Every finding on record at Seacrest Post-Acute Care Center

Based on interview and record review, the facility failed to ensure a Care Plan was created for one of three sampled residents (Resident 1) after Resident 1 fell on 4/18/2026.This failure placed Resident 1 at risk for repeated falls, injury and further decline. Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 had diagnoses including heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), muscle wasting (weakening, shrinking and muscle loss) and type 2 diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 2/20/2026, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding though thought, experiences, and the senses) was intact and was dependent on staff for toilet hygiene, showering, personal hygiene and putting on footwear.During a review of Resident 1's Incident Note, dated 4/18/2026, the Incident Note indicated at approximately 1 a.m., Resident 1 was found on the floor next to the bed, lying in a supine position. The Incident Note indicated Resident 1 was experiencing pain to the back of his head and lower back pain. The Incident Note indicated Resident 1 was transferred to a General Acute Care Hospital for evaluation and treatment. During an interview on 5/4/2026, at 10 a.m., Resident 1 stated on 4/18/2026, he tried to get out of bed independently, but he ended up falling onto the floor next to his bed. Resident 1 stated he knew that he shouldn't have gotten out of bed alone, but he thought he was able to stand. Resident 1 stated the fall caused pain to the back of his head and required transfer to the hospital.During an interview on 5/5/2026, at 3 p.m., the Director of Nursing (DON), stated based on her investigation, Resident 1 sustained an unwitnessed fall on 4/18/2026. Resident 1 was found on the floor next to his bed. The DON stated Resident 1 informed her that he decided to get out of bed on his own and it resulted in him falling. The DON stated Resident 1 complained of pain and was transferred to a GACH. The DON stated based on her review of Resident 1's Clinical Records, the nursing staff did not develop a Care Plan following Resident 1's unwitnessed fall. The DON stated failure to develop a Care Plan after Resident 1's fall on 4/18/2026, placed Resident 1 at risk for repeated falls, delayed assessments and care. The DON stated that when staff communicate the details and circumstances of a fall through the Care Plan, they can help reduce the likelihood of another fall.During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 2001, the P&P indicated assessments of residents are ongoing and care plans are revised as information about residents and the residents' conditions change.

Based on observation, interview, and record review, the facility failed to ensure three of eight sampled residents (Resident's 1, 2, and 3) were provided privacy when using the telephone. These failures resulted in Resident's 1, 2, and 3 being unable to make personal phone calls without staff's presence and monitoring, violating their rights to private communication. These deficient practices had the potential to cause psychosocial harm, including fear of being overheard when discussing personal information, and feelings of distress and isolation due to lack of communication with family. Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnoses including diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing) and chronic kidney disease ([CKD] a progressive loss in kidney function over a period of months or years).During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 2/11/2026, the MDS indicated Resident 1's cognition (the mental process of acquiring knowledge and understanding through thought, experience and the senses) was intact and required substantial assistance (helper does more than half the effort) from staff with transferring from bed to chair, sitting to standing, and walking. During a review of Resident 2's Face Sheet, the Face Sheet indicated Resident 2 was admitted to the facility on [DATE]. Resident 2 had diagnoses including heart failure (heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and CKD.During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognition was moderately impaired and was dependent on staff for transfer from bed to chair and from sitting to standing.During a review of Resident 3's Face Sheet, the Face Sheet indicated Resident 3 was admitted to the facility on [DATE]. Resident 3 had diagnoses including DM and atrial fibrillation (an abnormal heart rhythm).During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 2's cognition was mildly impaired and required supervision/touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance) from staff for transferring from bed to chair, and moderate assistance (helper does less than half the effort) from staff with walking more than 10 feet.During an interview on 4/17/2026 at 9:50 a.m., Registered Nurse (RN) 1 stated since 2/2026 they have not had a dedicated resident cell phone for residents. RN 1 stated residents who are able use the phone at the nursing station, but for bed bound residents they had been using the work cell phone the nursing staff use to communicate to physicians. RN 1 stated because there was sensitive information of many residents on the work cell phone bed bound residents use to make phone calls, they would stay with the resident who was using the cell phone. RN 1 stated it could be a violation of privacy since staff can hear their conversation, but they try not to listen to their phone calls. RN 1 stated they could not leave the work cell phone alone with the resident because it had sensitive health information on it.During a concurrent observation and interview on 4/17/2026 at 10:09 a.m., in Resident 2's room, Resident 2 was observed lying in bed. Resident 2 stated she used to talk to her daughter on the phone once a week, but she had not been able to speak to her daughter for a couple of months because the facility did not let her use the phone anymore. Resident 2 stated she missed talking to her daughter but cannot get out of bed to use the phone at the nursing station.During an interview on 4/17/2026 at 10:18 a.m., the Social [NAME] Director (SSD) stated during a recent transition with the facility changing ownership on 2/2/2026, the previous ownership confiscated all their work phones and the residents' phones for private use, without notice. The SSD stated they were currently using the RN supervisor's cell phone when residents need to make a phone call, but the RN supervisors would have to stay with the residents because of the sensitive information on the phone. The SSD stated if the resident's wanted privacy that could be an issue since the staff cannot leave the work cell phone unattended due to sensitive information on them.During an interview on 4/17/2026, at 11 a.m., Resident 3 stated when he needed to use the phone he would go to the nursing station to use the phone and would have conversations in front of staff.During an observation on 4/17/2026 at 11:26 a.m., Resident 1 was observed at nursing station 1 talking on the phone. RN 1 was observed sitting at the nurse's station while Resident 1 was on the phone. During an interview on 4/17/2026 at 3:12 p.m., the Administrator (ADM) stated sometime in 3/2026 the previous facility owner confiscated the phones, and she temporarily bought a cell phone for the residents' private use, but it went missing around 4/6/2026. The ADM stated as a temporary solution while they waited for the phone company to install their new phone system, she told nurses to let the residents use the RN supervisor's work cell phone. The ADM stated technically residents using the work cell phone could see private information, but they were just using it for a phone call and being monitored by nursing. The ADM stated that because the nurses must monitor the phone to ensure residents aren't navigating through it, there would be a lack of privacy for phone calls since nurses are standing by while residents are on the phone.During a review of the facility's undated policy and procedure (P&P), titled, Confidentiality of Information and Personal Privacy, the P&P indicated, the facility will protect and safeguard resident confidentiality and personal privacy regarding his written and telephone communications, and access to resident personal and medical records will be limited to authorized staff and business associates. During a review of facility's P&P, titled, Resident Rights, dated 12/2016, the P&P indicated, residents have access to a telephone, mail and email, and have the right to communicate in person, mail, email, and telephone with privacy.

