the presence of the ADM, AADM, and DON. The acceptable IJ Removal Plan included the following: 1. >On [DATE], the DON identified 17 other residents with dialysis access site who might have similar behaviors. > The 17 identified residents having dialysis were assessed on [DATE]. The dialysis assessment was completed on [DATE] by the DON and the ADON. There were five (5) residents identified with behavior of scratching (Residents 888, 882, 60, 102 and 219). > Beginning [DATE], Treatment Nurses conducted skin observation assessments on all 17 identified residents to determine if any residents were exhibiting behavior such as itching, picking, and scratching the skin. > On [DATE], Change of Condition (COC) was initiated by the DON for the 17 identified residents requiring behavior monitoring of picking, scratching, and itching of the skin. > On [DATE], care plans were reviewed, revised, and updated by the Minimum Data Set (MDS) Coordinator to assess and prevent the risk of further complications related to compromising the dialysis access site for all 17 identified residents on dialysis. It also reflected goals and interventions, such as monitoring of shunt site for itching, scratching, or picking of dialysis site. > An in-service on Dialysis Care was provided by the DON on [DATE] and on-going inservice was being conducted to include all licensed nurses for the 7AM to 3PM, 3PM to 11PM, and 11PM and 7AM shifts. The in-service emphasis was on inspecting the shunt site for color, warmth, redness, pain, drainage, for bruit (rumbling or swooshing sound that indicates a resident's dialysis site is working) and thrill (felt on the overlying skin as a vibration) and any behavior exhibited by the resident such as scratching or picking the skin. Furthermore, the in-service included monitoring the above dialysis site, behavior exhibited by the resident and documented on the Medication Administration Record (MAR) every shift. In the event of bleeding, to apply direct pressure on the AV shunt site, feel for pulsation (rhythmic throbbing or vibrating), and notify the attending physician of episode of bleeding. The in-service also included identification of changes in resident's behaviors and to address or intervene, monitor, protect and prevent serious complications/illness, death, and management of bleeding from the dialysis access site. > On [DATE], a call was placed to the facility's Medical Director and facility is waiting for his response. On the other hand, the Administrator will be contacting a resource person from an outside dialysis center/agency for further training education to be provided to facility licensed staff. 2. >Beginning [DATE], monitoring and documentation will be completed for residents admitted and readmitted who are on a hemodialysis treatment. Residents will be assessed to include AV shunt site for color, warmth, redness, pain, drainage, bruit, and thrill any behavior exhibited by the resident. > Beginning [DATE], DON/Designee or Quality Assurance (QA) Nurse will retrain licensed nurses for all three (3) shifts to identify resident changes in behaviors and address or intervene, monitor, protect and prevent serious complications/illness, death, and management of bleeding. > Beginning [DATE], DON/Designee will ensure the safety of all dialysis residents while they are in the care of facility's staff by ensuring all licensed nurses monitor and document resident's behaviors of itching, scratching, and picking at puncture sites. > On [DATE], Administrator contacted the dialysis center for an outside resource to provide further training to staff on dialysis care. This will again be followed through by the QA Nurse on [DATE] by calling dialysis centers to ensure that facility staff will be provided with the necessary information on how to handle dialysis patients while at the facility. > On [DATE], QA nurse began to conduct interviews of the dialysis center where each of the 18 residents received treatment to inquire of any behavior exhibited by the resident such as scratching, picking of skin on the dialysis site. 3. > Beginning [DATE], the DON was made responsible for auditing residents receiving dialysis care to ensure they are monitored for any itching, scratching, or picking the skin. The DON was also responsible for monitoring for any complications, identify changes in resident's behaviors and to address or intervene, monitor, protect and prevent serious complications/illness, death, and management of bleeding from the dialysis access site. Daily monitoring will be conducted for 30 days and weekly thereafter. > Beginning [DATE], the DON or Designee will provide the results of audits to the Quality Assurance Committee for recommendations, follow up and to ensure compliance. >The Performance Improvement Committee will monitor the process weekly for the next two weeks, then monthly for three months until compliance is achieved. Findings: On [DATE], an annual recertification health survey was conducted at the facility. A review of Resident 159's Admission Record indicated an initial admission to the facility on [DATE] and readmission on [DATE]. Resident 159's diagnoses included end stage renal disease (a medical condition in which a resident's kidneys stop functioning on a permanent basis leading to the need for a regular course of long-term dialysis [a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly] or a kidney transplant to maintain life), and dependence on renal dialysis. A review of Resident 159's Physician Orders, dated [DATE], indicated for the resident to receive hemodialysis on Tuesday, Thursday, and Saturday at 4:30 am to 8 am. A review of Resident 159's care plan, initiated [DATE], indicated Resident 159 was at risk for AV shunt rupture resulting to serious complication/bleeding due to a behavior problem related to picking on the left upper arm dialysis access site, compulsiveness / scratches himself, and history of pulling out Quinton catheter. The staff interventions included were for certified nurse assistant (CNA) to monitor behavior episodes and attempt to determine underlying cause, (consider location, time of day, person involved, and situations), and to document behavior and potential causes. A review of Resident 159's History and Physical, dated [DATE], indicated Resident 159 did not have the capacity to understand and make decisions. A review of Resident 159's Minimum Data Set (MDS, a standardized assessment and care planning screening tool) dated [DATE] indicated Resident 159's cognitive skills for daily decision making was severely impaired. Resident 159 required extensive assistance (staff provide weight bearing support) with one-person assist for bed mobility, dressing, and toilet use. Resident 159 required extensive assistance with two-person assist for transfer. Resident 159 was totally dependent (full staff performance) with one- person assist for personal hygiene. A review of Resident 159's Nurses' Note, dated [DATE], indicated around 2:10 am, during rounds (when a member of the healthcare team visits a resident to review the resident's status and care plan) in preparation of resident for dialysis, Licensed Vocational Nurse 1 (LVN 1) observed Resident 159 lying in a pool of blood. The Nurses' Note further indicated that on assessment, Resident 159 was warm to touch, pupils were fixed (do not respond to an outside stimulus such as light, which could be indicative of trauma to the brain) and dilated (when the black center of the eyes is larger than normal). A review of Resident 159's Change of Condition (COC) Assessment Form, dated [DATE], indicated during rounds at around 2:10 AM, LVN 1 noticed Resident 159 was bleeding from the dialysis access site (left upper arm AV shunt). LVN 1 applied pressure to Resident 159's dialysis access site. The COC indicated at 2:20 AM, Resident's 1 blood pressure was zero (0)/0 millimeter per mercury (mmHg, unit of measurement), pulse was 0 beats per minute, respiration was 0. The COC indicated LVN 1 notified the Registered Nurse (RN) supervisor. Resident 159's vital signs (reflect essential body functions, including the resident's heartbeat, breathing rate, temperature, and blood pressure [measure of the force that the heart uses to pump blood around the body]) were taken which showed 0. LVN 1 started chest compressions (act of applying pressure to the resident's chest to help blood flow through the heart in an emergency situation) on Resident 159 and called paramedics. A review of Resident 159's Death Record Form, dated [DATE], indicated Resident's date and time of death was [DATE] at 2:55 AM. During an interview on [DATE] at 6:35 AM, CNA 3 stated, she noticed Resident 159 had been scratching his AV shunt in the last 3 months (from ,d+[DATE] to ,d+[DATE]). CNA 3 stated, she did not report Resident 159's behavior to the supervisors. During an interview on [DATE] at 7:35 AM, RN 3 stated, there were many episodes Resident 159 scratched his dialysis access site. RN 3 stated, they should have informed Resident 159's doctor about his behavior and should have revised the care plan to implement non-drug interventions to alleviate resident's behavioral symptoms, in accordance with the facility policy. During an interview on [DATE] at 7:45 AM, LVN 2 stated, she was the charge nurse on [DATE] for the 11 PM to 7:30 AM shift. LVN 2 stated, Resident 159 was assigned to CNA 2 who was from the Registry (staff personnel provided by a placement service on a temporary or on a day-to-day basis, in a facility). During an interview on [DATE] at 9:20 AM, RN 4 stated, Resident 159 had behaviors of pulling and scratching with anything attached to him. RN 4 stated, Resident 159 was transferred out to the acute hospital so many times for replacement of G-Tube (tube inserted through the wall of the abdomen directly into the stomach, which can be used to give drugs and liquids, including liquid food) AV shunt, supra public catheter (hollow flexible tube that is used to drain urine from the bladder). During a telephone interview on [DATE] at 10:50 AM, CNA 1 stated, Resident 159 had a habit to scratch and pull his dialysis access or other tubes that were attached to him. CNA 1 stated, she observed Resident 159 playing with his dialysis access a few months ago (could not recall date) but she did not report to the charge nurse and did not do any intervention since everyone knew about it. During a concurrent interview with RN 6 and record review of Resident 159's care plan on [DATE] at 11:50 AM, RN 6 stated Resident 159's care plan was initiated on [DATE]. RN 6 stated, the resident's care plan indicated Resident 159 was at risk of AV shunt rupture resulting to serious complication/bleeding due to behavior problem related to picking on the left upper arm, compulsiveness/scratches himself, and history of pulling out his Quinton catheter. RN 6 stated care plan should have been revised on [DATE] to verify if interventions were effective and if they were not, care plan should have been revised to keep Resident 159 from picking on his AV shunt. RN 6 stated, Resident 159's care plan was not resident specific because it needed other interventions to prevent resident from picking on his AV shunt. During a concurrent interview with RN 4 and record review of Resident 159's care plan on [DATE] at 12:05 PM, RN 4 stated, Resident 159's care plan was initiated on [DATE]. RN 4 stated Resident 159's care plan was not effective because Resident 159 picked on his AV shunt, which resulted to death due to complications of bleeding from his AV shunt. RN 4 stated, the best option for intervention was to monitor Resident 159's behavior of pulling tubes and picking on dialysis access. RN 4 stated, care plan should have included interventions to prevent resident from picking on his AV shunt. During a concurrent interview with RN 4 and review of Resident 159's MAR and progress notes on [DATE] at 1:52 PM, RN 4 stated, Resident 159 tended to remove anything attached to him. RN 4 stated, based on Resident 159's care plan, staff should have monitored and documented Resident 159's episodes of behavior of picking skin on AV shunt. RN 4 stated, staff documentation can be found in the MAR or progress note. RN 4 stated he was not able to find documented evidence that nurses were monitoring and documenting Resident 159's behavior of picking on his AV shunt from [DATE] to [DATE]. During an interview on [DATE] at 2:43 PM, the DON stated, Resident 159's behaviors of picking on his AV shunt was not monitored, which resulted to bleeding and dislodgment of Resident 159's AV shunt. During an interview on [DATE] at 3:52 PM, the MDS Supervisor stated, Resident 159's care plan was initiated on [DATE]. MDS Supervisor stated, Resident 159's care plan should have been revised on [DATE] to ensure interventions were effective. The MDS Supervisor stated, based on Resident 159's care plan interventions, staff should have obtained an order to monitor resident's behavior and should have documented the episodes of behavior in the MAR. During a concurrent interview with RN 4 and record review of Resident 159's COC form on [DATE] at 11:24 AM, RN 4 stated the following: 1. On [DATE] at 2:06 AM, Resident 159 was noted to self-remove his dialysis catheter on the right upper chest. 2. On [DATE] at 4:35 PM, Resident 159 pulled out his Quinton catheter which resulted to minimal bleeding. During an interview on [DATE] at 12:30 PM, the MDS Nurse 1 stated, the licensed nurses should monitor Resident 159's behavior of picking on his AV shunt by documenting the number of episodes daily in accordance with the facility policy. During an interview on [DATE] at 1:08 PM, ADM stated, staff should have obtained a physician's order to monitor Resident 159's behavior when the care plan was initiated. The ADM stated, the care plan should be revisited quarterly in accordance with the facility policy. During a telephone interview on [DATE] at 1:59 PM, CNA 2 stated, she was working on [DATE] from 11PM to 7:30 AM shift and was assigned to Resident 159 when Resident 159 expired. CNA 2 stated, she was from Registry and was her first night assigned to Resident 159. CNA 2 stated, she was not instructed by LVN 2 to monitor Resident 159's behavior of picking on his AV shunt. CNA 2 stated, it was important for her to know so she could have monitored Resident 159's behavior. During an interview on [DATE] at 3:05 PM, the DON stated, CNAs who were assigned to Resident 159 should have been instructed to monitor Resident 159's behavior of picking on his AV shunt. The DON stated, there was no documented evidence that Resident 159's behavior was being monitored. A review of the facility's policy and procedure titled, Dialysis Care, revised on [DATE], indicated the facility will be responsible for the overall care delivered to the resident, monitoring of the resident prior to and after the completion of each dialysis treatment, and providing for all dialysis needs of the resident including during the time period when the resident is receiving dialysis. Care for AV shunt included: I. Inspect shunt site area for color, warmth, redness, tenderness, pain, edema, drainage, and bruit once per shift. ii.To check for a bruit: a. Place your fingertip slightly over the vein and feel for the thrill. b. Place the stethoscope over the vein and listen for the buzz or bruit. c. Document the findings in the medical record. In the event of bleeding, apply direct pressure on AV shunt site (when applying pressure, be sure the pulsation can be felt) and notify Attending Physician of bleeding event. Notify Attending Physician immediately if the bleeding does not stop. The Nursing Staff, Dialysis Provider Staff, and the Attending Physician will collaborate on a regular basis concerning the resident's care as follows: Nursing Staff will communicate pertinent information in writing to the Dialysis Staff which may include: Any recent changes in condition. Care Plan: A. The Interdisciplinary Team (IDT) will ensure that the resident's Care Plan includes documentation of the resident's renal condition and necessary precautions B. The resident's Care Plan will be updated as needed. C. Facility Staff will educate the resident on the importance of complying with the Care Plan and with Attending Physician orders. D. If the resident does not comply with his or her Care Plan, the Facility will document this non-compliance with following Care Plan and make the necessary adjustments, including providing additional education to the resident. If the resident continues to be non-compliant, the IDT will meet with the resident and his/her family to discuss risks and benefits. All documentation concerning dialysis services and care of the dialysis resident will be maintained in the resident's medical record. A review of the facility's policy titled, Behavior Management, revised on [DATE], indicated the facility is responsible for providing behavioral health care and services that create an environment that promotes emotional and psychosocial well-being, meet each