Based on observation, interview, and record review, the facility failed to provide enough time for one of one sampled resident (Resident 30) to enjoy their meals.This failure resulted in Resident 30 feeling sad and frustrated. Findings:During a review of Resident 30's admission Record, dated 3/12/2026, the admission Record indicated Resident 30 was admitted to the facility on [DATE] with diagnoses but not limited to diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (high blood pressure), and coronary artery disease (a narrowing or blockage of arteries supplying blood to the heart).During a review of Resident 30's Minimum Data Set (MDS -resident assessment tool), dated 3/19/2026, the MDS indicated Resident 30 was cognitively intact (ability to think, understand, learn, and remember).During an observation on 3/24/2026 at 12:51 p.m. in Resident 30's room, Certified Nursing Assistant (CNA) 5 was quickly feeding Resident 30 their lunch meal.During an interview on 3/25/2026 at 9:04 a.m. with Resident 30, Resident 30 stated yesterday they felt very sad and frustrated when the CNA rushed to feed them.During an interview on 3/25/2026 at 3:15 p.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 stated Resident 30 prefers to take their time eating. LVN 4 stated if a resident felt rushed while being fed by staff, the resident would feel they were not receiving compassionate care.During an interview on 3/27/2026 at 11:30 a.m. with the Director of Nursing (DON), the DON stated if a resident was not given enough time to finish their meal, the resident would feel frustrated, irritated, and dissatisfied.During a record review of the facility's policy and procedure, titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated April 2021, the P&P indicated the facility will maintain a culture of compassion and caring for all residents.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident's (Resident 30) light cord was within reach.This failure resulted in Resident 30 feeling frustrated and the potential to increase the risk of the resident falling.Findings:During a review of Resident 30's admission record, dated 3/12/2026, the admission Record indicated Resident 30 was admitted to the facility on [DATE] with diagnoses but not limited to diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (high blood pressure), and coronary artery disease (a narrowing or blockage of arteries supplying blood to the heart).During a review of Resident 30's Minimum Data Set (MDS - a comprehensive resident assessment tool), dated 3/19/2026, the MDS indicated Resident 30 was cognitively intact (ability to think, understand, learn, and remember).During an observation on 3/24/2026 at 9:10 a.m. in Resident 30's room, Resident 30 was laying in bed and the light switch cord was behind the resident's bed.During a concurrent observation and interview on 3/25/2026 at 9:04 a.m. with Resident 30 in Resident 30's room, the light switch cord was on the floor behind the resident's bed. Resident 30 stated it was frustrating their light switch cord was out of reach.During an interview on 3/26/2026 at 3:15 p.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 stated a resident would feel frustrated if their light switch cord was out of reach.During an interview on 3/27/2026 at 11:30 a.m. with the Director of Nursing (DON), the DON stated if a light switch cord was not within reach of a resident, the resident would be at risk for falling if they tried to get out of bed.During a record review of the facility's policy and procedure, titled Homelike Environment, dated May 2017, the P&P indicated the facility shall provide the resident comfortable yet adequate lighting.

Based on interview and record review, the facility failed to ensure the quarterly Minimum Data Set (MDS-a comprehensive assessment and care screening tool) assessment dated [DATE] was transmitted to Centers for Medicare and Medicaid Services (CMS) within the 120-day time frame for one of six sampled residents (Resident 11).This failure had the potential for the delay in identifying resident care concerns needing an individualized care plan, providing residents interventions necessary to provide quality care and a delay in the reimbursement process.Findings:During a review of Resident 11's admission Record (face sheet) dated 3/26/2026, the admission record indicated Resident 11 was admitted on [DATE] and readmitted on [DATE] with diagnosis including depression (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), atrial fibrillation (irregular heartbeat) and difficulty in walking.During a review of Resident 11's History and Physical (H&P) dated 1/30/2026, the H&P indicated, Resident 11 was alert and oriented to name.During a review of Resident 11's MDS dated [DATE], the MDS indicated Resident 11 had moderate cognitive impairment (decline in memory, thinking, or language skills). The MDS indicated Resident 11 was dependent (helper does all the effort) with activities of daily living ([ADLs] daily self-care activities like toileting, bathing and dressing).During a review of Resident 11's MDS's batch statis (date the MDS was transmitted) dated 3/26/2026, the MDS batch statis indicated the last assessment was transmitted to CMS on 11/17/2025 and accepted on 11/25/2025.During a concurrent interview and record review on 3/25/2026 at 3:27 p.m. with the Minimum Data Set Nurse (MDS Nurse) Resident 11's MDS quarterly assessment dated [DATE] was reviewed. The MDS nurse stated she forgot to send Resident 11's MDS quarterly assessment dated [DATE]. The MDS nurse stated Resident 11's quarterly assessment was late and was going to send it right away.During an interview on 3/27/2026 at 11:19 a.m. with the Director of Nurses (DON), the DON stated she was aware Resident 11's MDS quarterly assessment dated [DATE] was not sent to CMS and was late. The DON stated there was a potential for a delay in care and services for Resident 11.During a review of the facility's policy and procedure (P&P) titled Resident Assessment dated 4/2025, the P&P indicated a comprehensive assessment of each resident is completed at intervals designated by OBRA regulations and PPS requirements. The P&P indicated OBRA-required assessments are federally mandated, and therefore, must be performed for all residents of Medicare and/or Medicaid certified nursing homes. The P&P indicated OBRA assessments includes admission assessment, quarterly assessment, and annual assessment. Data from the Minimum Data Set (MDS) is submitted to the Internet Quality Improvement Evaluation System as required. The P&P indicated assessments are completed by staff members who have the skills and qualifications to assess relevant care areas and who are knowledgeable about the resident's strengths and areas of decline. The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts a timely and appropriate resident assessment.

Based on observation, interview, and record review, the facility failed to ensure the assessment entries on the Minimum Data Set (MDS), a standardized assessment and care screening tool) was accurate for two of six sampled residents (Resident 12 and 75) by failing to:1. Ensure Resident 12's hearing status was accurately coded to reflect Resident12 wore a hearing aid.2. Ensure Resident 75's dental status was accurately coded to reflect Resident 75's missing bottom teeth.These deficient practices had the potential to negatively affect Resident 12 and 75's plan of care and delivery of necessary care and services. Findings:1. During a review of Resident 12's admission Record (face sheet) dated 3/26/2026, the admission record indicated, Resident 12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including heart failure (heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen) , diabetes mellitus (a condition in which the body fails to process glucose (sugar) correctly), dementia (loss of memory, language, problem-solving and other thinking abilities).During a review of Resident 12's History and Physical (H&P) dated 1/30/2026, the H&P indicated, Resident 12 did not have the capacity to understand and make decisions.During a review of Resident 12's MDS dated [DATE], the MDS indicated Resident 12 did not have the capacity to understand and make decisions. The MDS indicated Resident 12 was dependent (helper does all the effort) with activities of daily living ([ADLs] daily self-care activities like toileting, bathing and dressing). The MDS indicated Resident 12 had minimal difficulty with hearing and did not wear a hearing aid.During an interview on 3/25/2026 at 7:40 a.m. with Resident 12 stated she was hard of hearing and only wore a hearing aid on the left side and the staff stored it in another room. 2. During a review of Resident 75's admission Record (face sheet) dated 3/26/2026, the admission record indicated Resident 75 was admitted to the facility on [DATE] with diagnosis including breast cancer (rapid growth of abnormal cells), atrial fibrillation (irregular heartbeat) and muscle weakness.During a review of Resident 75's (H&P) dated 1/30/2026, the H&P indicated Resident 75 was alert and oriented.During a review of Resident 75's Minimum Data Set MDS dated [DATE], the MDS indicated Resident 75's had moderate cognitive (decline in memory, thinking, or language skills) impairment. The MDS indicated Resident 75 needed substantial/maximal assistance (helper does more than half the work) with activities of daily living (ADLs] daily self-care activities like toileting, bathing and dressing). The MDS indicated Resident 75 had obvious or likely cavities or broken natural teeth.During a concurrent observation and interview on 3/24/2026 at 9:36 a.m. with Resident 75 at Resident 75's bedside. Resident 75's bottom teeth were observed to have two teeth, one was broken and one was loose. Resident 75 stated she would like to see a dentist, for some dentures so she would not have to eat baby food anymore.During a concurrent interview and record review on 3/25/2026 at 3:27 p.m. with the Minimum Data Set MDS nurse, Resident 12's hearing assessment dated [DATE] and Resident 75's Dental assessment dated [DATE] were reviewed. The MDS nurse stated MDS assessment are used to help formulate an individualized plan of care for the residents. The MDS nurse stated Resident 12's hearing assessment was inaccurate Resident 12's did wear a hearing aid. The MDS nurse stated Resident 75's dental assessment was inaccurate Resident 75 was missing her bottom teeth. The MDS nurse stated when assessments are inaccurate there is a potential for the Resident 12's needs not to be met and the health could decline.During an interview on 3/27/2026 at 11:19 a.m. with the Director of Nurses (DON), the DON stated she was aware Resident 12's hearing assessment and Resident 75's dental assessment was inaccurate. The DON stated MDS assessments help with developing an individualized plan of care for the residents. The DON stated there was a potential for a delay in care for Resident 75 when assessments are inaccurate.During a review of the facility's policy and procedure (P&P) titled Resident Assessment dated 4/2025, the P&P indicated, a comprehensive assessment of each resident is completed at intervals designated by OBRA regulations and PPS requirements. The P&P indicated data from the Minimum Data Set (MDS) is submitted to the Internet Quality Improvement Evaluation System as required. The P&P indicated assessments are completed by staff members who have the skills and qualifications to assess relevant care areas and who are knowledgeable about the resident's strengths and areas of decline. Information in the MDS assessments will consistently reflect information in the progress notes, plans of care and resident observations/interviews. The P&P indicated the resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts a timely and appropriate resident assessment.