resident's needs, and include individualized approaches to care. It indicated: I. When a resident displays adverse behavioral symptoms (e.g., crying, yelling, hitting, resisting care, etc.), Licensed Nursing Staff will assess the behavioral symptoms to determine possible causal factors, contact the Attending Physician, and implement non-drug interventions to alleviate the behavioral symptoms before initiating any psychotherapeutic agent(s). II. The facility must provide necessary behavioral health care and services which include: A. Ensuring that the necessary care and services are person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety; B. Ensuring that direct care staff interact and communicate in a manner that promotes mental and psychosocial well-being. Policy indicated the following for documentation of Behaviors: A. When the resident exhibits behaviors, the Licensed Nurse will document the resident's behavior in the medical record and include the following as indicated: i. Any precipitating factors ii. Interventions used to redirect behavior iii. The resident's response to the intervention iv. Notification of Attending Physician and responsible party as indicated v. Update the plan of care as indicated A review of the facility's policy titled, Care Planning, revised on [DATE], indicated to ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs. The Facility's Interdisciplinary team (IDT) will develop a baseline and/or comprehensive care Plan for each resident in accordance with the Omnibus Budget Reconciliation Act (OBRA, Nursing Home Reform Act, which dramatically improved the quality of care in the Nursing home) and MDS guidelines. The care plan serves as a course of action where the resident (resident's family and/or guardian or other legally authorized representative), resident's Attending Physician, and IDT work to help the resident move toward resident-specific goals that address the resident's medical, nursing, mental and psychosocial needs. The Facility will develop a person-centered Baseline Care Plan for each resident within 48 hours of admission. The Baseline Care Plan will be updated to reflect changes in the resident's condition or needs occurring prior to the development of the Comprehensive Care Plan. The IDT will revise the Comprehensive Care Plan as needed at the following intervals: A. Per Resident Assessment Instrument (RAI) schedules B. As dictated by changes in the resident's condition C. In preparation for discharge D. To address changes in behavior and care E. Other times as appropriate or necessary A review of the facility's policy titled Interdisciplinary Team/ Resident Care Plan Conference Review, dated 11/ 2022, indicated the IDT will revise the Comprehensive Care Plan as needed at the following intervals: A. Per RAI schedules B. As dictated by changes in the resident's condition C. In preparation for discharge D. To address changes in behavior and care E. Other times as appropriate or necessary

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) was free from accidents by ensuring the resident was provided a two-person assistance. Certified nursing assistant (CNA) 1 provided care and repositioned the resident alone while the resident was in bed. This deficient practice resulted Resident 1 falling (unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force) and landing on the floor in a prone position (prone position is a body position in which the person lies flat with the chest down and the backup) The resident sustained two lacerations to the right side of the face and was transferred to the general acute hospital (GACH) where the resident was found to have sustained facial fractures. Findings: A review of Resident 1's Face Sheet indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of chronic obstructive pulmonary disorder (COPD- a group of diseases that cause airflow blockage and breathing-related problems), functional quadriplegia (the complete inability to move due to severe disability or frailty caused by another medical condition), and congestive heart failure (heart can't pump enough blood). A review of Resident 1's Minimum Data Set (MDS: a standardized assessment and care planning screening tool) dated 1/3/23, indicated Resident 1 had moderate cognitive impairment. The MDS indicated Resident 1 required extensive assistance (staff provide weight bearing support) with two- persons physical assist for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture). Resident 1 was totally dependent (full staff performance) requiring two- person physical assist with toilet use. A review of Resident 1's care plan (a document that outlines a resident's health and social care needs and how their needs will be supported) for Risk for Fall, initiated 12/22/22, indicated the goal was for Resident 1 to be free of falls and free of injury. The care plan interventions indicated to anticipate and meet the residents needs and to follow the facility's fall protocol. The Care plan interventions indicated to alter/remove any potential cause of fall if possible. A review of Resident 1's nursing admission assessment dated [DATE], indicated resident was high risk for fall. A review of Resident 1's care plan for Activity of Daily Living (ADL: a series of basic activities necessary for independent living at home or in the community) for self-care performance, initiated 12/28/22, indicated Resident 1 was totally dependent on staff for repositioning and turning in bed. The care plan indicated Resident 1 was totally dependent on staff for toilet use. A Review of Resident 1's Change in Condition (COC a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains), dated 1/7/23 indicated Resident 1 sustained a fall with two (2) lacerations to the right cheek. The COC indicated laceration 1 measuring at 2.5-centimeter (cm: a unit of measurement) x 0.5cm located by the resident's right ear, and laceration 2 measuring at 0.2cm x 0.1cm with scant moderate amount of bleeding. The COC indicated a physician's order to transfer Resident 1 to the general acute care hospital (GACH). A review of Resident 1's Fall/ Event Interdisciplinary team (IDT) Progress note, dated 1/7/23, indicated certified nurse assistant (CNA)1 was providing care alone, for Resident 1, when Resident 1 fell and landed on the floor in prone position. The IDT note indicated Resident 1 sustained two lacerations to the right side of Resident 1's face. A review of Resident 1's Nurses Notes on 1/7/23 at 7:10PM, Licensed vocational nurse (LVN)1 indicated at 1:40PM, CNA1 notified LVN1 that Resident 1 fell out of bed while CNA1 was providing care. The Note indicated Resident 1 sustained two lacerations to the right cheek. A review of Resident 1's Nurses Note on 1/7/23 at 11:02PM, the Assistant Director of Nurses (ADON) indicated Resident 1 was at the GACH and sustained an occipital (posterior cranial bone) fracture. A review of the GACH Diagnostic Imaging for a computed tomography (CT: medical imaging technique used to obtain detailed internal images of the body) scan of the facial bone without contrast dated 1/7/23 indicated Resident 1 had a nondisplaced fracture (still broken bones, but the pieces weren't moved far enough during the break to be out of alignment) involving the right zygoma (bony arch of the cheek), right lateral maxillary wall (also known as the upper jaw), the right anterior maxillary wall (mouth), the left lateral orbital wall (side of the eye), and the right orbital floor (below the eye). The results indicated the findings were consistent with zygomaticomaxillary complex (ZMC: a major buttress of the midfacial skeleton. The ZMC is important to structural, functional, and aesthetic appearances of the facial skeleton) fracture. The results indicated a non-displaced right occipital (back part of the head) fracture. A review of Resident 1's Nurses note dated 1/8/23 at 1AM, indicated Resident 1 returned from the GACH with discoloration to the right lower eye and right cheek bone, and noted with swelling to the right ear, extending to the jaw line. The note indicated x-ray results indicating fracture to the right occipital, right zygoma (cheekbone) and right lateral maxillary (lateral, border of the nose) sinus. During an interview on 2/3/23 at 1:32PM, CNA1 stated Resident 1 sustained a fall in the facility while CNA1 was providing care and changing Resident 1's brief while resident was in bed. CNA1 stated he did not ask for assistance from another facility staff when repositioning Resident 1. CNA1 stated, even before the fall on 1/7/23, every time CNA1 needs to reposition Resident 1 in bed, CNA1 did not ask for assistance and was able to reposition the resident by himself. CNA1 stated on 1/7/23, while repositioning Resident 1 in bed to be on left side lying position, Resident 1 made a sudden movement, and fell on to the side where CNA1 was standing. CNA1 stated he could not stop Resident 1 from falling out of bed. CNA1 stated Resident 1 fell on the floor and had a laceration on Resident 1's face with blood present. CNA1 stated after Resident 1 fell out of bed, CNA1 immediately carried Resident 1 back into bed since CNA1 did not want to leave him on the floor, then notified LVN1. CNA1 stated it was important to ask for assistance when providing care to Resident 1 for safety and stated that CNA1 was unaware that Resident 1 required 2 persons assist for bed mobility. CNA 1 stated two-person assist would be utilized so each person could be on each side of the resident just in case a resident might roll out of bed. CNA1 stated if another facility staff had been present, Resident 1 would not have fallen out of bed. CNA1 stated he was unaware that licensed nurse (LN) should have assessed the resident prior to placing Resident 1 back into bed. CNA1 stated the importance of assessing a resident after a fall and prior to placing a resident back into bed was to identify if there were any other injuries and prevent more injuries. During an interview on 2/3/23 at 2:43 PM, LVN2 stated Resident 1 was totally dependent on staff and required 2 people assist for safety. LVN 1 stated during repositioning and to prevent a resident from falling out of bed, staff must be on each side of the resident to ensure falls or rolling out of bed does not occur, therefore having 2 persons present during resident care, could prevent resident falls. LVN 2 stated after a fall occurs, certified nurse assistants were aware that they should not move or touch the resident and to immediately call for help. LVN2 stated one staff are to stay with the resident, while the other calls for assistance. LVN2 stated moving a resident before being assessed for injuries must be done by a licensed nurse, and a resident was not moved until cleared to move after a body assessment was conducted to rule out other injuries and trauma. LVN2 stated staff are to assist by safely placing the resident back to bed. LVN 2 stated never should a CNA carry a resident alone back into bed. During an interview on 2/3/23 at 2:55PM, the Director of Nurses (DON) stated it was the responsibility of the LN to ensure that CNAs were aware of the type of dependence on staff (one-person, two person) a resident required, and was based on the mobility of a resident. The DON stated CNA1 was alone when providing care for Resident 1 and that two- persons should have been present. The DON stated the fall was avoidable, had two persons been present. The DON stated the purpose of having two person was for safety and because Resident 1 was totally dependent on staff and did not move on his own. The DON stated after Resident 1 sustained a fall, CNA1 independently carried Resident 1 back into bed without a body assessment conducted by licensed nurses. The DON stated the facility's fall protocol was for certified nurse assistants to wait for licensed nurses to assess the resident prior to moving or placing a resident back to bed to avoid further injury to the resident. A review of the facility's policy titled Fall Prevention Program dated 12/16 indicated the facility would identify interventions to prevent the resident from falling and to try and minimize complications from falling. A review of the facility's policy titled, Standard of Care Activities of Daily Living (ADL), dated 2/17, indicated to assess resident's skill in performing ADLs on admission, quarterly and as needed. The policy indicated Resident would perform self-care with ADLs at the level on the CNA care plan and assist the resident to be clean.

Based on observation, interview and record review, the facility failed to maintain an effective pest control program to eradicate (destroy) and prevent rodent infestation (the presence of an unusually large number of rodents [rats or mice that can be carriers and spread infectious diseases]) in the facility's kitchen for 200 of 200 residents. The deficient practice resulted in the presence of one dead rodent in the kitchen steamtable (a type of food holding equipment designed to keep foods warm) placing 200 residents at risk of serious diseases that can be transmitted through various routes (direct contact or inhalation) and by contaminating human food with germs (small living things/cells, especially one which cause diseases) that rodents pick up in garbage dumps and outside grounds. On 4/28/2021, at 11:45 am, the Registered Environmental Health Specialist (REHS-a health inspector who inspects various facilities and properties to determine conformance with applicable State laws and County Ordinance Code sections) from the Department of Public Health (DPH) observed one dead rodent in the facility's kitchen, under the kitchen's steamtable. On 4/28/2021, at 2:30 pm, the REHS from DPH and the surveyor conducted a joint inspection in the facility. During a concurrent observation (same time) with the REHS from DPH, the dead rat found under the steamtable measured 5 inches long. On 4/28/2021, at 2:45 pm, an Immediate Jeopardy (IJ-a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident or residents) was declared and the facility's administrator was notified of the situation and concerns regarding maintaining an effective pest control program. On 4/28/2021, at 4:40 pm, the REHS from DPH closed the facility kitchen for food service operations. On 4/30/2021, at 11:55 am, the IJ was removed in the presence of the administrator after the implementation of the acceptable plan of action (POA, interventions to correct the deficient practice) was verified and confirmed on an onsite visit through observation, interview and record review. The acceptable POA included the following actions: 1. The administrator immediately seized the use of the kitchen and utilized the kitchen from the assisted living facility (ALF), associated with the facility, located across the facility's parking lot to prepare and cook meals from 4/28/2021(dinner time) and ongoing until the facility's kitchen was re-inspected and permitted to be fully operational on 4/30/21 at 10:55 am. 2. The facility's meals was prepared by the facility's dietary staff according to the policy for emergency menu on 4/28/2021 and was prepared from the assisted living facility's kitchen. 3. The nursing supervisors checked all dinner meals prior to serving the residents according to their diets and texture of the meal ordered and prepared on 4/28/2021, and ongoing. 4. All meals prepared by the facility's dietary staff beginning 4/28/2021 in individual disposable containers from the ALF. Prepared meals placed in insulated food containers to maintain correct food temperature while transporting to the facility from the ALF's kitchen beginning 4/28/2021. 5. The facility communicated with the Pest Control company on 4/28/2021 and will be coming to the facility every day for the next five days and weekly thereafter. 6. The facility's nursing staff will dispose the disposable containers used by the residents beginning 4/28/2021. 7. The facility's dietary staff will be preparing all meals beginning 4/28/2021 according to the residents/patients' dietary restrictions and specifications. 8. The facility's dietary staff to transport all meals using a closed secured meal cart beginning 4/28/2021. 9. On 4/28/2021, the administrator obtained access and had a mobile kitchen unit delivered in the facility and will request for immediate public health permit if the facility kitchen is closed for an extended period. 10. The housekeeping and dietary staff began deep cleaning and sanitizing the kitchen equipment, food contact surfaces and floor on 4/28/2021. 11. The soap dispensers were re-stocked by housekeeping supervisor in the kitchen, on 4/28/2021. 12. The maintenance supervisor conducted a kitchen environmental inspection and is repairing all open areas, removing accumulation of rust, grease and grime from all surfaces, repaired any conveyor or food prep table openings, and seal ¼'' gap in the bottom of the entrance door starting 4/28/2021. 13. The maintenance supervisor removed the unapproved tack board from the wall above the food preparation sink on 4/29/2021. 