Based on observation, interview and record review, the facility failed to revise the communication plan of care for one of six sampled residents, (Resident 12) who was hard of hearing to reflect Resident 12's current care plan.This failure had the potential to negatively affect the care and services for Resident 12.Findings:During a review of Resident 12's admission Record (face sheet) dated 3/26/2026, the admission record indicated, Resident 12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including heart failure (heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), diabetes mellitus (a condition in which the body fails to process glucose (sugar) correctly), dementia (loss of memory, language, problem-solving and other thinking abilities).During a review of Resident 12's History and Physical (H&P) dated 1/30/2026, the H&P indicated, Resident 12 did not have the capacity to understand and make decisions.During a review of Resident 12's Minimum Data Set (MDS) a standardized assessment and care screening tool) dated 2/5/2026, the MDS indicated Resident 12 did not have the capacity to understand and make decisions. The MDS indicated Resident 12 was dependent (helper does all the effort) with activities of daily living ([ADLs] daily self-care activities like toileting, bathing and dressing). The MDS indicated Resident 12 had minimal difficulty with hearing and did not wear a hearing aid.During a concurrent observation and interview on 3/25/2026 at 7:40 a.m. with Resident 12 at Resident 12's bedside. Resident 12 was observed not wearing hearing aids. Resident 12 stated Can you repeat yourself, I can't hear you, what I can't hear you, can you repeat yourself. Resident 12 stated she only needed her hearing aid on the left side when she talks to people.During an interview on 3/25/2026 at 11:43 a.m. with Family Member 1 (FM1), FM1 stated Resident 12 wore a hearing aid in her left ear and that the staff held on to it and only put it in when Resident 12 has visitors.During a concurrent interview and record review on 3/25/2026 at 3:04 p.m. with Licensed Vocational Nurse 4 (LVN 4) Resident 12's care plan titled Risk for Communication Deficit dated 7/17/2024 was reviewed, LVN 4 stated Resident 12 was hard of hearing and only wore a hearing aid in her left ear. LVN 4 stated Resident 12's care plan needed to be updated with Resident 12's current plan of care so the staff will be able to provide Resident 12 with good quality care by ensuring Resident 12 was communicating properly.During an interview on 3/27/2026 at 11:25 a.m. with the Director of Nursing (DON), the DON stated a care plan is a guide the staff uses to provide the residents with the appropriate care. The DON stated Resident 12's communication care plan needed to be revised to reflect Resident 12's current plan of care. The DON stated when care plans are not revised there may be missed opportunities for providing care to Resident 12.During a review of the facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person - Centered dated 3/2022, the P&P indicated, the comprehensive, person-centered care plan, includes measurable objectives and timeframes. Describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions changes

Based on observation, interview and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives services to maintain good grooming for one of three residents sampled residents (Resident 60) by failing to change Resident 60's soiled incontinent pad ( absorbent pad worn by residents) for long period of time. This deficient practice resulted in Resident 60 feeling frustrated and embarrassed, due to lack of or delay in receiving sufficient services to maintain good grooming, and incontinent care and had the potential to lead to skin breakdown. Findings:During a review of Resident 60's admission Record, the admission Record indicated Resident 60 was admitted to the facility on [DATE] with diagnoses including, muscle weakness generalized ( loss of power or function affecting most of the body), difficulty in walking, muscle wasting and atrophy (refers to the loss or thinning of muscle tissue).During a review of Resident 60's Minimum Data Set (MDS - a resident assessment tool) dated 03/01/2026, the MDS indicated Resident 60 had moderately cognitive (ability to think, understand, learn, and remember) impairment. The MDS indicated Resident 60, was dependent (helper does all the effort. Resident does none of the effect to complete the activity) with activities of daily living (ADL routine self-care tasks performed daily-such as eating, bathing, dressing, and toileting).During concurrent observation and interview on 03/24/2026 at 10:25 am, Resident 60 was observed in bed. Resident 60 stated he needs his incontinent pad change and he has not been changed since the previous shift (11 p.m. to 7 a.m.)During an observation on 03/24/2026 at 10:30, with Certified Nursing Assistant (CNA 4), CNA 4 performed personal care to Resident 60. During the observation of changing Resident 60's incontinent pad and cleaning Resident 60, Resident 60 incontinent pad was observed soiled with heavy bowel movement and redness around the buttocks area.During an interview on 03/24/26 at 2:28 p.m. with CNA 4, CNA 4 stated she normally changed Resident 60 after breakfast. CNA 4 stated today (3/24/2026) she was behind because she has orientee that slows her down. CNA 4 stated she noticed Resident 60 incontinent pad was full when Resident 60 lifted his gown up when she walked in his room, but she was busy with another resident and told Resident 60 she will come back in 15miniutes. CNA 4 stated she feels bad for Resident 60 filled with soiled incontinent pad full of heavy feces (stool). CNA 4 stated that was like a loss of dignity and staff cannot meet residents' needs. CNA 4 stated she feels bad and she will try to do better next time and prioritize her assignment. CNA 4 stated she should know which one needs the most care more and ask for help whenever she was behind because this could look like neglect.During an interview on 03/26/2026 at 3:40 p.m., with the Director of Nursing (DON), the DON stated that all CNAs were expected to clean and change residents in a timely manner and to request assistance if they fall behind with their workload. The DON stated she started working at the facility three weeks ago and has been observing CNA practices and implementing changes to better support resident care.During a review of the facility's P&P titled, Activities of Daily Living (ADLs) Supporting dated 03/2025, the P&P indicated Residents who are unable to carry out activities of daily living independently will receive the service necessary to maintain good nutrition, grooming and personal and oral hygiene.