14. The maintenance supervisor will provide an approved indirect drainage connection for the food preparation sink once the materials for the plumbing for the sink arrives on 4/30/2021, which will allow replumbing of the drainage line to the floor sink with and one-inch air gap between the end of drainage line and the plane of the floor sink. 15. The administrator paid the permit for retail food official inspection report on 4/29/2021 and facility status score and grade will be posted in the kitchen and consumer board area once permit is received. 16. The administrator purchased bottled drinking water on 4/28/21 for residents and until the kitchen is inspected by the DPH REHS and fully operational. 17. The facility started working on the following physical changes in the facility kitchen on 4/28/2021 and will be completed by 4/30/2021. a. Resurface the uneven and deteriorating walls and floor in the facility kitchen located under and next to the utensil sink and under and next to the automatic dish washing machine. b. Replace the missing grouting material (a composite material generally consisting of water, cement, and sand) between floor tiles located in the utensil wash area c. Provide approved minimum 6-inch-high metal base coving (a concave-shaped molding) with a 3/8 radius slope (direction of a line) to the floor throughout the kitchen where the base coving is missing. d. Replace the missing and damaged floor tiles to the floor located in front of and next to the cooking equipment. e. Seal all gaps in walls through which drainage pipes enter, observed gaps in the wall under the food preparations sinks. f. Provide a smooth and cleanable surface and at final work to use metal rings as a final sealer to the drainpipe (a pipe that carries liquid waste and water away from buildings) gas in the walls. 18. The maintenance supervisor will inspect all of non-resident rooms for any rodent droppings and any gaps by the doors and repair any findings beginning 4/30/2021. 19. The maintenance supervisor will conduct an environment inspection beginning 4/30/2021 of the facility premises to identify potential areas for harboring of rodents. 20. One-on-one training/in-service was provided by the facility's nurse consultant regarding kitchen sanitation on 4/28/2021. 21. Dietary staff training was conducted beginning 4/28/2021 on ensuring that staff knows how to identify and recognize rodent droppings and will continue until all staff had been retrained. Findings: A review of the County of Los Angeles, Department of Public Health, Rodent-Borne Diseases: Risk Reduction Recommendations (retrieved on April 29, 2021, from http://www.publichealth.lacounty.gov/eh/docs/Specialized/Vector_Management/roden_Borne.pdf) indicated rodents can pose a risk to human health. Rodents had shown to carry viruses and/or bacteria that can cause disease in humans that can be transmitted through various routes. Some are contracted by the bite of an infected rodent flea. Others can be transmitted by direct contact or inhalation of aerosols (a suspension system of solid or liquid particles in a gas which is usually air) from infected rodents, their urine, feces, or nesting material (a structure or shelter in which other animals such as insects or rodents, deposit their eggs or tend their young). A review of the Centers for Disease Control and Prevention, Guidelines for Environmental Infection Control in Health Care Facilities, updated July 1, 2019 (retrieved on April 29, 2021, from (https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html) indicated the guidelines were recommendations for the prevention and control of infectious diseases that are associated with healthcare environments. The guidelines indicated Pest Control included rodents from inside the health care facilities that can serve as agents for the mechanical transmission (the passive transfer of causative agents of a disease) of microorganisms (small living thing/cell), or as active participants in the disease transmission process by serving as a vector (a live carrier that transfers infectious pathogens/germs) to animals or humans. A review of the facility's census report, dated 4/29/2021, indicated there were 200 residents residing in the facility. A review of the facility's last pest control service report, dated 2/14/2021, 3/10/2021, and 4/15/2021 indicated a pest control technician applied treatment (a pesticide/chemical to kill or control pests) in the kitchen's interior and no signs or presence of rodents. The pest control service reports for 3/10/2021 and 4/15/2021 under structural concerns both indicated findings of multiple gaps and holes noted underneath both dishwashing areas. The service reports dated 3/10/2021 and 4/15/2021 indicated recommended actions from the facility to seal the gaps and holes to reduce the number of pests entering the area. The pest control service reports for 3/10/2021 and 4/15/2021 under sanitation issues both indicated there were noted food debris in the floor drains located throughout the kitchen. The service reports dated 3/10/2021 and 4/15/2021indicated recommended actions from the facility to clean in and around drains frequently to help prevent breeding sites (sites where pests lay eggs or reproduce). The service reports dated 3/10/2021 and 4/15/2021 indicated there were no rodent activity noted during the inspection and/or service. There was no documented evidence service work had been completed according to the recommended actions from 3/10/21 to 4/28/21. On 4/28/2021, at 11:45 am, the REHS from DPH arrived at the facility and started a routine inspection of the facility's kitchen. During this inspection, the REHS located one dead rat located beneath the motor of the conveyor/steamtable, which was in the middle of the facility's kitchen. There were also 50 to 60 rat droppings (feces) found under the steamtable. On 4/28/2021 at 2:30 pm, the REHS from DPH completed the kitchen inspection and informed the administrator there was one dead rat found under the steamtable. During a concurrent observation with the REHS, the dead rat found under the steamtable measured 5 inches long. The REHS told the administrator the facility's kitchen needed to be closed and food was not to be prepared from the facility's kitchen due to pest control issues. A review of the REHS's Official Inspection Report dated 4/28/2021, indicated that one dead rat was beneath the conveyor/steamtable with 50 to 60 rats' droppings. The report indicated there were 12 to 20 rat droppings beneath the north-side section of the conveyor/food preparation/steamtable, and two rat droppings on the floor behind the cooking equipment. On 4/28/2021, at 4:20 pm, during an interview, the administrator stated that the facility had monthly pest control services and the pest control services did not observe the presence of rodents in the facility. On 4/28/2021, at 4:40 pm, the REHS posted a county food closure sign on the facility's kitchen door and informed the administrator that this sign should not be removed until the REHS reopened the kitchen. A review of an email communication sent by the administrator to the Department of Public Health dated 5/7/2021 timed at 4:08 pm, indicated the administrator could not provide a policy for the facility's pest control program.

Based on observation, interview, and record review, the facility failed to ensure and maintain sanitary conditions in the food services department when: 1. Three of three ice machines were not cleaned and sanitized as required, and were found to have orange, brown, grayish, and black substances inside the ice machines, 2. Flies were flying inside the kitchen, and 3. A dietary staff was walking without a hairnet inside the kitchen. These failures created the overall unsanitary condition of the food services department and the failure to maintain the ice machine resulted in an immediate jeopardy situation that could cause food borne illnesses to all residents in the facility. Due to the unsanitary conditions in the food services department related to ice machine not being sanitized properly, on 9/25/18 at 7:15 PM, the survey team identified a situation of Immediate Jeopardy (IJ) and verbally notified the Administrator and Director of Nursing. The Administrator was informed of the observations, record reviews, and interviews with the facility staff. The IJ was removed in the presence of the Administrator and Director of Nursing, on 9/27/18 at 12:51 PM, after an acceptable corrective action plan provided by the Administrator, and observation of immediate action that took place, staff interviews, and record reviews: Ice machine deep cleaning and staff training. Findings: 1. a. During an observation with the Dietary Director (DD), on (MONTH) 25, (YEAR), at 3:38 PM, the kitchen ice machine was noted to have a significant build up of brownish and grayish residue on the inside part of ice machine. A clean white paper towel was used to swipe off the side area of the inside compartment and ice machine's chute and it produced a significant accumulation of the brownish and grayish substances. During an interview with the DD, on (MONTH) 25, (YEAR), at 3:40 PM, the DD described the brownish and grayish substance/particles inside the kitchen ice machine and stated, Those are dust and rust. The DD further stated the Dietary Aides were not the one who cleans the ice machines. The DD stated, The outside staff, like housekeeping. A review of facility census dated (MONTH) 25, (YEAR), indicated 353 residents. 309 residents had the potential to be affected, and residents with gastrostomy tubes (GT- tube inserted directly into the abdomen to deliver nutrition) were excluded. b. During an observation with the Infection Control Nurse (ICN), on (MONTH) 25, (YEAR), at 5:00 PM, the two (2) ice machines (one that is near unit 200 and one near unit 900) were noted to have a significant build up of orange, brownish and black substance/particles on the inside part of ice machines. A clean white paper towel was used to swipe off the side area of the inside compartment of the ice machine and a significant accumulation of the orange, brownish and black substance in the side area and ice machine's chute. During an interview with the ICN on (MONTH) 25, (YEAR), at 5:10 PM, the ICN described the observations as orange, brownish, and grayish particles. The ICN stated, It (orange, brownish, and grayish particles) may cause infection or other disease conditions. The ICN further stated the two ice machines in different units (Unit 200 and Unit 900) were maintained by the housekeeping department, and dietary ice machine was maintained by dietary staff. The ICN stated the dietary ice machine was not included on his oversight. During an interview with the Housekeeping Manager (HM), on (MONTH) 25, (YEAR), at 5:17 PM, the HM stated, We (Housekeeping) only clean the outside part of the ice machines. We do not clean the inside part of it. The HM further stated, The Maintenance Department cleans it every month. During an interview with the Maintenance Manager (MM), on (MONTH) 25, (YEAR), at 5:23 PM, the MM stated I clean the screen and the coil at the back of ice machines. The MM further stated The housekeeping cleans the inside part of the ice machine. During an interview with the facility Operational Manager (OM), (MONTH) 25, (YEAR), at 5:30 PM, the OM stated the facility ice machine should have been maintained clean all the time. During an interview with Certified Nursing Assistant (CNA 6), on (MONTH) 25, (YEAR), at 5:54 PM, CNA 6 stated, We (CNAs) get the ice from ice machines near Unit 200 and near Unit 900. During an interview with Licensed Vocational Nurse (LVN 10), on (MONTH) 25, (YEAR), at 5:58 PM, the LVN 10 stated, The ice machines should be clean and not contaminated with dust, because our residents has allergic reactions and will get sick from it. During an interview with HM, on (MONTH) 25, (YEAR), at 6 PM, the HM was not able to provide the manufacturer's instructions for the use of the ice machine. The HM discussed the process of cleaning the facility ice machines by: First, unplugging it (ice machine), remove all ice, clean and sanitize using bleach with the ratio of 1 is to 10 (1:10), one (1) part of bleach and nine (9) part of water. Then rinse with water, and plug it in. And it is ready to use. The HM was not able to provide the manufacturer's instructions for use of the ice machine. During an interview with OM, on (MONTH) 25, (YEAR), at 6:30 PM, the OM stated, We (facility staff) cannot find the ice machine manual instructions of how to clean it. A review of facility census dated (MONTH) 25, (YEAR), indicated 353 residents. 309 residents had the potential to be affected and residents with GT were excluded. A review of facility policy and procedures titled Cleaning Instructions: Cleaning Ice Machine and Scoop dated 2005, indicated, Policy: The Ice machine and equipment will be cleaned on a regular basis to maintain a clean, sanitary condition . Procedure: 1. Unplug machine and remove ice. 2. Wash interior thoroughly using detergent solution. Rinse and drain with clean hot tap water. 3. Sanitize. 4. Air dry. 5. Turn the machine on. 6. Clean exterior of machine with detergent solution. Rinse and allow to dry. Clean area underneath and around the machine. 7. Ice scoop will be . A review of instruction manual titled (name of the company) Ice Systems, dated (MONTH) (YEAR) on page 38, indicated, Cleaning A, B or C Series: All models have an indicator light that switches on to inform the user that the cleaning interval has been reached It does not stop the machine from making ice. All models have a Clean mode. In the A, B, or C series machines, it is a two step, user timed system , the first push of the Clean button drains the reservoir and refills it. The cleaning process is designed to use straight nickel safe ice machine scale remover, added between draining and refilling. After the scale remover has been added, the person cleaning the machine is in control of how long to circulate the scale remover. It is important that the Sump Empty light switch on during this part of cleaning, if it does not the inlet water valve will not add water and the scale remover cannot circulate. If this occurs, push off un snap the Water Level Sensor and lift slightly, then push clean again. A second push of the Clean button starts the flush out process. This drains and refills the reservoir until the person cleaning the machine pushes Off button. This process should last at least 20 minutes to fully flush out the scale remover and loose the scale. It is the second push of the Clean button that clears the cleaning reminders. After the scale remover has been drained out, the water distributor must be inspected for loose scale and cleaned of any. Removal of the sump cover, pump bracket and curtain is next to be sure those parts have been cleaned. Cycle power to the controller as a final step before restarting ice making. 2. During an observation of the facility Dietary Department, on (MONTH) 25, (YEAR), at 3:25 PM, there were two blue light fly catcher (a device that attracts and kills flying insects that are attracted by light) that were plugged in. The Dietary Department had two kitchen doors: one towards the kitchen staff office and one towards the kitchen sinks. The kitchen doors did not close completely. The kitchen was found to have three live flies flying near the sink area where newly washed dishes were stored, and three live flies crawling on three bread rolling pins. During an interview with the DD, on (MONTH) 25, (YEAR), at 3:30 PM, the DD stated, Yes, the doors do not close completely, and flies are coming in. There should be no flies here (kitchen). It (flies) may go to the food we are preparing. The DD further stated, We are always busy here because we are serving more than three hundred residents. A review of facility policy and procedure titled Pest Control, dated 2005, indicated, If pests are seen in the kitchen, the food service director or appropriate staff shall be informed, describing where the pest and when. Appropriate action will be taken to eliminate any reported pest situation in the department. 3. During an observation of the facility Dietary Department, on (MONTH) 25, (YEAR), at 3:38 PM, A dietary aide was walking inside the kitchen near the food preparation tables and was refilling beverage in his personal tumbler from the kitchen beverage dispenser without a hairnet. During an interview with the Dietary Aide (DA 1), on (MONTH) 25, (YEAR), at 3:41 PM, the DA 1 stated, I am going home now, that is why I do not have hairnet. During an interview with the Dietary Director (DD), on (MONTH) 25, (YEAR), at 3:43 PM, the DD stated, Anyone who is inside the kitchen should wear a hairnet. A review of facility policy and procedure titled, Policy: All kitchen employees will practice standard sanitary procedures .Procedure: All employees shall: 1. Wear hair restraints and clean clothes .