Based on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant 4 (CNA 4) report changes in resident skin condition for one of four sampled residents (Resident 60).The facility failed to:1. Ensure CNA 4 completed required daily shift body check and skin assessment for Resident 60 on 3/24/2026.These failures placed Resident 60 at increased risk for delayed identification and treatment of skin breakdown.Findings:During a review of Resident 60's admission Record, the admission Record indicated Resident 60 was admitted to the facility on [DATE] with diagnoses including, muscle weakness generalized ( loss of power or function affecting most of the body), difficulty in walking, muscle wasting and atrophy (refers to the loss or thinning of muscle tissue).During a review of Resident 60's Minimum Data Set (MDS - a resident assessment tool) dated 03/01/2026, the MDS indicated Resident 60 had moderately cognitive (ability to think, understand, learn, and remember) impairment. The MDS indicated Resident 60, was dependent (helper does all the effort. Resident does none of the effect to complete the activity) with activities of daily living (ADL routine self-care tasks performed daily-such as eating, bathing, dressing, and toileting).During an observation on 03/24/2026 at 10:30, with Certified Nursing Assistant (CNA 4), CNA 4 performed personal care to Resident 60. During the observation of changing Resident 60's incontinent pad and cleaning Resident 60, Resident 60 incontinent pad was observed soiled with heavy bowel movement and redness around the buttocks area. CNA 4 stated she will report the skin redness to the charge nurse and do Resident 60 daily shift body check per protocol.During the concurrent interview on 03/25/206 at 2:09 pm with CNA 4, Licensed Vocational Nurse (LVN) 5, and LVN 6 all together at the nursing station. CNA 4 stated she thought she reported Resident 60's redness around the buttocks to the charge nurse on 03/24/2026 but did not. CNA 4 stated she failed to do the daily shift body check skin assessment for Resident 60. CNA 4 stated by failing to report skin change of condition, it can make the condition worsen if not taking care off right away. During concurrent interviews with LVN 5 and LVN 6, both stated CNA 4 did not report Resident 60's redness around the buttocks on 3/24/2026.During an interview on 03/26/2026 at 3:40 p.m. with the Director of Nursing (DON), the DON stated skin assessments must be completed daily and any significant change in condition must be reported to the charge nurse and the treatment nurse. The DON stated failure to identify and report changes promptly may cause the condition to worsen and places residents at risk for skin breakdown.During a review of the facility's policy and procedure (P&P) titled, Pressure Injury Risk Assessment Revised 07/2025, the P&P indicated skin will be assess for the presence of developing pressure injury (injury to skin and underlying tissue resulting from prolonged pressure on the skin) on a weekly basis or more frequently if indicated. Staff will be maintaining a skin check performing routine skin inspection daily or on shower days as needed the skin completed worksheet will be retained for three months. Nurses are to be notified to inspect the skin if the skin changes are identified. Nurses will conduct skin assessment at least weekly to identify changes.

Based on observation, interview and record review, the facility failed to assess one of four sampled residents (Resident 56) who had indwelling urinary catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage) upon admission to determine the indication for the catheter and whether it should be removed.This failure placed Resident 56 at risk for unnecessary indwelling urinary catheter use, potential infection, lose ability to regain control of bladder function and other complications related to improper catheter management.Findings:During a review of Resident 56's admission Record, the admission Record indicated Resident 56 was admitted to the facility on [DATE] with diagnoses including, muscle weakness generalized ( a loss of power or function affecting most of the body), difficulty in walking, retention of urine, (the inability to completely or partially empty the bladder, causing pain, discomfort, and a strong urge to urinate without success). During a review of Resident 56's Minimum Data Set (MDS- a resident assessment tool) dated 03/10/2026 indicated Resident 56 with severe impairment in cognitive (ability to think, understand, learn, and remember) function. The MDS indicated Resident 56, is dependents (helper does all the effort. Residents do none of the effect to complete the activity) with activities of daily living (ADL- daily self-care activities).During a review of Physician Order Summary report, dated 03/10/2026, the report indicated an order for indwelling urinary catheter to straight drainage with no indication.During concurrent interview and record review on 3/25/26 at 12:12 pm with the Director of Nursing (DON), Physician Order Summary was reviewed. The DON stated there was no indication noted in the Physician Order for Resident 56's indwelling urinary catheter. The DON stated the physician order should specify the reason for using the indwelling urinary catheter.During an interview on 03/27/2026 at 10:58 a.m. with Registered Nurse 2 (RNS 2), RNS 2 stated all residents admitted with an indwelling urinary catheter should be assessed upon admission. RNS 2 stated staff should assess the catheter, determine the reason for its use, identify when it should be discontinued, notify the physician if removal was appropriate, and follow up with urologist (medical doctor specializes in diagnosis and treating diseases of the urinary tract) if needed. RNS 2 stated failing to assess the catheter places residents at risk for infections and discomfort. RNS 2 stated it was good practice to call and clarify orders and ask for the indication.During a follow up interview on 03/27/2026 at 12:22 p.m. with the DON, the DON stated staff should ensure there was an order and an indication for any indwelling urinary catheter upon admission. The DON stated staff should clarify with the physician whether the catheter should be continued to prevent urinary tract infections (UTIs-infection in the urine) and to ensure residents receive an appropriate diagnosis and continued catheter use only when necessary.

Based on observation, interview and record review the facility failed to ensure one of three sampled residents ( Resident 27) maintained adequate nutritional status. The facility failed to:1.Provide one-on-one feeding assistance ( a staff member supports a single resident with eating for the entire meal) as ordered.2.Ensure Boost (nutritional supplement) was administered to Resident 27 as ordered.3.Monitor and respond to Resident 27's declining meal intake.4.Ensure effective communication and follow-through of Registered Dietician nutritional interventions.These deficient practices placed Resident 27 at risk for inadequate nutritional and fluid intake which could lead to malnutrition (a condition resulting from an unbalanced diet), significant weight loss, dehydration (not having enough water in the body), skin impairment, hypoglycemia (low blood sugar), aspiration (the accidental breathing in of food, liquid, saliva, or vomit into the airway and lungs), and subsequently resulted in Resident 27 being admitted to a General Acute Care Hospital (GACH) on 3/27/2026 for poor oral intake and abdominal distention (the visible swelling or enlargement of the belly).Findings:During a review of Resident 27's admission Record, the admission Record indicated Resident 27 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), and diabetes mellitus type 2 (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 27's Minimum Data Set (MDS a resident assessment tool) dated 2/1/2026, the MDS indicated Resident 27's cognition (ability to think, understand, learn, and remember) was severely impaired. The MDS indicated Resident 27 was dependent (helper does all of the effort) with eating, toileting, and showering. During a review of Resident 27's Order Summary Report dated 3/23/2023, the Order Summary Report indicated an order for feeding assists for all meals.During a review of Resident 27's Order Summary Report dated 3/24/2023, the Order Summary Report indicated an order for Aspiration Precautions (safety measures designed to prevent food, fluids, or vomit from entering the airway and lungs), head of bed (HOB) elevated at 75 to 90 degrees for meals, feeding assists for all meals.During a review of Resident 27's Care Plan titled Nutritional Status: Resident 27 has impaired nutritional status., dated 4/17/2023, the care plan goal indicated Resident 27 will remain well nourished and hydrated, as evidenced by moist mucous membranes (tissues that line the mouth) through the review date. The care plan interventions indicated for staff to monitor oral intake, evaluate for any problems, and notify the physician as needed.During a review of Resident 27's Order Summary Report dated 1/11/2024, the Order Summary Report indicated, and order for Fortified diet (foods with extra nutrients), mechanical soft texture (a soft food diet intended to reduce or eliminate the need to chew food), regular liquid consistency three times a day.During an observation on 3/24/2026 at 12:55 p.m., Resident 27 was lying in bed asleep. Resident 27's lunch tray was on the bedside table within Resident 27's reach. The tray contained food and beverages that appeared untouched, with all items unopened and in their original condition. No staff were present to provide assistance at the time of the observation.During an interview on 3/24/2026 at 3:07 p.m., with Certified Nurse Assistant (CNA) 1, CNA 1 stated Resident 27 requires one to one feeding assistance and cannot eat independently. CNA 1 stated she left the tray at the bedside and intended to return to feed the resident. She stated that leaving the tray within reach without supervision could place the resident at risk because Resident 27 might attempt to eat independently, which could cause choking or food going down the wrong way. CNA 1 stated Resident 27 usually eats 25-40% of her meals but her intake had been declining. CNA 1 stated the resident had been extremely sleepy during meals. CNA 1 stated the charge nurse should be notified when a resident shows a decline in food intake. She also stated Resident 27 did not eat breakfast or lunch and did not drink any liquids during breakfast. CNA 1 stated she did not report this to the charge nurse. CNA 1 could not explain why she failed to report it and stated she should have notified the charge nurse immediately.During an interview on 3/24/2026 at 3:27 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 27 requires one to one assistance with feeding and sometimes refuses to eat. LVN 1 stated staff should not leave meal trays at the bedside for residents who require one to one assistance. She stated that leaving a tray without supervision may result in the resident attempting to eat independently while lying in a reclined position without proper head of bed elevation. LVN 1 stated these places Resident 27 at risk for choking and aspiration, which could lead to aspiration pneumonia (lung infection caused by inhaling food or liquid), respiratory distress, or airway obstruction. LVN 1 stated Resident 27's nutritional intake had been declining for several weeks and the resident's average intake was about 25%. She stated when a resident does not consume enough food or supplements, such as Boost( supplements), staff were required to notify the physician and follow the care plan interventions. LVN 1 stated failing to provide ordered supplements or report decreased food intake to the physician places the resident at risk for malnutrition, significant weight loss, dehydration, hypoglycemia (low blood sugar), and skin impairment.During an observation on 3/25/2026 at 8:11 a.m., Resident 27 was asleep in bed with the head of the bed elevated approximately 20-30 degrees. No staff were present at the bedside to provide one to one feeding assistance. Resident 27's meal tray was within reach on the bedside table, and several food items, including the juice, remained unopened. At the time of the observation, there was no evidence that the resident had eaten any portion of the meal.During a concurrent observation and interview on 3/26/2026 at 8:00 a.m. with Certified Nurse Assistant (CNA) 1, Resident 27's breakfast tray was on the meal cart outside the resident's room. The tray appeared untouched, with all food and liquids unopened and in their original condition. It was placed with other completed trays and appeared ready for pickup by dietary staff. CNA 1 stated the breakfast tray belonged to Resident 27 and confirmed it had not been eaten. CNA 1 stated Certified CNA 2 assisted Resident 27 with breakfast.During an interview on 3/26/2026 at 8:30 a.m., with CNA 2, CNA 2 stated she assisted Resident 27 with breakfast. CNA 2 stated Resident 27 was extremely sleepy and did not want to eat that morning. She stated the resident usually eats about 25% of her meals. CNA 2 stated she informed LVN 2, and LVN 2 told her she would notify CNA 1, who was assigned to Resident 27, to provide Boost to the resident.During an interview on 3/26/2026 at 9:04 a.m. with CNA 1, CNA 1 stated she was not informed by LVN 2 Resident 27 needed Boost. CNA 1 stated she did not provide the Boost supplement to Resident 27.During a concurrent interview and record review on 3/26/2026 at 9:25 a.m. with LVN 2, Resident 27's Medication Administration Record (MAR) dated 3/2026 was reviewed. The MAR indicated, Boost (237 milliliters) three times a day for supplement with medication pass. LVN 2 stated she had not been administering the Boost supplement to Resident 27 during medication passes and could not explain why she failed to give it as ordered. LVN 2 stated Resident 27 requires one to one assistance with meals and had experienced a decline in oral intake. LVN 2 stated a decline in a resident's oral intake constitutes a change in condition and requires physician notification. LVN 2 stated she did not remember to instruct CNA 1 to administer the resident's ordered Boost after CNA 2 informed her that Resident 27 did not eat breakfast. LVN 2 stated failing to provide one to one feeding assistance, failing to administer ordered supplements, and failing to notify the physician of a change in condition places the resident at risk for malnutrition, weight loss, dehydration, hypoglycemia, aspiration, and other complications that could lead to aspiration pneumonia, respiratory distress, or hospitalization.During a concurrent interview and record review on 3/26/2026 at 3:02 p.m. with the Registered Dietitian (RD), reviewed Resident 27's Nutrition/Dietary Note dated 3/22/2026. The note indicated, Body Mass Index (BMI medical screening tool to calculate person body fat) = 18.1 (underweight). otherwise oral intake is poor for most meals. Refusing Remeron ( medication used for appetite stimulant) to stimulate appetite. The RD stated Resident 27's nutritional status does not meet nutritional standards, and the resident is at risk for malnutrition. The RD stated Resident 27's oral intake does not meet her daily caloric needs. The RD stated the resident typically consumes only 25-50% of meals. The RD stated Resident 27 was supposed to receive Boost three times a day with the medication pass and Remeron 30 milligram (mg-unit of measurement) at bedtime; however, nursing staff were not implementing these interventions consistently or on time. The RD stated that based on the resident's low caloric intake, the Remeron does not appear to be effective. The RD stated she communicates her recommendations to nursing staff by emailing the Director of Nursing (DON), the Director of Staff Development (DSD), the Dietary Supervisor (DS), and the Administrator. She stated that interventions such as supplements (Boost) were not consistently being carried out by nursing staff and staff do not provide follow up to her. The RD stated that if a resident is not eating and supplements are ordered, staff are expected to notify her so she can re-evaluate the plan of care and involve the family if necessary. The RD stated if Resident 27 continues to consume only about 25% of meals, she is at risk for malnourishment, significant weight loss, dehydration, skin impairment, and hypoglycemia. The RD further stated that without proper feeding assistance, the resident is also at risk for poor oral intake, choking, weight loss, and aspiration pneumonia. The RD stated Resident 27's intake had declined and no longer met her nutritional needs and acknowledged this decline constitutes a change in condition that should have been communicated to the physician. The RD stated she did not notify the physician and was unsure why it was not communicated. She stated timely communication with the physician is necessary to ensure appropriate interventions and prevent further decline in the resident's condition.During a concurrent interview and record review on 3/27/2026 at 10:10 a.m. with the Director of Nursing (DON), reviewed Resident 27's Priority Reports dated 3/8/2026, 3/15/2026, and 3/22/2026. The Priority Reports indicated Decreased Meal + Weight Loss. The DON stated she was aware Resident 27 had poor intake and the resident's nutritional intake had recently declined. She stated residents who require one to one feeding must be assisted during meals and properly positioned, and staff are expected to ensure they are fed safely. The DON stated when residents are not eating, staff should notify the physician, offer supplements such as Boost, document intake, and monitor them closely. She stated staff should have given Resident 27 the ordered Boost when she did not eat. The DON there was a breakdown in communication regarding Resident 27's interventions. The DON stated LVNs are responsible for supervising CNAs, ensuring interventions were implemented, and following up on resident care. She stated LVNs must ensure ordered interventions were carried out. She stated that if LVNs do not check residents' trays or review CNA intake documentation, this would not meet facility expectations. The DON stated a decline in a resident's nutritional intake was considered a change in condition and should be reported to the physician immediately. She stated that based on the information provided, it does not appear Resident 27's condition was communicated to the physician in a timely manner. The DON stated Resident 27 who require one to one assistance and do not receive it are at risk for weight loss, malnutrition, dehydration, skin breakdown, aspiration, and overall decline. She stated based on the information presented, Resident 27 needs were not fully met.During a review of Resident 27's Task: Amount Eaten, the amount eaten indicated the following:2/25/2026 at 9:00 a.m. 26% - 50%2/25/2026 at 1:00 p.m. 26%- 50%2/25/2026 at 6:30 p.m. 26% - 50%2/25/2026 at 6:52 p.m. 0-25%2/27/2026 at 10:08 p.m. 0-25%3/8/2026 at 2:04 p.m. 0-25%3/10/2026 at 2:04 p.m. 0-25%3/11/2026 at 10:23 p.m. 0-25%3/12/2026 at 2:26 p.m. 0-25%3/19/2026 at 1:40 p.m. 0-25%3/22/2026 at 1:58 p.m. 0-25%3/22/2026 at 7:39 p.m. 0-25%During a review of Resident 27's Transfer Form, dated 3/27/2026, the Transfer Form indicated, Resident 27 was transferred to General Acute Care Hospital (GACH) due to abnormal lab test, abdominal distention, and poor oral intake.During a review of the facility's policy and procedure (P&P) titled, Assistance with Meals, dated 2022, the P&P indicated Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity.During a review of the facility's P&P titled, Change in a Resident's Condition or Status, dated 2021, the P&P indicated The nurse will notify the resident's attending physician or physician on call when there has been a(an).specific instruction to notify the physician of changes in the resident's condition.During a review of the facility's P&P titled, Dysphagia, dated 20212, the P&P indicated In addition, the nurse shall assess and document/report the following: Decreased intake with potential for dehydration or malnutrition.