Based on observation, interview, and record review, the facility failed to: 1. Show the water temperature used for the washing machine are within the required temperature of 160 F (Fahrenheit: a scale for measure of heat and cold) to sanitize the residents' personal clothing, bedspreads, and blankets for 355 out of 355 residents in the facility. This failure had the potential to spread disease and infection to other residents in the facility due to improper washing of residents' personal clothing, bedspreads, and blankets, 2. Ensure that oxygen tubing, nasal cannula (tubing used to help deliver oxygen), oxygen mask, and humidifier (device used to increase moisture) were dated for three residents (Resident 275, 301, and 556). This failure had the potential to result in cross-contamination and the spread of infection. 3. Ensure that a flush bag (container with water used for Gastrostomy tube (G tube; tube inserted through the abdomen which delivers nutrition directly to the stomach)) were dated and labeled for use for one resident (Resident 112). This failure had the potential to result in cross-contamination and the spread of infection. 4. Ensure a Certified Nurse Assistant (CNA 8) provided a resident (Resident 69) with an unused spoon for eating after placing the spoon in a bin with used dishes and utensils. This failure had the potential to place Resident 69 at an increased risk to develop an infection. An Immediate Jeopardy was called in the presence of the Administrator and Director of Nursing (DON) on 10/1/18 at 5:24 PM in the Administrator's Office and they were verbally notified of the findings. The Corrective Action Plan was received, reviewed and accepted on 10/2/18 at 3:11 PM. The specific actions taken by the facility to correct the deficient practice were: 1. Washing of linens was stopped after being informed that washing machine was out of compliance with water temperature. 2. The chemical company was contacted to check the facility's washing machine and washing product levels. 3. A laundry service was contacted to acquire an interim laundry service agreement. 4. Temperature checks will be completed for all washing machines prior to using them every day by the laundry staff. If the temperature is below the required temperature of 160 degrees F, the staff will stop washing until the temperature returns to the required temperature. 5. Housekeeping supervisor will monitor compliance with daily temperature checks with every cycle of the bedspread and personal clothing and will monitor the temperatures. The temperatures will be taken from the gauge above the machine. 6. The housekeeping supervisor will monitor washing products and ensure they are used for every day. 7. The water heating engineering company that checks the boiler will provide monthly inspection checks to ensure functionality. 8. In service training were initiated on 10/2/18 for all available laundry and housekeeping staff on maintaining temperature and proper use of washing products by the chemical company representative, DON, IP Nurse and Housekeeping supervisor. In services will be on going as laundry staff returns to work prior to being assigned to washing laundry by 10/5/18. Findings: 1. During an environmental tour observation with the Maintenance Supervisor (MS) and Director of Environmental (DES) on (MONTH) 1, (YEAR) at 1:45 PM, the water temperature in the main hot water line of the facility laundry read 152 degrees F (Fahrenheit: a scale for measuring heat and cold). During an interview with Maintenance Supervisor (MS) and Director of Environmental (DES) on (MONTH) 1, (YEAR) at 1:45 PM, both the MS and the DES agreed that the temperature of 152 degrees F was too low. The DES stated she was not sure what the temperature should be. During an interview with the Infection Control Nurse (ICN) on (MONTH) 1, (YEAR) at 3:20 PM, the Infection Control Nurse (ICN) stated that Resident 309 was one resident on contact isolation for ESBL (extended spectrum beta lactamase a contagious bacterium that caused a drug resistant Infection- keep resident in isolation to prevent the spread of bacteria, parasites, [MEDICAL CONDITION] from one person to another. A type of isolation to prevent the spread of germs when touching an infected person and their dirty items, such as clothing, and surfaces). A review of the clinical record for Resident 309 indicated Resident 309 was readmitted to the facility on (MONTH) 1, (YEAR) for Extended Spectrum Beta Lactamase (ESBL type of chemical produced by a bacteria). A review of a Physician's Telephone order for Resident 309 on 10/1/2018, indicated for contact isolation precaution (ESBL urine) During an interview with the Facility Maintenance Supervisor (FMS) on (MONTH) 1, (YEAR) at 3:20 PM, he stated that the laundry items contaminated with contagious bacteria were placed in the same white cloth bag as the other clothes and then they would be washed in a washing machine without sanitizer. He further stated that there was no labeling or special bagging for contaminated patient's clothes, bedspreads, and blankets done. The FMS stated that after these items were finished being washed, the washer was used to wash the patient clothing, bedspreads, and blankets for other non infected residents without any sanitization. During a phone interview with the Ecolab Representative (ER) on (MONTH) 1, (YEAR) at 2:30 PM, the ER stated that no bleach or other low temperature sanitizing product was used in the facility for the residents' personal clothing, bedspreads, and blankets. ER stated that temperature of 144 degree F from the main hot water line of the facility laundry was not high enough to sanitize the patients' clothing, bedspreads, and blankets. The ER stated that the laundry temperature should be at least 160 degrees F and above in the main hot water line to sanitize the laundry if they do not use bleach or a sanitizing product. In an interview with the Facility Maintenance Supervisor, on (MONTH) 1 at 4:00 PM, the FMS stated that it was his job to monitor the water temperature. The FMS further stated that the facility could not use bleach for the patient's belongings, bedspreads, and blankets because they would ruin them. During a telephone interview with the Ecolab Manager (EM) on (MONTH) 2, (YEAR) at 2:30 PM, the EM stated that none of the products except the bleach product sanitizes the laundry. The EM stated that if the bleach was used on the colored laundry it would ruin it and for that reason it should not be used on these items. The EM stated that high temperature laundry water would sanitize laundry. In an interview with the Quality Assurance (QA) Nurse Consultant on (MONTH) 2, (YEAR) at 3:30 PM, she stated that the water temperature should have been 160 degrees F for at least 15 minutes. During an attempt to review the washer and dryer records on (MONTH) 2, (YEAR) at 9:30 AM, the ADM was asked for a manufacturer's handbook for the washers and dryers, but the ADM was not able to produce them by the end of the survey, (MONTH) 2, (YEAR). 2a. During an initial tour observation of the facility on (MONTH) 25, (YEAR), at 9 AM, Resident 556 was on oxygen via nasal cannula tubing (a device used to deliver supplemental oxygen via nose). The nasal cannula was undated. During an interview with the Licensed Vocational Nurse (LVN 13) (MONTH) 25, (YEAR), at 9:40 AM, LVN 13 confirmed the nasal cannula tubing was undated. LVN 13 stated, Yes, there is no date on this tubing. LVN 13 further stated, We need to put a date because every week we need to change it. Now, we do not know if it is clean or not. A review of the clinical record for Resident 556 indicated [DIAGNOSES REDACTED]. Resident 556's physician orders, dated (MONTH) 25, (YEAR), indicated oxygen at 2 L (liters unit of measure)/min (minutes) via nasal cannula continuously for shortness of breath, difficulty of breathing, and cyanosis (bluish discoloration of the skin). A review of facility policy and procedure titled, Departmental (Respiratory Therapy) Prevention of Infection, dated and revised on (MONTH) 2012, indicated Steps in the procedure: Infection Control Considerations Related to Oxygen Administration . 7. Change the oxygen cannula and tubing every seven (7) days, or as needed. A review of facility document titled. Job descriptions Administration: Charge Nurse dated 2003, indicated Duties and Responsibilities: Implement and maintain established nursing objectives and standards .Inspect the nursing services treatment areas daily to ensure that they are maintained in a clean and safe manner .Safety and Sanitation: Monitor your assigned personnel to ensure that they are following established regulations in the use of equipment and supplies. 2b. During an initial tour observation on (MONTH) 25, (YEAR), at 9:03 in room [ROOM NUMBER], there were undated oxygen mask, nasal cannula, and humidifier for Resident 301 by the bedside. During and observation and a concurrent interview with Licensed Vocational Nurse (LVN 1) on (MONTH) 25, (YEAR), at 9:12 AM, LVN 1 verified the findings and stated, There are no dates for the mask, nasal cannula and humidifier. They are supposed to have one. A review of the clinical records for Resident 301 indicated the Resident 301 was readmitted to the facility on (MONTH) 11, (YEAR) for heart failure and pneumonia (lung disease). Resident 301 was admitted to (Name of Hospice Agency) Hospice for End Stage [MEDICAL CONDITION] under General Inpatient Level of care for shortness of breath management. 2c. During an initial tour observation and a concurrent interview with Certified Nurse Assistant (CNA 7) on (MONTH) 25, (YEAR), at 10:15 AM in room [ROOM NUMBER], there was an oxygen mask dated (MONTH) 11, (YEAR) for Resident 275. CNA 7 verified the finding and stated the oxygen mask should be changed every week. A review of the clinical records for Resident 275 indicated Resident 275 was readmitted to the facility on (MONTH) 9, (YEAR) for cardiac arrhythmia (irregular heartbeat) and [MEDICAL CONDITION] disease affecting left non dominant side (medical condition that affects brain circulation). During an interview with the Infection Control Nurse (ICN) on (MONTH) 25, (YEAR), at 6:15 PM, the ICN stated, For every oxygen tubing, oxygen mask, concentrator tubes, and humidifier, they need to be dated and labeled, and changed weekly to make sure the facility is using clean equipment. A review of the facility's policy and procedure titled, Departmental (Respiratory Therapy) Prevention of Infection, with revised date of (MONTH) 2012, indicated, Steps in the Procedure: Infection Control Considerations Related to Oxygen Administration .7. Change the oxygen cannula and tubing every seven (7) days, or as needed. 3. During initial tour observation on (MONTH) 25, (YEAR) at 9:09 AM, an undated and unlabeled flush bag was found hanging and being used for Resident 112 ' s G tube feeding. During an observation and concurrent interview with Licensed Vocational Nurse (LVN 4) on (MONTH) 25, (YEAR) at 9:11 AM, LVN 4 verified the finding and stated, The flush bag should have been dated and labeled. During an interview with the Infection Control Nurse (ICN) on (MONTH) 25, (YEAR) at 6:17 PM, the ICN stated, flush bags Should be dated and labeled whenever the bag is changed. G tube feeding and water bag needs to be dated and labeled individually. 4. During an observation on (MONTH) 25, (YEAR), at 1:08 PM, Resident 69 was sitting in the dining room after eating lunch. Certified Nursing Assistant 8 cleaned the table and placed the residents' used dishes and utensils on a tray. CNA 8 saw a food container, which was still closed and untouched. CNA 8 opened the food container and picked up the residents' used teaspoon. CNA 8 patted the teaspoon on top of the table to remove left over food particles. After removing the leftover food particles, CNA 8 placed the teaspoon on the tray with the rest of the residents' used dishes and utensils. CNA 8 then picked up the same teaspoon from the tray of used dishes and placed it inside Resident 69's untouched food. CNA 8 served the food to the resident, and Resident 69 began to eat using the spoon from the tray with used dishes and utensils. During an interview with CNA 8 on (MONTH) 25, (YEAR), at 1:10 PM, CNA 8 confirmed the teaspoon given to the resident for use came from the tray of used dishes and utensil. CNA 8 stated, I have no other spoon to give her. During an interview with LVN 4, on (MONTH) 25, (YEAR), at 1:11 PM, stated, CNA 8 should not have used the dirty teaspoon. LVN 4 further stated, (CNA 8) should have gotten a new and clean spoon to use.

Based on observation, interview, and record review the facility failed to ensure pain management was provided for one of 45 sampled residents (Resident 126). The failed practice resulted in a delay in treatment and unresolved severe pain for approximately 19 hours for Resident 126. Due to the delay in treatment and unresolved severe pain for approximately 19 hours for Resident 126, on 9/26/18, at 7:34 PM, the survey team identified a situation of Immediate Jeopardy (IJ) and verbally notified the Administrator and Director of Nursing (DON). The Administrator was informed of the observations, interviews, and record reviews. The IJ was removed in the presence of the Administrator and DON, on 9/27/18, at 5:23 PM, after an acceptable corrective action plan was provided by the Administrator, and observation of immediate action that took place, staff and resident interviews and record reviews: provision of pain management, staff training, and record reviews. Findings: During an initial tour observation of the facility, on (MONTH) 25, (YEAR), at 10:26 AM, Resident 126 was in his room, and was lying in bed. Resident 126 had a wheelchair and long stick for walking. Resident 126 was awake, had partially open eyes, and was in flat position and not moving while in bed. During an interview with Resident 126, on (MONTH) 25, (YEAR), at 10:28 AM, Resident 126 stated he was blind, a smoker, and currently experiencing pain. Resident 126 further stated, They (facility) have a problem in getting my [MEDICATION NAME] (Schedule II narcotic pain medication have a high potential for abuse which may lead to severe psychological or physical dependence). Resident 126 further stated that last night at 9 PM, he was in pain, and he knew from the facility staff that his pain medication [MEDICATION NAME] has not arrived yet. Resident 126 stated his pain affected his activities. Resident 126 stated, Yes, I always go and stay in the patio but I am in pain, so I just stay here in bed. I do not want to move. Resident 126 stated his pain level last night was between 8 and 9 (10 as the maximum). A review of the Resident 126's clinical records indicated an admitted (MONTH) 24, (YEAR), with [DIAGNOSES REDACTED]. Resident 126 had unsigned physician order, dated (MONTH) 6, (YEAR), of [MEDICATION NAME] 7.5 mg (milligram unit of measure) by mouth every six (6) hours as needed for pain. Resident 126 had the capacity to understand and make decisions. A review of the Resident 126's Medication Record Administration, indicated that [MEDICATION NAME] 7.5 325 mg ([MEDICATION NAME] (an opioid pain reliever)-[MEDICATION NAME]- (a non-opioid pain reliever)) was last given on (MONTH) 24, (YEAR), at 2:20 PM. A review of Resident 126's medical records titled Narcotic and Hypnotic Record, indicated [MEDICATION NAME] 7.5 325 mg ([MEDICATION NAME]), take one tablet by mouth every 6 hours as needed for severe pain. The last date and time the medication [MEDICATION NAME] was administered was on (MONTH) 24, (YEAR), at 2:20 PM. During an interview with the Licensed Vocational Nurse (LVN 17), on (MONTH) 25, (YEAR), at 10:30 AM, the LVN 17 stated that Resident 126 had generalized body pain related to [MEDICAL CONDITION] (a disease, or dysfunction of one or more nerves especially of the peripheral nervous system that is typically marked by burning or shooting pain, numbness, tingling, or muscle weakness). The LVN 17 further stated We (facility staff) ordered for refill last (MONTH) 23. I offered Tylenol (non narcotic pain medication) but he (Resident 126) refused taking it. During an interview with Certified Nursing Assistant (CNA 10), on (MONTH) 25, (YEAR), at 1:30 PM, the CNA 10 stated, I helped him (Resident 126) today going to the patio but it was less than 10 minutes because he said he was not feeling well. Then I brought him back to his room. During a concurrent observation and an interview with the Resident 126, on (MONTH) 25, (YEAR), at 1:45 PM, Resident 126's bedside table had a cup of juice that he had not drank. Resident 126 stated, I don't have appetite to eat. The medication (referring to pain medication) is not here yet. During a record review of Resident 126's medical records and concurrent interview with LVN 10, on (MONTH) 25, (YEAR), at 2:43 PM, there was no care plan related to use of [MEDICATION NAME] for pain management. The LVN 10 confirmed that there was no care plan related to use of [MEDICATION NAME] for pain management. During an interview with LVN 17, on (MONTH) 26, (YEAR), at 12:30 PM, the LVN 17 stated, We (facility staff) are supposed to fax with the sticker (referring to the medication with barcodes) and signed prescription from the doctor to the pharmacy, but we faxed the sticker only. The pharmacy requested the prescription, but I faxed the unsigned prescription of the doctor. Then the pharmacy called the doctor. The LVN 17 also stated that he did not know if the facility had [MEDICATION NAME] medication in the narcotic emergency kit (e-kit). During an interview with LVN 10, on (MONTH) 26, (YEAR), at 2:10 PM, the LVN 10 stated, If the medication has four to five tablets remaining, we order for a refill. And the refill needs a signed prescription from the doctor. During an interview with LVN 12 on (MONTH) 26, (YEAR), at 3:27 PM, LVN 12 stated, We do not have [MEDICATION NAME] in our unit. We need to order it from the pharmacy. During an interview with LVN 15, on (MONTH) 26, (YEAR), at 3:38 PM, the LVN 15 stated, The resident should have pain medication and cannot wait for two hours for pain medication. The LVN 15 further stated, We do not have [MEDICATION NAME] here in the facility, that is why we need to order the refill before it runs out. During an interview with the Director of Nursing (DON), on (MONTH) 26, (YEAR), at 3:45 PM, the DON stated, The [MEDICATION NAME] medication is in Nursing office. We have a locked cabinet for that medication. The nursing supervisors has an access to it (locked cabinet). During a concurrent interview and observation with the Registered Nurse (RN 5), on (MONTH) 26, (YEAR), at 3:53 PM, RN 5 stated [MEDICATION NAME] medication can be found in each e kit of each unit. The RN 5 took one e-kit and brought to the nursing office with the DON, and stated, Where is that (referring to [MEDICATION NAME]). How come it is not here? The DON did not say anything. A review of narcotic e kits and labels, on (MONTH) 26, (YEAR), at 3:57 PM, indicated there were no [MEDICATION NAME] listed on narcotic e-kits and labels. During an interview with the pharmacy personnel (PHARM 1) via telephone, on (MONTH) 27, (YEAR), at 10:25 AM, the PHARM 1 stated, In order to refill narcotic medication, they need to have a signed prescription, and we (pharmacy) will follow up to the doctor. With four to five hours, we must deliver the narcotics. A review of fax document titled Transmission Verification Report dated (MONTH) 23, (YEAR), at 10:37 PM, indicated a sticker with Resident 126's name and name of medication. A review of fax document titled Transmission Verification Report dated (MONTH) 24, (YEAR), at 1:14 PM, indicated an order of [MEDICATION NAME], dated (MONTH) 6, (YEAR), for Resident 126 with no physician signature. A review of Resident 126's BIMS (Brief Interview for Mental Status assessment for mental status) score of 15, 15 as the highest score which indicated Resident 126 was cognitively intact. A review of facility policy and procedures titled Ordering & Receipt of PRN (if necessary) Controlled Medications, undated, indicated 1. Schedule II refill requests must be called or faxed to the Pharmacy when a FIVE DAY supply remains in the facility. 2. Requests for refills of PRN orders for Schedule III and IV medications will be made in the same manner as non Schedule medications. Refills should be requested when a FIVE DAY supply remains. A review of facility policy and procedure titled Pain Assessment and Management, revised and dated (MONTH) 2010, indicated General guidelines: .2. 'Pain management' is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. A review of facility policy and procedure titled, Transmitting Medication Orders, indicated, Procedure: Refill Orders: .2. Federal schedule II controlled substances: a. Inform the pharmacy when a five day supply remains in the medication storage. There is no authorized automatic refill available for schedule II controlled substances.