Based on observation, interviews, and record review, the facility failed to ensure medications were not left open and unattended for one of four sampled residents (Resident 63)'s bedside.This deficient practice placed Resident 63 at risk for medication errors, including missed, duplicated, or inappropriate administration.Findings:During a review of Resident 63's admission Record, the admission Record indicated Resident 63 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease (lasting damage to the kidneys), and transient ischemic attack ([TIA]-brief episode of neurologic [relating to the nervous system] dysfunction).During a review of Resident 63's Minimum Data Set (MDS a resident assessment tool) dated 3/11/2026, the MDS indicated Resident 63 required dependent assistance (helper does all of the effort) with toileting, oral hygiene, bathing, and showering.During a concurrent observation and interview on 3/24/2026 at 10:53 a.m. with Resident 63, open medications (nine pills) were observed to be left unattended at Resident 63's bedside. No licensed nurse or staff member was present at the time of observation. Resident 63 was observed lying in bed with the medications within reach. Resident 63 stated the medications had been sitting at the bedside for a while but were unable to specify the exact length of time. Resident 63 stated leaving medications at the bedside was a usual practice, and that he sometimes takes the medications and sometimes does not, depending on how he feels.During a review of Resident 63's Medication Administration Record (MAR) dated 3/2026, the MAR indicated, on 3/24/2026, for the 9:00 a.m. administration time there were staff initials in the box for Resident 63's indicating that the following medications were administered:Cholecalciferol (helps maintain strong bones and teeth) oral tablet 50 microgram (mcg-unit of measurement)Clopidogrel Bisulfate (used to prevent dangerous blood clots) oral tablet 75 milligram (mg-unit of measurement)Cyanocobalamin (helps maintain nerve health) oral tablet 1000 mcgFerrous Sulfate (iron [mineral supplement]) oral tablet 325 mgFolic Acid (vitamin) oral tablet 800 mcgMagnesium Oxide (mineral supplement) oral tablet 400 mgRena-Vite (used to treat or prevent vitamin deficiency due to poor diet) oral tabletDuring a concurrent observation, and interview, on 3/24/2026 at 11:00 a.m. with License Vocational Nurse (LVN) 3 observed opened medications at Resident 63's bedside within the resident's reach. LVN 3 stated the medications were left by him. LVN 3 was unable to provide an explanation as to why the medications were left at the bedside. LVN 3 stated Resident 63 was not approved for self-administration of medications. LVN 3 stated per facility policy, medications should not be left at the bedside because there was no assurance the residents will take them as prescribed. LVN 3 stated medications are to be administered directly to the residents and should remain secure and not accessible to others to ensure safe and proper administration. LVN 3 stated medications left unattended could be accessed by others or become contaminated, compromising resident safety. During an interview on 3/27/2026 at 12:00 p.m. with the Director of Nursing (DON), the DON stated that, per facility policy, medications should not be stored or left at the resident's bedside. The DON stated the nurse was expected to remain with the resident until the medications were administered. The DON stated only residents who have been assessed and approved may self-administer medications. The DON stated unauthorized access to medications by visitors or roommates is prevented by ensuring medication was not left unattended at the bedside. The DON stated that compliance with federal and state regulations is ensured through ongoing monitoring, including daily oversight and additional review as needed. The DON stated leaving medications at the bedside creates potential risks, including the possibility of medications being taken by others, medications not being taken in a timely manner, and delay or ineffective therapeutic outcomes. During a review of the facility's policy and procedure (P&P) titled, Self-Administration of Medication revised 2/2021, the P&P indicated, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the residents to do so. If the team determines that a resident cannot safely self-administer medications, the nursing staff administer the resident's medication.During a review of the facility's policy and procedure (P&P) titled, Medication Labeling and Storage, dated 2023, the P&P indicated, The facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls.

Based on observation, interviews and record review, the facility failed to ensure a monthly Medication Regimen Review ([MRR]- a thorough evaluation of a patient's complete medication list to ensure the medication therapy is safe, necessary, and effective) was conducted and maintained by a licensed pharmacist for one of three residents Resident (27). This failure resulted in a lack of professional oversight to identify potential medication irregularities and placed the residents at risk for adverse drug events, excessive sedation, and the continued use of potentially unnecessary medications.Findings: During a review of Resident 27's admission Record, the admission Record indicated Resident 27 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), and diabetes mellitus type 2 (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 27's Minimum Data Set (MDS a resident assessment tool) dated 2/1/2026, the MDS indicated Resident 27's cognition (ability to think, understand, learn, and remember) was severely impaired. The MDS indicated Resident 27 was dependent (helper does all of the effort) with eating, toileting, and showering. During a review of Resident 27's Order Summary Report, dated 7/24/2024, the Order Summary Report indicated, Remeron (medication used for patients with depression [persistent sadness and loss of interest], insomnia [difficulty sleeping], and poor appetite) oral tablet 30 milligrams ([mg]- unit of measurement) give one tablet by mouth at bedtime for depression manifested by poor appetite. During an interview on 3/26/2026 at 8:30 a.m. with Certified Nurse Assistant (CNA) 2, CNA 2 stated she assisted Resident 27 with breakfast. CNA 2 stated Resident 27 was extremely sleepy and did not want to eat this morning. CNA 2 stated the residents usually eat 25% of her meals.During an observation on 3/26/2026 at 10:30 a.m. Resident 27 lying in bed with eyes closed, sleepy, and responded only to tactile stimuli (by touch). During a concurrent interview and record review on 03/26/2026 at 11:20 a.m. with the Director of Nursing (DON), Resident 27's MRR dated 1/2026 and 2/2026 was reviewed, the MRR indicated no evidence of a pharmacist conducted monthly medication review for Resident 27. The DON stated she was unable to provide documentation of completed MRR's for Resident 27 for the following months: September 2025, October 2025, November 2025, December 2025, January 2026, and February 2026. The DON was unable to explain why the required reviews were not conducted. The DON stated MRR was required to ensure a licensed pharmacist evaluates each resident's medications monthly in order to identify medication irregularities, prevent adverse drug reactions, ensure medications were clinically appropriate, and recommend changes to the physician when needed. The DON stated lack of a monthly MRR places residents at risk for undetected adverse drug reactions, continued use of unnecessary or inappropriate medication, excessive sedation, and decline in condition. During an interview on 3/26/2026 at 3:02 p.m. with the Registered Dietician (RD), the RD stated despite the resident being prescribed Remeron for depression manifested by poor appetited, the resident continues to demonstrate consistently low caloric intake (the total amount of energy an individual consumes from food and beverages each day) , indicating the medication has not been effective in improving Resident 27's appetite. During a review of the facility's policy and procedure (P&P) title, dated, Medication Monitoring Drug Regimen Review (Monthly Report) [undated], the P&P indicated, Reviewing the medication regimen (drug regimen review) of each resident at least monthly, incorporating federally mandated standards of care in addition to other applicable professional standards, and documenting the review and findings in the consultation report.