Based on observation, interview and record review the facility failed to protect the resident from verbal abuse for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1's having anxiety, anger and frustration from verbal abuse. Findings: A review of Resident 1's Admission Face Sheet indicated he was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set Assessment ((MDS) a standardized assessment and care planing tool) dated 5/16/17, indicated Resident 1 was able to make himself understood and he was able to understand others. Resident 1 scored 15 out of 15 for the brief interview of his mental status ((BIMS) a total score of 15 indicates intact cognitive). Resident 1 required extensive assistance (staff provide weight bearing support) with two persons physical assist for his bed mobility, transfer and toilet use. Resident 1 was occasionally incontinent of urine (less than seven episodes of incontinence). A review of the Licensed Progress Note dated 8/2/17, indicated the Restorative Nursing Assistant 1 (RNA 1) notified the unit Supervisor of Resident 1's complaint about Certified Nursing Assistant 1 (CNA1) from 3 p.m. through 11p.m. shift. CNA 1 scolded Resident 1 several times throughout the shift for using his call light. Resident 1 stated he used the call light to be repositioned in bed and to ask for the urinal. CNA 1 told Resident 1 he had just used the urinal and to urinate in his diaper. A review of the Social Work Progress Note dated 8/2/17, indicated Resident 1 notified the Social Service Designee regarding the incident that happened on 8/1/17, involving CNA 1. Resident 1 stated he pushed his call light at 8:45 p.m. CNA 1 answered the call light and asked Resident 1 what he needed. Resident 1 asked for a urinal and was told by CNA 1 to urinate in his diaper. Resident 1 stated he told CNA 1 that he wanted a urinal because he did not want to pee in his diaper. CNA 1 stepped out of the room and did not return until 9:15 p.m. to give the urinal to Resident 1. Resident 1 stated he felt Anxious of CNA 1 when the incident happened. During an interview on 8/17/17 at 7:42 a.m., Resident 1 stated CNA 1 was good at doing her work but she had a bad attitude. Resident 1 stated he would pray everyday that CNA1 would be in a good mood when she arrived to work. Resident 1 pushed his call light because he needed to use the restroom. He was unable to reach his urinal due to right sided weakness. Resident 1's urinal was observed on the floor behind his bed. Resident 1 stated, If I could get up and go to the bathroom I would. CNA 1 responded to his call light and told Resident 1 Why are you ringing the call light? Resident 1 told CNA1 that he needed his urinal to pee. CNA stated, Just go in your diaper. Resident 1 responded, I don't want to go in my diaper. CNA 1 ignored Resident 1's request to use his urinal and left the resident's room. Resident 1 stated he was left feeling Angry and frustrated. He informed RNA 1 on 8/2/17, regarding the incident with CNA 1. On 8/17/17 at 9:49 a.m., the Director of Nursing (DON) was interviewed. The DON stated CNA 1 was terminated on 8/9/17. The facility's investigation concluded that CNA 1 verbally abused Resident 1. The DON stated Resident 1 felt frustrated and angry with CNA 1 following the incident on 8/1/17. A review of the facility's undated Resident Abuse Policy and Procedure indicated facility staff shall uphold resident's right to be free from verbal abuse. The resident shall not be subjected to abuse by anyone including but not limited to facility staff, other residents, consultants, staff of other agencies serving the individual, family members, legal guardians, friends or other individuals.

Based on observation, interview, and record review, the facility failed to provide the necessary care and treatment for [REDACTED]. 1. For RSR ( randomly selected resident) 34, facility failed to assess and monitor resident's skin rashes, and administer [MEDICATION NAME] cream (medication to treat infestation of scabies) and [MEDICATION NAME] 1% ointment (medication used to decrease inflammation and relieve itching) to treat the skin rashes as ordered by the physician who suspected scabies infection. RSR 34 was observed with generalized reddened pink rashes, scratch marks, excoriation (abrading or wearing off of the skin) and scabs (a dry, rough protective crust that forms over a cut or wound during healing caused by intense itching and scratching) and complained of severe itching that was not completely relieved by [MEDICATION NAME] (medication to decrease inflammation and relieve itching). These failures resulted in RSR 34 unnecessary suffering and experiencing discomfort and skin injuries from intense itching and scratching. 2. For Resident 28, facility failed to properly identify resident's rashes, and implement in a timely manner the treatment and services appropriate for Resident 28's skin condition. These deficient practices resulted in Resident 28 suffering and experiencing unnecessary discomfort and failed to prevent the potential spread of infection to other residents and staff. 3. For Resident 29, the facility failed to provide four medications to the resident while out on pass (leave of absence from the facility with a physician's orders [REDACTED]. This deficient practice had the potential to prevent Resident 29 from being adequately medicated. 4. For Resident 6, a care plan titled: [DIAGNOSES REDACTED] (a chronic blistering of the skin), dated 11/14/16 and revised 11/2017, did not indicate clearly any interventions currently in place to address Resident 6's skin condition. 5. For Resident 1, facility failed to administer pneumonia vaccine to the resident as ordered by the physician. Additionally, a facility staff failed to shake the bottle of multivitamins prior to administering to Resident 1. Findings: 1. A review of the admission record (face sheet) indicated RSR 34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RSR 34's record titled Minimum Data Set (MDS, a resident assessment and care screening tool), dated 9/7/17, indicated that RSR 34 was usually able to express ideas and wants and able to understand verbal content with distinct intelligible words and required extensive assistance (resident involved in activity and staff provide weight bearing support) with one person assistance on mobility and personal hygiene. On 11/7/17 at 9 a.m. in an interview with the director of nursing (DON) stated there are residents with rashes in Unit 300 and skin scrapping was done at an outside agency and was positive for scabies. On 11/8/17 at 8:50 a.m. in an interview the director of nursing (DON) and the assistant director of nursing (ADON) and the Infection Control Nurse stated, all resident in Unit 300 (where RSR 34 resides) were assessed for rashes on 11/7/17, and a total of 8 residents were identified with rashes, which most had a preexisting rashes, and had been seen by the dermatologist (a medical doctor specialized to treat skin disorders). The DON stated the residents with rashes will be tested via skin scraping to rule out scabies. On 11/9/17 at 11:20 a.m. during a facility tour of Unit 300, RSR 34 was observed seated with four other residents in the dining room. RSR 34 was asked if his skin could be checked, RSR 34 agreed and stated, Yes, please help me I am so itchy all over the body at all times of the day. RSR 34 was assisted by LVN 12 to his room and to bed and was provided privacy. During an observation in the presence of LVN 12, RSR 34's skin was observed with red pinpoint rashes, scratch marks, excoriated rashes, and scattered scabs on arms and legs, abdomen, chest, armpits and the back of the neck and back. In a concurrent interview RSR 34 stated, They give me lotion but only helps for a little bit, they should give it to me all day. I am still itching all over and it's getting worst. In a concurrent interview, LVN 12 stated, he was in charge of RSR 34's care during the morning shift for over a month now and was aware that RSR 34 had been complaining of itching on the arms and was being given [MEDICATION NAME] cream, but he did not assess RSR 34 for presence of rashes or for continued complain of itching on the arms. On 11/9/17 at 11:40 a.m. during a concurrent record review of RSR 34's clinical record with the licensed nursing supervisor for Unit 300 (LVN 10) indicated the following: A physician's orders [REDACTED]. The Medication Administration Record [REDACTED] 1. (MONTH) 25, (YEAR) at 10 a.m. 2. (MONTH) 27, (YEAR) at 12 p.m. 3. (MONTH) 28, (YEAR) at 1 p.m. 4. (MONTH) 31, (YEAR) at 2 p.m. 5. (MONTH) 3, 2107 at 10 a.m. 6. (MONTH) 6, (YEAR) at 7 a.m. There was no documented evidence a plan of care was developed to assist RSR 34 to relieve discomfort from itching or to treat the rashes, excoriations and scratches. In a concurrent interview on 11/9/17 at 11:45 a.m. LVN 10 stated he observed RSR 34 with rashes and administered [MEDICATION NAME] for the itching but did not assess or document the extent of the rashes because the treatment nurse was responsible for assessing and documenting RSR 34's skin rashes or breakdown. LVN 10 also stated, he was in charge of developing a plan of care to the residents but did not develop a plan of care for RSR 34's complaints of rashes and itching to determine the care RSR 34 needed. On 11/9/17 at 3:10 p.m. a review of the C[NAME]/Interact Assessment Form (a form used to document the resident's change of condition) dated 11/7/17 timed at 7:30 p.m. indicated RSR 34 had a change of condition (C[NAME]) with rashes and possible scabies. In a concurrent interview, LVN 9 stated, he was aware that RSR 34 had generalized body rash and complaint of itching that had worsened on 11/7/17. He informed the primary physician (MD 1) who assessed RSR 34 on 11/7/17 and ordered to administer the following: 1. Skin scrapping for scabies on 11/8/17 2. Apply [MEDICATION NAME] Cream for 12 hours and repeat after seven days 3. Apply [MEDICATION NAME] 1% ointment between [MEDICATION NAME] treatments However, these physician's orders [REDACTED]. On 11/9/17 at 3:15 p.m. in a concurrent interview and record review, LVN 9 stated, he did not thoroughly assess and document RSR 34's skin condition with rashes and scratch marks because he relied on the assessment of the treatment nurse (LVN 8). LVN 9 also stated, he did not administer the [MEDICATION NAME] treatment and [MEDICATION NAME] 1% ointment as ordered by MD 1. LVN 9 explained I received the physician's orders [REDACTED]. On 11/9/17 at 4 p.m. during a telephone interview, MD 1 stated, on the evening of 11/7/17 he observed RSR 34 with rashes all over the body and was complaining of itching. MD 1 stated, he ordered for skin scrapping, [MEDICATION NAME] cream and [MEDICATION NAME] ointment because of suspected scabies. During an interview on 11/9/17 at 4:10 p.m., CNA 5 stated, RSR 34 often complained of itching and was observed scratching because of the scattered red rashes on the stomach, sides, back, chest, and arms. CNA 5 stated the charge nurses were informed for more than a week. CNA 5 stated, RSR 34 had been itching and scratching and the charge nurse already knew about it. According to CNA 5, she would apply lotion to RSR 34's body which sometimes helps relieve the itching. During an observation on 11/9/17 at 4:15 p.m. RSR 34 was observed lying in bed and stated that he was still itching and scratching all over the body. In a concurrent interview RSR 34 stated, he felt very uncomfortable from itching and scratching too much. On 11/9/17 at 4:30 p.m. a review of the Weekly Body Check dated 10/4/17 to 11/6/17 conducted with the LVN 8 indicated RSR 34 had no rashes or skin breakdown. In a concurrent interview LVN 8 stated, RSR 34 complained of itching on the arm in which she applied [MEDICATION NAME] cream, however, she did not observed RSR 34 with rashes on the arms nor did she assessed RSR 34 for the presence of rashes when a resident in the same unit tested positive for scabies on 11/6/17. On 11/9/17 at 5:05 p.m. during a record review of RSR 34's clinical record conducted with the DON, the C[NAME]/Interact Assessment Form, dated 11/7/17, indicated no documented evidence that RSR 34 was administered with [MEDICATION NAME] cream or [MEDICATION NAME] as ordered by MD 1. The DON stated, she could not find the physician order [REDACTED]. On 11/9/17 at 6 p.m., in an interview, LVN 8 stated RSR 34 was assessed on 11/9/17 by LVN 8 in the presence of the Dermatologist and the following was observed and documented on the Skin Admission Body/Skin Assessment Reassessment: 1. Neck-multiple scattered red and dry excoriations and multiple dry scratch marks 2. Chest area-multiple dry light red excoriations and dry scratches 3. Abdomen-multiple light red excoriations and dry scratch marks 4. Left groin-multiple light red excoriations and dry scratch marks 5. Bilateral lateral trochanter (hip area)-multiple dry light red excoriation and scratch marks 6. Right shoulder-multiple dry light red excoriations and scratch marks 7. Bilateral upper extremities-multiple scattered light red excoriations