Based on observation, interview and record review the facility failed to ensure one of six sampled residents (Resident 75) was seen by a dentist for her broken, loose missing teeth.This failure had the potential to result in the inability to effectively chew foods, weight loss, lack of energy and loss of muscle mass for Resident 75.Findings:During a review of Resident 75's admission Record (face sheet) dated 3/26/2026, the admission record indicated Resident 75 was admitted to the facility with diagnosis including breast cancer (rapid growth of abnormal cells), atrial fibrillation (irregular heartbeat) and muscle weakness.During a review of Resident 75's History and Physical (H&P) dated 1/30/2026, the H&P indicated, Resident 75 was alert and oriented.During a review of Resident 75's Minimum Data Set (MDS) a standardized assessment and care screening tool) dated 3/6/2026, the MDS indicated Resident 75 had moderate cognitive impairment. The MDS indicated Resident 12 needed substantial/maximal assistance (helper does more than half the work) with activities of daily living ([ADLs] daily self-care activities like toileting, bathing and dressing). The MDS indicated Resident 75 had obvious or likely cavities or broken natural teeth.During a concurrent observation and interview on 3/24/2026 at 9:36 a.m. with Resident 75 at Resident 75's bedside. Resident 75's bottom teeth were observed to have two teeth, one was broken and one was loose. Resident 75 stated she had not seen a dentist in a long time and would like to see about getting some dentures. Resident 75 stated it would be easier to eat with dentures, and she would like to not have to eat baby food anymore.During an interview on 3/27/2026 at 11:33 a.m. with Registered Nurse Supervisor1 (RNS 1), RNS 1 stated she was the nurse who admitted Resident 75 to the facility and she was aware Resident 75 was missing teeth and forgot to put in the order for Resident 75 to see a dentist. RNS1 stated Resident 75 was at risk for malnutrition and needed to see a dentist.During an interview on 3/27/2026 at 11:33 a.m. with the Director of Nurses (DON), the DON stated residents with missing teeth need to be seen by a dentist to have an oral assessment to provide interventions. The DON stated Resident 75 may not be able to chew or eat well and may feel self-conscious about how they look.During a review of the facility's policy and procedure (P&P) titled Dental Consultant dated 4/2007, the P&P indicated, a consultant dentist is retained by our facility and is responsible for providing consultation to physicians and providing other services relative to dental matters. Providing a dental assessment of each resident within ninety (90) days of admission. Performing or supervising an annual dental reevaluation for each resident. Providing staff in-service education assuring that emergency dental services are available. Providing necessary information concerning residents to appropriate staff, care planning conferences, and/or committees.

Based on observation, interviews, and record review, the facility failed to ensure the accuracy of the medical record for one of three residents (Resident 63). As evidence by documentation indicating medications were administered on 3/24/2026 at 8:08 a.m., while observation revealed medications were left opened/unattended at the bedside and not confirmed as administered.This deficient practice resulted in inaccurate documentation of medication administration and had the potential to affect Resident 63's treatment and care.Findings:During a review of Resident 63's admission Record, the admission Record indicated Resident 63 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease (lasting damage to the kidneys), and transient ischemic attack ([TIA]-brief episode of neurologic [relating to the nervous system] dysfunction).During a review of Resident 63's Minimum Data Set (MDS a resident assessment tool) dated 3/11/2026, the MDS indicated Resident 63 required dependent assistance (helper does all of the effort) with toileting, oral hygiene, bathing, and showering.During a concurrent observation and interview on 3/24/2026 at 10:53 a.m. with Resident 63, open medications (nine pills) were observed to be left unattended at Resident 63's bedside. No licensed nurse or staff member was present at the time of observation. Resident 63 was observed lying in bed with the medications within reach. Resident 63 stated the medications had been sitting at the bedside for a while, but were unable to specify the exact length of time. Resident 63 stated leaving medications at the bedside was a usual practice, and that he sometimes takes the medications and sometimes does not, depending on how he feels.During a review of Resident 63's Medication Administration Record MAR dated 3/2026, the MAR indicated, on 3/24/2026, for the 9:00 a.m. administration time there were staff initials in the box for Resident 63's indicating that the following medications were administered:Cholecalciferol ( helps maintain strong bones and teeth) oral tablet 50 microgram (mcg-unit of measurement)Clopidogrel Bisulfate (used to prevent dangerous blood clots) oral tablet 75 milligram (mg-unit of measurement)Cyanocobalamin ( helps maintain nerve health) oral tablet 1000 mcgFerrous Sulfate (iron [mineral supplement]) oral tablet 325 mgFolic Acid (vitamin) oral tablet 800 mcgMagnesium Oxide (mineral supplement) oral tablet 400 mgRena-Vite (used to treat or prevent vitamin deficiency due to poor diet) oral tabletDuring a review of Resident 63's Medication Administration Audit Report dated 3/24/2026 at 11:08 a.m., the Medication Administration Audit Report indicated the following medications administered:Cholecalciferol oral tablet 50 mcgClopidogrel Bisulfate oral tablet 75 mgCyanocobalamin oral tablet 1000 mcgFerrous Sulfate oral tablet 325 mgFolic Acid oral tablet 800 mcgMagnesium Oxide oral tablet 400 mgRena-Vite oral tabletDuring an interview on 3/24/2026 at 11:30 a.m. with License Vocational Nurse (LVN) 3, LVN 3 stated he documented the administration of Resident 63's medications on 3/24/2026 at 8:08 a.m. before the medications were administered. LVN 3 stated the medications were left at Resident 63's bedside and had not been administered at the time of documentation. LVN 3 stated this practice could result in medications being missed, delayed, or duplicated. LVN 3 stated inaccurate documentation could place the resident at risk for ineffective therapy, adverse drug events, or other medications errors. LVN 3 stated medications must be administered directly to the resident and accurately documented at the time of administration.During a concurrent interview and record review on 3/37/2026 at 12:00 p.m. with the Director of Nursing (DON), Resident 63's Medication Administration Audit Report dated 3/24/2026 at 8:08 was reviewed, the Medication Administration Audit Report indicated LVN 3 documented administration of Resident 63's medications. The DON stated documentation of medication administration must accurately reflect the time and action of administration. The DON stated documenting medications before they are actually given was not in accordance with facility policy or professional standards. The DON stated medications should be administered directly to the residents, verified, and immediately documented in the MAR. The DON stated inaccurate documentation could lead to missed, delayed, or duplicated doses, creating a risk of ineffective therapy, adverse drug events, or other medication errors. The DON stated inaccurate records compromise resident safety and could place the facility at risk for regulatory non-compliance.During a review of the facility's policy and procedure (P&P) titled, Administering Medications dated 2019, the P&P indicated, Medications are administered in accordance with prescriber order, including any required time frame.During a review of the facility's P&P titled, Administering Medications dated 2029, the P&P indicated, If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose.During a review of the facility's P&P titled, Administering Medications dated 2029, the P&P indicated The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones.Cross reference F755