and scratch marks 8. Back-multiple light red dry excoriations and scratch marks 9. Left lower extremities-scattered dry light red excoriations and scratches The dermatologist findings indicated the general body excoriation was related to RSR 34's scratching. According to the undated facility's policy and procedure, titled Skin Rash Tracking, the facility will utilize the rash tracking form to identify rashes and provide dermatological (skin) assessment to ensure that the resident's skin conditions were managed, including the identification of scabies and other reportable condition. The Rashes will be identified on a weekly basis and will be added to the monthly rash tracking form. 2. A review of Resident 28's admission record (face sheet) indicated Resident 28 was originally admitted to the facility on [DATE], and was readmitted on [DATE], with [DIAGNOSES REDACTED]. enough [MEDICAL CONDITION] hormone) and [MEDICAL CONDITION] (a condition in which there are high levels of fat particles in the blood). A review of Resident 28's Minimum Data Set (MDS, an assessment and care screening tool) dated 4/5/17, indicated a Brief Interview for Mental Status (BIMS, a screening tool used to assess cognition (thinking process)) score of 15 (a score of 13-15 points indicates resident is intact cognitively). The skin conditions section on the MDS, indicated that ointments/medications were applied to areas other than the feet. A review of another MDS dated [DATE], for Resident 28, did not indicate that there were any skin rashes being treated. A review of Resident 28's physician's orders [REDACTED]. Another physician's orders [REDACTED]. A review of Resident 28's medical record indicated a non-pressure sore skin problem report, dated 3/28/17, of spots spreading on bilateral anterior arms. During a review of Resident 28's care Plan for rashes, dated 4/18/17, indicated Resident 28 had a whole body skin rash. The care plan goal indicated Resident 28's rashes will resolve without complications, with a target date of 5/16/17, and itching will be resolved. The listed nursing interventions included medication administration as ordered, monitor rash and advise physician of progress and/or complications, educate resident/family regarding rash with interdisciplinary team (IDT), dermatological consultation monthly until resolved, and notify dermatologist of non-response. A review of the non-pressure sore skin problem report, dated 4/18/17, indicated resident had rashes on upper trunk, shoulders, and upper back. A review of a non-pressure sore skin problem report, dated 4/27/17, indicated rashes were found on upper chest, upper back and axillary areas, and [MEDICATION NAME] (a topical medication used to treat scabies, a condition caused by tiny insects called mites that infest and irritate your skin) was applied two times on 4/19/17 and 4/26/17. There was no documentation that a skin scrapping was done to properly identify Resident 28's skin rashes. Additionally, there was no documentation that Resident 28 was placed on isolation prior to treating resident with [MEDICATION NAME], as written in their policy and procedure. A review of the treatment record, dated 4/27/17, indicated [MEDICATION NAME] (a topical antiseptic (fights bacteria) used to clean the skin to prevent infection) wash to be done daily, for seven days, for the rashes. On 4/29/17, the non-pressure sore skin problem report indicated that Resident 28 complained of itching and rashes had spread to Resident 28's inner thighs. On 5/2/17 a review of the physician's orders [REDACTED]. Westcort (medication used to treat a variety of skin conditions, for example, [MEDICAL CONDITIONS], allergies [REDACTED]. Another physician's orders [REDACTED]. This was after the resident was previously treated with [MEDICATION NAME] on 5/2/17. On 5/4/17 a laboratory report indicated no sarcoptes scabies (the parasitic itch mite that burrows into skin and causes scabies) was seen. A physician's orders [REDACTED]. A physician's orders [REDACTED]. [MEDICATION NAME] (medication used to treat anxiety, nausea, vomiting, allergies [REDACTED]. A review of the physician's orders [REDACTED]. The 6/7/17 physician's orders [REDACTED]. A review of the physician's orders [REDACTED]. A review of the physician's orders [REDACTED]. During a record review a Dermatology Consultation Note indicated Resident 28 was diagnosed by the dermatologist with [MEDICAL CONDITION] on 10/26/17. During a record review, a Fungal/Parasitology Report received and dated 11/6/17, from the resident's private physician, indicated Resident 28 was positive for sarcoptes scabies, eggs and scybala (hardened masses of feces). A review of the physician's orders [REDACTED]. During an initial tour observation of the facility on 11/6/17, there was no isolation sign posted that indicated isolation precautions were in place for any resident in Unit 300. During an observation on 11/7/17, at 2:35 p.m., with LVN 8, Resident 28 was observed lying in bed and when being turned by LVN 8 in preparation for treatment. A red rash with some areas of scabbing was observed on the side of Resident 28's left lower abdomen, on her left and right breast, her left and right upper and lower arms, and on the left and right side of her back. During an interview with the infection control nurse and the director of nursing (DON) on 11/8/17 at 9:10 a.m., he stated Resident 28 had a rash present for approximately three months and Unit 300 has a history of rashes. He stated that the facility's medical director treated Resident 28 with [MEDICATION NAME] and it was an automatic protocol to place resident on isolation precautions. He stated that all three residents in room [ROOM NUMBER] were treated with [MEDICATION NAME] and Resident 28 was showered, her clothing was bagged and sent to the laundry, and room [ROOM NUMBER] was disinfected with one part bleach, nine parts water by housekeeping on 11/7/17 at 7:00 p.m. He stated a line listing was completed on 11/6/17. During an interview with Licensed Vocational Nurse 8 (LVN 8) on 11/7/17 at 3:25 p.m., LVN 8 stated Resident 28 went out to the resident's private physician at 3:00 to 4:00 p.m. on 11/6/17 for skin scraping. LVN 8 stated when Resident 28 returned, resident was placed on isolation at 5:00 p.m. on 11/6/17 and treated with [MEDICATION NAME]. LVN 8 stated the isolation for Resident 28 was discontinued on 11/7/17 at 6:30 a.m. and resident remained in room [ROOM NUMBER]. LVN 8 stated around 6:00 p.m. on 11/6/17, Resident 28's roommates were treated with [MEDICATION NAME]. LVN 8 stated Resident 28, and a roommate, were ambulatory and goes to the dining room. During an interview with Resident 28 on 11/8/17, at 2:15 p.m., she stated that the itching began in about (MONTH) and she has told everyone in the facility that would listen. She stated she went to her own private physician, in November, (YEAR), because the rash was not getting better and the facility wasn't doing anything about the rash. Resident 28 stated she could feel a bulb under her skin. She stated at night the itching is worse. She stated that the facility performed a scraping of her skin after the scraping that was done at her private physician's office, however, she thought the facility did not do the scraping right, because, she stated that after the scraping was done by the facility, she didn't have any of the red areas on her right lower arm like she did after her private physician's office completed the scraping. The facility's policy and procedure, undated, titled, Scabies: Prevention and Control, indicated patients with signs and symptoms suggestive of scabies will be placed in contact isolation until the infestation has been ruled out or treated. Personal protective clothing that includes gloves and long sleeved gowns when in direct contact with a patient with signs and symptoms suggestive of scabies will be worn. Skin scrapings will be performed as ordered for suspected cases. 3. A review of the Resident 29's admission record indicated the resident was admitted to the facility on [DATE]. Resident 29's [DIAGNOSES REDACTED]. loss of consciousness) and collapse, and orthostatic [MEDICAL CONDITION] (form of low blood pressure that happens when an individuals stands up from sitting or lying down). A review of Resident 29's clinical record included physician's orders [REDACTED]. A physician's orders [REDACTED].½ tablets by mouth, four times per day for [MEDICAL CONDITION]. A review of Resident 29's Release of Responsibility for Leave of Absence document indicated the resident left and returned to the facility a total of 25 times from 8/13/17 to 11/6/17. A review of Resident 29's Medication Administration Record [REDACTED]. During an interview on 11/9/17 at 11:28 a.m., Licensed Vocational Nurse 5 (LVN 5) stated Resident 29 required [MEDICATION NAME] to prevent the resident from feeling dizzy, faint, or passing out due to a drop in blood pressure. LVN 5 stated that Resident 29 required Ropinirole [MEDICATION NAME] to prevent tremors in both legs. LVN 5 stated that Resident 29 required the [MEDICATION NAME] due to [MEDICAL CONDITION]. LVN 5 stated medications can be administered either one hour before or one hour after the administration time. LVN 5 was unable to administer medications to Resident 29 on 9/6/17 and 9/14/17 since the resident did not return to the facility in time. LVN 5 did not know the facility's policy regarding medication administration when a resident was out on pass. During an interview on 11/9/17 at 11:52 a.m., the Director of Nursing (DON) stated the licensed nurse should have notified the physician that Resident 29 missed doses of medication. DON stated that the facility will coordinate the medications with Resident 29's physician to adjust medications since the resident goes out on pass frequently. 4. A review of Resident 6's admission record (Face Sheet) indicated resident was admitted to the facility on [DATE]. A review of Resident 6's History and Physical (H&P), dated 7/13/17, indicated Resident 6's working [DIAGNOSES REDACTED]. A review of Resident's 6's MDS, dated [DATE], indicated Resident 6 had the ability to understand and be understood by others and had a Brief Interview for Mental Status (BIMS) score of 13 (8-15= interviewable). According to the MDS, Resident 6 was dependent on staff for eating, personal hygiene and bathing, and required extensive assistance with transferring and dressing. On 11/7/17 at 3:29 p.m., during a treatment observation of Resident 6, it was noted the resident had several fluid filled blisters on the face some were brown and other yellow in color. During a concurrent interview, licensed vocational nurse (LVN 4) stated he would notify the physician about the findings. On 11/7/17 at 3:33 p.m., during an interview, LVN 4 stated someone should have looked at Resident 6's face and inform the physician for a dermatology consult. On 11/7/17 during Resident 6's record review, a Care Plan titled: [DIAGNOSES REDACTED] dated 11/14/16 and revised 11/2017, did not indicate clearly any interventions currently in place to address Resident 6's skin condition. On 11/9/17 at 7:17 p.m., during an interview, the director of nursing (DON) stated Resident 6's [DIAGNOSES REDACTED] Care Plan interventions should have been checked and interventions should have been initiated, in addition, DON stated Care Plan was not very clear. 5. Resident 1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was fed and medicated through a gastrostomy tube ([DEVICE], a tube inserted through a small incision in the abdomen into the stomach used for long-term nutrition and medication administration). The Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 10/16/17 indicated the resident was dependent on staff for eating, personal hygiene and bathing, and required extensive assistance with transfers and dressing. A review of the physician's orders [REDACTED]. The Immunization Record indicated the last pneumonia vaccine was administered on 5/23/11. During an interview on 11/7/17, at 10:50 a.m., a licensed nurse (LVN 2) acknowledged the facility's failure of not administering the pneumonia vaccine to the resident. The facility's undated policy and procedures, titled Pneumococcal Immunization, indicated, Orders will be obtained from all attending physicians for pneumococcal immunization on admission for all residents unless contraindicated. The facility will order the pneumococcal vaccine from the pharmacy as needed for resident use. Additionally, on 11/7/17, at 7:42 a.m., a licensed nurse (LVN 1) was observed as she prepared and administered Resident 1's morning medications through the [DEVICE]. LVN 1 failed to shake the bottle of multivitamins prior to dispensing the medication. During an interview on 11/7/17, at 8:24 a.m., LVN 1 acknowledged her failure to shake the bottle of multivitamins prior to pouring. Shaking evenly distributes the drug particles/ingredients to get the full strength and roughly the same amount of active drug in every dose. The medication bottle instructions indicated to shake well prior to use.

Based on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 1) was free from verbal abuse by Certified Nursing Assistant (CNA) 1. This resulted in mental and emotional harm to Resident 1 by making the resident cry when reminded of the incident and feel scared of CNA 1. Findings: A review of the Record of Admission of Resident 1 indicated the resident was originally admitted to the facility on [DATE], and was readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), a standardized assessment and care planning tool, dated December 4, 2016, indicated Resident 1 understood others and was able to make self-understood, scored a 15 on the brief interview for mental status (BIMS, a score of 13 to 15 means cognitively intact), memory was intact, did not display any physical, verbal, or any other behavioral symptoms directed at others or to self, and required extensive assistance to total dependence with assistance of two or more staff with bed mobility, transfer, dressing, and bathing. A review of the facility's investigative report dated January 12, 2017, indicated on January 12, 2017, at 11 a.m., CNA 2 who was giving Resident 1 a shower notified Licensed Vocational Nurse (LVN) 1 that Resident 1 was crying. LVN 1 immediately went to Resident 1 and asked why she was crying. Resident 1 then reported to LVN 1 that about a month ago, CNA 1 called her a cry baby and that she cries at everything. Resident 1 also reported that when CNA 1 used the mechanical lift (a device designed primarily to lift and transfer patients to/from the bed, chair, toilet, and floor) on her, it caused pain to her toes by pinching them. LVN 1 immediately assessed the resident's toes and did not see any redness, swelling or injuries. The report further indicated, the facility made multiple attempts to contact CNA 1, but was unable to interview her due to her being on medical leave. Further review of the facility's investigative report dated January 12, 2017, indicated during an interview with Resident 1 on January 12, 2017, at 4 p.m., when asked why she did not report the incident right away, Resident 1 stated that it happened about a month ago and she did not report it because according to her, I am just like that. Resident 1 stated that she was reminded of the incident when she had her shower today, cried and became emotional. According to a nurse's note dated January 12, 2017, at 11 a.m., Resident 1 complained about her toes being pinched during shower with CNA 1. CNA 1 called her a cry baby and crying for everything, which make her, feel very sad. The note indicated Resident 1 wanted CNA 1 removed from taking care of her. The note further indicated Resident 1's responsible party (son) was notified. A review of a nurse's note dated January 13, 2017, at 1 p.m., indicated Resident 1's son visited the resident last night. The note indicated the son confirmed with his mom what had happened and explained that his mom would not make up any stories. A review of the facility's untimed interview with CNA 1 dated January 20, 2017, indicated CNA 1 denied calling the resident a cry baby. CNA 1 stated she was aware that Resident 1 accidentally hit the mechanical lift, but she did not report it to the charge nurse. CNA 1 also stated that she recalled Resident 1 crying and saying it hurt, and that she told Resident 1 You cry at everything and that she cries at everything too. During an interview on January 27, 2017, at 11:26 a.m., LVN 1 stated that Resident 1 complained to her that CNA 1 assisted her with the mechanical lift and the lift made her feel like she was being pinched on her toes. Resident 1 complained that CNA 1 did not bother to see what was wrong. CNA 1 told Resident 1 that she was a cry baby and she cries about everything. LVN 1 stated that Resident 1 did not know the exact date of the incident and this is the first time Resident 1 complained about CNA 1. According to LVN 1, Resident 1 is alert and oriented, knows what is going on and has no history of making up stories. During an interview on January 27, 2017, at 12:10 p.m., Resident 1 stated that over a month ago, CNA 1 was putting her back to bed using the mechanical lift when her knee and toe got caught in it somehow and made her feel so much pain. Resident 1 stated that she was crying and screaming because it hurt, but CNA 1 did not stop and continued to put her back to bed. According to Resident 1, when she got in the bed, CNA 1 told her she was such a cry baby and cries about everything. Resident 1 stated that she did not like how CNA 1 talked to her. That made her feel scared of CNA 1 and scared of using the lift again. Resident 1 further stated that she did not tell anyone what happened for a long time because she is the type of person who keeps everything inside. During an interview on January 27, 2017, at 1:15 p.m., the Director of Nursing (DON) stated that CNA 1 was still on medical leave and was suspended with possible termination when she reports back to the facility. During a telephone interview on January 31, 2017, at 8:14 a.m., CNA 1 stated that over a month ago, something might have happened when she was putting Resident 1 back to bed with the mechanical lift. CNA 1 stated that she does not know what she did wrong, but Resident 1 was crying about her toe. CNA 1 stated that she told Resident 1, You cry about everything, me too. CNA 1 further stated that she never called the resident a cry baby and that she told her Please don't cry, you're making me feel bad. According to CNA 1, she did not do anything wrong to Resident 1, but should have reported what happened to the charge nurse. During a follow-up interview on June 21, 2017, at 1:10 p.m., Resident 1 stated that she was terrified of using the lift and seeing CNA 1 after the incident. Resident 1 stated that she dreaded being cared for by CNA 1 and this made her feel more depressed. According to Resident 1, she kept it inside and bore it until she could not anymore and finally told the staff about it. Resident 1 stated that she finally reached her limit. Resident 1 further stated that she feels better and happier now that CNA 1 does not care for her anymore and feels ok to use the mechanical lift. During an interview on June 21, 2017, at 1:43 p.m., LVN 1 stated that Resident 1 is doing better, happier, smiling, talking and interacting more since CNA 1 does not care for the resident anymore. A review of the facility's policy and procedure titled Resident Abuse Policy and Procedure dated January 1, 2013, indicated the facility shall uphold resident's right to be free from verbal, sexual, physical, mental abuse, corporal punishment and involuntary seclusion. Residents shall not be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants, staff of other agencies serving the individual, family members or legal guardians, friends, or other individuals.

Based on observation, interview, and record review, the facility failed to ensure that its infection control program was implemented to prevent the spread of infection to all residents in the facility, by failing to: 1) Ensure that single-resident use items were only used for the same residents. 2) Ensure that isolation precautions (a practice where staff wear protective gear to prevent the spread of infection. Gear may include a special mask, a gown, and gloves), were properly followed. 3) Clean and disinfect resident's supplies according to the facility's policies, the manufacturer's directions, and current professional standards of practice. These failures had the potential to spread infectious diseases to all residents in the facility, especially diseases that may be spread via the fecal-oral route including hepatitis (a virus that effects the liver), norovirus (a virus that effects the stomach and intestines), and other nosocomial infections (hospital acquired infections), including Clostridium difficile (C-diff, which is a bacteria that can affect your intestines and cause diarrhea) or other Multi-Drug Resistant Organisms (MDRO's for short, which are organisms such as bacteria that are resistant to certain or all available antibiotics) such as [MEDICATION NAME] Resistant [MEDICATION NAME] (VRE for short, commonly found in the intestines, that can cause infections in areas such as a wound or urinary tract) and Methicillin Resistant Staphylococcus aureus (MRSA for short, which is a bacteria that is commonly carried in the nostrils. This can cause infections in multiple body sites including wounds). These infections have the potential to cause illnesses that may lead to complications resulting in severe discomfort or even death. During multiple observations, the facility staff failed to properly implement the facility policy and procedures for disinfecting resident's bed pans and wash basins, including the wash basin from an isolation room of a resident diagnosed with [REDACTED]. On November 17, 2016 at 11:20 a.m., in the presence of the Director of Nurses (DON), and the administrator an immediate jeopardy was called. The team ' s concerns included: 1. The recycling and reusing of wash basins/bed pans designated for single resident use which were used for multiple different residents, including residents with contagious diseases. 2. The solution being used to clean the wash basins/bed pans was not the recommended solution for disinfecting patient equipment contaminated with[DIAGNOSES REDACTED]. 3. The facility's policies/procedures for disinfection were not followed. 4. There was no consistency in the method the facility staff used to clean and disinfect the wash basins/bed pans among the different units (total of 8 units in the facility). On November 18, 2016, a plan of correction (POC) was submitted to the Department. The POC included the following: Immediate Actions: 1. On November 17, 2016 all wash basins and bedpans were disposed of. New wash basins and bed pans were provided to each resident and labeled with their respective names and stored at the bottom of the bedside drawer. 2. On November 17, 2016 all utility rooms and wash sinks were cleaned and disinfected using a 1:10 bleach solution by housekeeping. On November 17, 2016 all buckets and brushes were removed from the utility rooms and replaced with a spray bottle clearly labeled with 1:10 bleach solution and replaced and dated daily. Potentially Affected: 3. The rooms for Resident 34 and 35 who were admitted with[DIAGNOSES REDACTED] were cleaned and disinfected. The certified nurse assistants (CNAs) assigned to the two residents were both observed by the director of staff development (DSD) to ensure the facility's policy was followed for the cleaning and disinfection of the wash basins and bedpans. 4. Housekeepers, licensed vocational nurses (LVNs), and CNAs were in-serviced on the facility's policy and procedure for the cleaning and disinfecting non-critical care items, with emphasis on single use resident items, labeling of single use items with residents names, and the use of an EPA (environmental protection agency) registered solution or 1:10 bleach solution and according to manufacturer's directions. 5. Upon admission all residents will be provided their own wash basins, urinals, and bed pans, and labeled with their respective names. Following an acceptable plan of correction on November 18, 2016, at 10:05 a.m. the Immediate Jeopardy was abated. Findings: 1) The failure to ensure that single resident use items were only used for the same residents: During the initial tour on 11/15/16 at 7:50 AM in the 200 Unit, in the restroom of room [ROOM NUMBER], a wash basin was observed without any name or identifier to indicate which of the three residents who occupied the room, the wash basin belonged to. At 8:07 AM in the restroom of room [ROOM NUMBER], there were three wash basins with no names or identifiers to indicate which wash basin belong to each of the three residents who occupied the room. LVN 13 confirmed there were no resident names or identifiers on the wash basins. At 8:15 AM, LVN 13 confirmed that there were 3 wash basins with no names or identifiers in room [ROOM NUMBER] restroom to identify which of the three residents who occupied the room they belong to. During an interview with LVN 13 on 11/16/15 at 3:09 PM, LVN 13 verbalized that all of the resident wash basins in the 200 Unit were unmarked and that every resident received a different wash basin every day. LVN 13 stated that the CNAs collect all of the wash basins during the evening shift, clean all of the wash basins, and then re-distribute the wash basins to all of the residents. LVN 13 was asked how CNAs clean and disinfect the wash basins. LVN 13 replied, I don't know how they wash them, but they use a disinfectant. At 3:18 PM on 11/16/15 in the 200 Unit Utility Room, there were three piles of wash basins on the sink counter by a sign that indicated dirty. LVN 13 verbalized that the clean wash basins were stored on the shelf near the sink. According to the facility's policy titled Cleaning and disinfecting of Non-Critical Resident-Care Items, last revised August 2012 and approved by the facility on November 18, 2015, indicated under the General Guidelines section: 2. Single resident use items are for single resident use only. Mark with the resident's name and/or room number and discard upon transfer or discharge. Single resident-use items are cleaned/disinfected between uses by a single resident and disposed of afterwards (e.g. bedpans, urinals). 3. Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment), and 5. Manufacturer's instructions will be followed for proper use of disinfecting. 2) The failure to ensure that isolation precautions were properly followed. On November 16, 2016 at 1:35 p.m., CNA 16 stated they are given the same assignments. According to CNA 16 when a resident is on isolation staff must use appropriate protection when providing care for the resident. When asked the type of isolation precautions are used for residents with[DIAGNOSES REDACTED]. CNA 16 stated gowns and gloves. According to CNA 16 residents are given showers twice per week, in between they are given bed baths. Residents are given wash basins every morning which are taken from the utility room. The wash basins are kept in the resident ' s rooms until the late shift (11 pm-7 am). The wash basins are then collected and washed by the CNA's. When asked how the wash basins are cleaned CNA 16 stated there is a bucket in the utility room with a disinfectant and a brush that is used to clean the wash basins. The wash basins are then placed on the clean side ready for redistribution to residents in the morning. During an interview on November 16, 2016 at 2:10 p.m., RN 2 stated randomly selected resident (RSR) 34 was admitted to the facility with a [DIAGNOSES REDACTED]. RN 2 stated RSR 34 was no longer on isolation precautions. On November 14, 2016, RSR 34 had two episodes of loose stools, and was placed back on contact isolation (isolation that requires persons to wear a gown and gloves) precautions. The antibiotic treatment ([MEDICATION NAME]) was extended for seven additional days from the original physician's orders [REDACTED].>RSR 34's room was located in the 500 Unit. During an observation of the utility room in the 500 Unit on November 16, 2016 at 3:11 p.m., 21 wash basins were observed stacked in three piles on the clean side. On the dirty side two bedpans, one wash basin, and three buckets were observed. On the floor was a bucket half filled with an unidentified solution, and a brush was inside. A review of RSR 35's admission face sheet indicated RSR 35 was admitted to the facility on [DATE], and readmitted on [DATE]. RSR 35's [DIAGNOSES REDACTED]. RSR 35 was placed on contact isolation for[DIAGNOSES REDACTED] on November 16, 2016. RSR 35's room was located in the 800 Unit. Review of RSR 35's care plan for MDRO (multi drug resistant organism) dated November 16, 2016 indicated RSR 35 had a [DIAGNOSES REDACTED]. During an interview on November 16, 2016 at 4:50 p.m., the director of nursing (DON) stated bedpans and wash basins are collected by the 11 p.m.-7 a.m. shift and two CNA's are assigned to clean and disinfect them. The bedpans and wash basins are placed on a shelf to dry and are redistributed to residents in the morning. Wash basins and bedpans are distributed randomly. During an observation of the evening shift on 11/16/2016 at 10:50 PM in the 500 Unit, it was observed that RSR 34 had isolation equipment outside of the room for staff and visitors to wear. RSR 34 was on isolation for[DIAGNOSES REDACTED]. CNA 10 entered RSR 34's room with gloves, but did not put on an isolation gown. CNA 10 was observed speaking with RSR 34 who was complaining of discomfort. CNA 10 was observed touching the resident's legs and linens, then left the room to inform the nurse of the resident's complaint of pain and discomfort. CNA 10 returned and applied contact isolation gear to assist RSR 34 with repositioning. CNA 10 was then observed removing the isolation gear and took the wash basins of RSR 34 and RSR 34's roommate to the utility room. CNA 10 placed both wash basins on the top of the pile of wash basins observed in the dirty utility room at this time, then removed her gloves and washed her hands. According to the facility's policy titled Clostridium Difficile, preventative measures will be taken to prevent the occurrence of Clostridium difficile infections among residents and precautions will be taken while caring for residents with [DIAGNOSES REDACTED]icile (to prevent transmission of [DIAGNOSES REDACTED]icile to others. The policy indicates under Contact Precautions that residents with diarrhea associated with [DIAGNOSES REDACTED]icle (i.e. residents who are colonized and symptomatic) will be placed on contact precautions for the duration of the illness. Healthcare workers and visitors will don gloves and gowns when entering the room of a resident with [DIAGNOSES REDACTED]icile infection. 3) The failure to clean and disinfect resident supplies according to the facility's policies, the manufacturer's directions, and current professional standards of practice. During an observation and interview on November 16, 2016, at 11:30 p.m., in the 900 Unit , CAN 12 stated that she sprays the wash basins with Disinfectant 1, she then scrubs the wash basins all the way around. She added, if it is an isolation resident, we clean it the same way along with the dirty wash basins. We do the same for bed pans as well, even if the resident is on isolation. We have done it this way since I have started this job five years ago. During an interview on November 16, 2016 at 11:45 p.m., with CNA 13 from the 600 Unit, CNA 13 stated we spray the wash basins and we leave it for twenty minutes then we use the sponge to clean them one by one then rinse them and let it air dry. Then at 3 am we wipe them down and put it on the clean side. We would do the same process for the bed pans as well. During an observation and concurrent interview of CNA 11, on 11/16/16 at 11:41 PM, CNA 11 stated that she was going to clean the wash basins for the evening. There was a pile of wash basins from all of the residents on the right of the sink. In addition to the wash basins were bed pans and bedside commode buckets. One of the bed side buckets was visibly soiled with feces, as confirmed by CNA 11. CNA 11 proceeded to attempt to flush the sink of the utility room after applying her gloves. The sink resembled a large square toilet. The sink had a handle that allowed the sink to be flushed like a toilet. CNA 11 attempted to flush the sink, but the sink would not properly drain the dirty water in it. CNA 11 stated, Sometimes it is not working. CNA 11 then turned on the warm water to the sink and picked up a spray bottle with Disinfectant 1 and attempted to spray the first wash basin which was from Resident 34's room, who was on isolation for[DIAGNOSES REDACTED]. The spray bottle was not functioning and did not spray out any disinfectant. CNA 11 stated It's not working. CNA 11 put down the spray bottle and placed it to the side. CNA 11 then picked up a scrub brush that appeared to be made out of a sponge-like material that was stored in an open, white, unlabeled container and began to scrub the first wash basin after rinsing it with water. CNA 11 used the scrub brush from the container and began scrubbing all the surfaces of the wash basin. Once all surfaces of the wash basin was touched by the sponge, the CNA placed the scrub brush back into the bucket and immediately rinsed the solution off of the wash basin. Contact time was less than 5 seconds for this observation. CNA 11 then proceeded to place the wash basin on the counter to the left of the sink to dry. CNA 11 then picked up the next wash basin that also came from Resident 34's room and repeated the practice. CNA 11 was then observed picking up the rest of the wash basins one by one. She rinsed each basin with warm water, applied the solution from the unlabeled white container with the scrub brush, and then immediately rinsed off the solution that was applied. For each of the wash basins that were washed, edges of the wash basins made contact with the dirty water in the sink and on the surface edges of the sink. All wash basins were stored on the counter to the left of the sink to dry. There was a long black hair still observed on one of the wash basins that CNA 11 washed and stored to dry. After the wash basins were done, CNA 11 proceeded to wash the bedpans and bedside commode buckets. CNA 11 used the same procedure to wash them. CNA 11 stacked the wash basins, bedpans, and bedside commode buckets on top of one another, to let them air dry. CNA 11 finished washing all of the items at 12:08 AM on 11/17/16. CNA 11 wore the same pair of gloves to wash and stack all of the wash basins, bedpans, and bedside commode buckets. CNA 11 was interviewed after she completed the washing at 12:08 AM. CNA 11 confirmed that there was no label on the white bucket to indicate how old the solution, what kind of solution was in the bucket, and what the concentration was. CNA 11 stated that the container contained disinfectant solution. CNA 11 stated the housekeeping staff prepares the containers of disinfectant solution in the morning. CNA 11 verbalized that no further cleaning of the wash basins were going to take place and that they were going to be disperse to all of the residents in the morning. CNA 11 confirmed that she rinsed off the solution right after applying it. CNA 11 was asked if she was supposed to leave the solution on the equipment for a certain amount of time. CNA 11 stated We press very hard. We are supposed to spray first and leave on for 10 minutes, but we don't usually do. We just press very hard. CNA 11 clarified that they press the scrub brush with solution very hard against the surfaces of the equipment instead of leaving the solution on for 10 minutes. CNA 11 verbalized that she did not know which wash basins came from Resident 34's room. During an observation at 12:35 AM on 11/17/16, CNA 12 was observed washing wash basins in the 200 Unit. CNA 12 was not wearing gloves. CNA 12 sprayed the wash basin with Disinfectant 1 , then rinsed the solution off immediately with warm water, and then reapplied the Disinfectant 1. CNA 12 placed the wash basin to the side of the sink and stated she was going to let it air dry. Then, after it is dry, she was going to repeat the process. CNA 12 stated they don't normally use the scrub brush to clean the wash basins and that they only use it to clean bedpans. According to the facility's policy titled Isolation-Categories of Transmission-Based Precautions, the policy indicates under the Resident-Care Equipment During Contact Precautions section that f. (1) When possible, dedicate the use of non-critical resident-care equipment items such as a stethoscope, sphygmomanometer, bedside commode, or electronic thermometer to a single resident (or cohort of residents) to avoid sharing between residents. (2) If use of common items is unavoidable, then adequately clean and disinfect them before use with another resident. The facility's policy titled Cleaning and disinfecting Non-Critical Resident Care Items indicates under the general guidelines that gloves should be worn and to not use a brush to clean the bedpan or urinal as this may cause splashes or spatters of urine or feces. According to the facility's policy titled Basin Procedure, the procedure indicates: 1) 11-7 Shift will use 1 basin per resident, after use of basin CNA will rinse and dry off, then basin will be placed in the bottom drawer of each resident's nightstand. 2) 7-3 Shift will use the same basin found in the bottom drawer of each residents nightstand. After each use CNA will rinse and dry off, then basin will be placed in the bottom drawer of nightstand. 3) 3-11 Shift will use the same basin found in the bottom drawer of each resident ' s nightstand. After each use CNA will rinse and dry off, then basin will be placed will be placed in the bottom drawer of nightstand. *At the end of the 3-11 Shift, CNA's will take all wash basins out of bottom drawers of nightstands. The wash basins will be taken to the utility room and placed on the dirty side. 4) 11-7 Shift will disinfect all wash basins left on the dirty side with Disinfectant 1 and leave for 10 minutes). Then wash basins will be rinsed off and placed on the clean side to dry. The manufacturer of Disinfectant 1 indicated that it is a disinfectant, virucide (kills viruses), and fungicide (kills fungus). The directions for use indicated that the solution must maintain contact on surfaces and stay wet with the solution for 10 minutes to kill all of the germs listed on the manufacturer's label. The manufacturer's label did not indicate that Disinfectant 1 could kill active[DIAGNOSES REDACTED] bacteria or[DIAGNOSES REDACTED] spores. A review of the facility's lesson plan titled Housekeeping Procedures for[DIAGNOSES REDACTED] Rooms dated August 20, 2016, indicated the sanitizing solution that should be used for equipment belonging to residents with[DIAGNOSES REDACTED] is 1:10 concentration of bleach to water ratio. The solution must be left damp and allow to air dry 15 minutes minimum before a second disinfection or procedure takes place. Cross Reference F 520

Based on interview and record review, the facility failed to readmit one of 30 residents (Resident 27) to the facility after a brief stay at the acute hospital in accordance with its readmission policy and procedure. Resident 27 was discharged from the acute hospital to the SNF (skilled nursing facility) via an ambulance. Once the ambulance arrived at the facility, the SNF indicated they were not ready for the resident and consequently the resident was transported back to the acute hospital emergency room . The emergency room evaluated the resident, found no problem, and then called the SNF to return the resident, however, the SNF still refused to accept the resident back. The facility failed to provide a calm and relaxing environment according to the facility ' s Alzheimer's plan of care, by refusing to re-admit the resident and to include the resident ' s family in the re-admission process that resulted in the resident ' s agitation and subsequently becoming extremely upset. Findings: According to the record of admission, Resident 27 was admitted to the facility on [DATE], and readmitted on [DATE], from the acute care hospital, with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was moderately impaired in cognitive skills for daily decision making, was usually understood and able to understand others, was verbally abusive, resists care, and had a responsible family member. A review of the licensed nurse ' s progress notes dated August 20, 2010, at 7:20 a.m. and 2 p.m., indicated that Resident 27 was transferred to an acute care hospital due to verbally abusive behavior, hitting staff members, and refusing to shower, take medications and allow staff to take her vital signs. According to the acute hospital geriatric discharge summary dated September 7, 2010, the resident remained in the acute hospital geriatric- psychiatric unit from August 20, 2010, to September 7, 2010. The resident's [DIAGNOSES REDACTED]. A review of the acute care hospital physician's orders [REDACTED]." The physician discharge notes also indicated that Resident 27 was appropriate for a lower level of care with a prescription and outpatient follow up. At 3 p.m., on September 7, 2010, another order was written which indicated the resident was medically stable for discharge. A review of the ambulance service report (undated) received on September 21, 2010, at 11 a.m. indicated that the resident was transported from the acute hospital leaving at 3:47 p.m. to the SNF and arrived at the SNF at 4:17 p.m. The ambulance dispatcher was notified that the SNF was not accepting the resident back because the SNF did not tell the acute care hospital that it was ready to admit the resident. The ambulance service report also indicated that it took about two hours of trying to resolve the situation, when finally the SNF advised the crew of the ambulance service to transport the resident back to the acute care hospital emergency room because the resident had complained of leg pain. The report further indicated that the resident was extremely upset and became agitated and did not want to stay at the SNF and the transport person had no choice but to transport the resident back to the acute hospital. The resident arrived at the acute care emergency roiagnom on [DATE] at 6:34 p.m. over two and a half hours after the resident initially left the acute care hospital. A review of the acute facility Multi-Disciplinary Progress Notes dated September 7, 2010, at 7 p.m. indicated that the resident was brought back to the acute care emergency room for leg pain, but the resident denied any leg pain and refused treatment. The acute care hospital emergency room then attempted to send the resident back to the SNF but the SNF still refused to admit the resident the second time. According to the SNF ' s " Daily Census Report " dated September 7, 2010, the SNF had fourteen beds available in semi private rooms and ready for occupancy in Unit 200 for female residents. A review of the acute hospital acute facility Multi-Disciplinary Progress Notes dated September 7, 2010, at 7:30 p.m. indicated the emergency room nurse called the SNF but the SNF still refused to accept the resident back. A review of the acute hospital geriatric progress note, dated September 8, 2010, stated "the resident was discharged yesterday to a skilled nursing facility which apparently accepted her when the social services contacted them. The resident was discharged and transported to the SNF, but no sooner did she arrive there but they called back and said they would not accept her, and they dropped her off at the emergency room saying the patient is complaining of leg pain." There was no placement available immediately; hence the resident's discharge from the acute hospital was rescinded and the resident was later readmitted to the Gero-psychiatric Unit for continuation of treatment and alternative placement arrangements were made by the social services. The resident was alert and ambulated using a wheelchair. The report stated that the resident was pleasant and there were no behavioral problems reported. During an interview with the acute hospital social worker on September 8, 2010, at 3:27 p.m., she stated that in the morning of September 7, 2010, she spoke to the SNF ' s admissions' coordinator over the phone and informed her that the resident was discharged and would be returning to the SNF. The SNF ' s admissions coordinator agreed and stated that there was a bed available and asked the acute hospital social worker to fax over some information. On September 7, 2010 at 10 a.m. the resident ' s information was faxed over to the SNF . In an interview with the acute care hospital social worker on September 9, 2010, at 10:45 a.m., she stated that she called the SNF ' s admissions' coordinator on September 7, 2010 at 1 p.m., to verify if the resident ' s bed was ready and the SNF admission coordinator indicated that the facility was ready to accept the resident. However, on September 8, 2010 at or around 4 p.m., the administrator stated that the SNF was not expecting the resident when the resident arrived at the facility. In an another interview with the acute care hospital social worker on September 8, 2010, (at unspecified time) she stated that after the resident had left the acute hospital by ambulance on September 7, 2010, the SNF admissions' coordinator informed her that the SNF was not going to take the resident back because the bed had been given away. A review of the Ambulance Incident Report indicated that on September 7, 2010 at 4:17 p.m. the ambulance driver arrived at the SNF and the SNF was making arrangements to accept the resident. A few minutes later, the SNF decided not to accept the resident and the resident was transferred back to the acute hospital emergency room for leg pain 6:08 p.m. The resident was extremely upset and agitated between the time she arrived at the SNF at 4:17 p.m. and the time she was transported back to the acute hospital emergency room at 6:08 p.m. and arrived at the acute facility at 4:34 p.m. The Ambulance Incident Report further indicated ... it is very uncomfortable for residents to lay on a gurney for long periods of time. During an interview on September 8, 2010, at 3:55 p.m., with the skilled nursing facility Admissions' Coordinator she stated that the resident refused to stay at the facility and refused to be readmitted on [DATE]. In an interview conducted on September 8, 2010, at 4:05 p.m. with a SNF administrative staff, he stated the SNF was not expecting the resident who was refusing to stay at the SNF and the physician was called. The administrative staff stated the physician directed the SNF to send the resident back to the acute hospital. In an interview with the ADON on September 8, 2010, at 4:10 p.m. she stated that the there was no evidence of a physician' s order to send the resident back to the acute care hospital because the resident did not complete an admission to the SNF facility. A further interview was conducted with the SNF's Assistant Director of Nursing (ADON) on September 8, 2010, at 4:10 p.m. The ADON stated that the facility had received the faxed inquiry from the acute care hospital at about 3:30 p.m. on September 7, 2010. The ADON also stated that she did not expect the resident to be at the SNF immediately as they were still preparing a room for the resident. She also reported that as soon as the resident arrived at the SNF, the resident became agitated, screaming, hitting the facility staff members and was refusing to be taken to her room. She also added the resident had refused to be admitted to the SNF even after SNF staff had talked to her. The ADON then stated that the facility called the resident's psychiatrist for advice. The psychiatrist then told the SNF that since the resident was not conserved, the SNF can call 911 so the resident can be transported back to the same acute care hospital to be re-evaluated by an emergency room psychiatrist. The ADON also stated that since the resident was not formally admitted to the SNF, there were no admissions on file or physician or psychiatrist ' s written orders from the SNF. During an interview with the family member on September 9, 2010, at 10:46 a.m., she stated she knew that her mother was leaving the acute hospital to go back to the SNF, but she did not know that Resident 27 was sent back to the acute hospital. She stated that she had thought her mother was already back at the SNF. The family member further stated that the acute hospital had called and left a voice mail message informing her that the resident would be transferred back to the SNF facility. She also stated that her house was directly across from the SNF facility and she did not want her mother sent to another facility. Furthermore, Resident 27 did not have the ability to make those types of decisions. Although Resident 27 had an involved responsible family member, on September 7, 2010, the SNF failed to notify the responsible family member about the resident's refusal to be readmitted to the SNF and of the resident's pending transfer to the acute facility emergency room as a result of the resident's refusal to be readmitted . According to the SNF ' s policy and procedure for Bed Holds and Readmitted d February 2005, " If the facility participates in Medi-Cal and the resident is eligible for Medi-Cal, if the resident is away from the facility for more than seven days due to hospitalization or other treatment, we will readmit you to the first available bed in a semi-private room if you need the care provided by our facility and wish to be readmitted . " The SNF failed to immediately readmit Resident 27 to the SNF and as a result the resident became extremely upset and agitated. According the [MEDICAL CONDITION] Education and Referral Center, publication: "Understanding How AD ([MEDICAL CONDITION]) Changes People - Challenges and Coping Strategies", some other causes of agitation and aggression include: Sudden change in a well-known place, routine, or person, too much noise or confusion or too many people in the room, Being pushed by others to do something-for example, to bathe, or remember events or people-when AD has made the activity very hard or impossible ... On September 15, 2010, eight days after the SNF ' s refusal to readmit the resident, the facility accepted and readmitted Resident 27 to the SNF.