Based on observation, interview, and record review, the facility failed to ensure infection control measures were observed for three of six sampled residents (Residents 6, 12 and 79). The facility failed to:1.Ensure signage for Enhanced Barrier Precautions (EBP- infection control intervention using gown and gloves during high contact resident care activities designed to reduce the transmission of multi-drug-resistant organisms {microorganisms, predominantly bacteria, that are resistant to one or more classes of antimicrobial agents}) was in place for Resident 6.2.Ensure the laundry staff cleaned and documented the dryer lint trap screens every two hours.3.Ensure the kitchen staff monitored and documented the refrigerator temperatures.4. Ensure staff member wore personal protective equipment (PPE-gown, gloves) before providing patient care to Resident 12 who was on EBP for stasis ulcers (open sores).5. Ensure Resident 79's care giver removed PPE before exiting Resident 79's room to walk down the hallway after providing personal care.These deficient practices had the potential to result in cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another) and place residents at risk for the spread of infection.Findings: 1.During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and congestive heart failure (CHF- a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 6's Order Summary Report, the Order Summary Report indicated an order dated 2/26/2026 for EBP for a left heel wound. During a review of Resident 6's Minimum Data Set (MDS- a resident assessment tool) dated 3/6/2026, indicated Resident 6's cognition (ability to think, understand, learn, and remember) for daily decision making was severely impaired. The MDS indicated Resident 6 was dependent (helper does all the effort) with activities of daily living (ADLs- routine tasks such as bathing, dressing, and toileting a person performs daily to care for themselves). During a concurrent observation and interview on 3/24/2026 at 1:01 p.m. with Certified Nurse Assistant (CNA) 3, in Resident 6's room, CNA 3 indicated Resident 6 was on EBP but there was no signage indicating Resident 6 was on isolation. CNA 3 stated there should be signage outside the room to indicate the type of isolation Resident 6 was on and what precautions to take. During an interview on 3/25/2026 at 12:09 p.m., with the Infection Prevention Nurse (IPN), IPN stated the isolation precaution signage is placed outside the resident's rooms to indicate what type of isolation and what precautions to take. IPN stated there should be signage for all residents on isolation to ensure the staff are taking proper precautions and to prevent the spread of infection. 2.During a concurrent observation and interview on 3/26/2026 at 7:10 a.m., in the laundry room, Laundry Aide (LA) 1 was observed cleaning the dryer lint trap screens which were full of lint. LA 1 stated he last cleaned the lint trap at 2:00 a.m. and 4:00 a.m. but did not document that he cleaned it. During an interview on 3/26/2026 at 7:59 a.m., with the Laundry Supervisor (LS) 1, LS 1 stated the dryer lint trap screens are supposed to be cleaned every two hours and documented on the log sheet. LS 1 stated it's important to clean the dryer lint trap screen to ensure the clothes dry at the right temperature and for safety because not doing so is a fire hazard. 3.During an observation on 3/24/2026 at 8:17 a.m., in the kitchen, the snack refrigerator temperature log was not up to date. Dates missing were 3/22/3026 and 3/23/2026. During an interview on 3/26/2026 at 2:41 p.m., [NAME] © 1, C 1 stated it is her responsibility to check the refrigerator temperatures and document on the log sheet. C 1 stated I messed up the other day and should have made sure to check the temperatures because not doing so could result in food being served at the wrong temperatures which could cause the residents to get sick. During an interview on 3/27/2026 at 9:38 a.m., with the Dietary Supervisor (DS), DS stated it is her process to check and document the refrigerator temperatures per shift in a timely manner. DS stated it is important that the refrigerator temperatures are monitored per shift for the safety of the residents; they could get sick and possibly die. During an interview on 3/27/2026 at 1:07 p.m., with the Director of Nursing (DON), DON stated it's important to have isolation precaution signage present to alert the staff and visitors to ensure the appropriate isolation precautions are being taken. The DON stated dryer lint trap screens should be cleaned for infection control because if the lint accumulates, the linens will not dry properly and because it's also a fire hazard. The DON stated the refrigerator temperatures should be checked and documented to ensure the food does not spoil because it could lead to the residents getting sick. During a review of the facility's policy and procedure (P&P) titled, Policies and Practices- Infection Control dated 10/2018, the P&P indicated, The facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. During a review of the facility's P&P titled, Maintenance of the Laundry Room and Laundry Equipment, undated, Clean lint filters after each use of washer or dryer every three hours.: During a review of the facility's P&P titled, Refrigerators and Freezers, dated 11/2022, the P&P indicated, The facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. The P&P indicated, Food service supervisors or designated employees check and record refrigerator and freezer temperatures daily with first opening and first closing in the evening. 4. During an observation on 3/24/2026 at 12:49 p.m. in Resident 12's room, the Director of Staff Development (DSD) was observed repositioning Resident 12 not wearing PPE. During an observation on 3/25/2026 at 7:10 a.m. outside of Resident 79's room, Resident 79's care giver was observed not removing her PPE before leaving Resident 79's room to walk down the hallway to access the dirty linen cart. During a review of Resident 12's admission Record (face sheet) dated 3/26/2026, the admission record indicated, Resident 12 was admitted on [DATE] and readmitted on [DATE], with diagnosis including heart failure (heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), diabetes mellitus (a condition in which the body fails to process glucose (sugar) correctly), dementia (loss of memory, language, problem-solving and other thinking abilities). During a review of Resident 12's History and Physical (H&P) dated 1/30/2026, the H&P indicated, Resident 12 did not have the capacity to understand and make decisions. During a review of Resident 12's Minimum Data Set (MDS) a standardized assessment and care screening tool) dated 2/5/2026, the MDS indicated Resident 12 did not have the capacity to understand and make decisions. The MDS indicated Resident 12 was dependent (helper does all the effort) with activities of daily living ([ADLs] daily self-care activities like toileting, bathing and dressing). During a review of Resident 12's Order Summary Report dated 3/26/2026, the order summary report indicated Resident 12 was on EBP for stasis ulcers. The order summary report indicated betadine (antiseptic) solution apply to left leg topically (on the skin) every day shift for stasis dermatitis (skin condition) for 21 days, cleanse with normal saline (ns), pat dry, apply betadine solution, cover with an abdominal pad (absorbent pads) followed by a bandage roll. The order summary report indicated Silvadene cream (topical antibiotic) apply to right leg topically every day shift for stasis dermatitis for 21 days, cleanse with ns, pat dry, apply Silvadene cream cover with abdominal pad followed by bandage roll. During a review of Resident 79's admission Record (face sheet) dated 3/26/2026, the admission record indicated, Resident 79 was admitted on [DATE], with diagnosis including fracture of left tibia (broken shinbone), anemia (a condition in which there is lack of enough red blood cells) and muscle weakness. During a review of Resident 79's History and Physical (H&P) dated 1/10/2026, the H&P indicated, Resident 79's had normal level of consciousness. During a review of Resident 79's Minimum Data Set (MDS) a standardized assessment and care screening tool) dated 1/13/2026, the MDS indicated, Resident 79 had the capacity to understand and make decisions. The MDS indicated Resident 79 needed substantial/maximal assistance (helper does more than half the effort) with activities of daily living (ADLs] daily self-care activities like toileting, bathing and dressing. During an interview on 3/24/2025 at 1:13 p.m. with the DSD, the DSD stated Resident 12 was on EBP for her leg wounds. The DSD stated she should have been wearing PPE when repositioning Resident 12. The DSD stated Resident 12 was at an increased risk for infection when not wearing PPE while providing direct patient care. 5.During an interview on 3/25/2026 at 7:20 a.m. with Resident 79's care giver, the care giver stated she had finished caring for Resident 79 and walked down the hallway to put the dirty linen in the linen cart. The care giver stated she was not educated by the staff about PPE and she was not aware she should take of her dirty PPE before walking in the hallway. During an interview on 3/27/2026 at 8:48 p.m. with the infection preventionist (IP), the IP stated EBP is an infection control measure used to protect the resident from bacteria and germs. The IP stated residents are at risk for cross contamination when staff are not wearing PPE. The IP stated PPE is not to be worn in the hallway it is to be removed in the room and put in a closed trash receptacle to prevent cross contamination. During an interview on 3/27/2026 at 11:47 a.m. with the Director of Nursing (DON), the DON stated she was aware the DSD did not wear PPE before providing care to Resident 12. The DON stated she was aware the care giver for Resident 79 did not take off her PPE before leaving Resident 79's room after providing care. The DON stated there was a risk for cross contamination when infection control measures are not followed. During a review of the facility's policy and procedure (P&P) titled Standard Precautions, Enhanced Barrier Precautions and Transmission dated 5/25/2025, the P&P indicated it provided guidelines for infection control practices to reduce the potential for transmission of pathogens including COVD-19 and multi-drug-resistant organisms and viruses. Enhanced Barrier Precautions (EBP- primarily is the use of gowns and gloves for specific high contact care activities, based on the resident's characteristics associated with a high risk of [NAME] colonization and transmission. Presence of indwelling medical devices (e.g., urinary catheter, feeding tube, endotracheal or tracheostomy tube, central/vascular catheters, etc.). Chronic and open non-healing wounds (Vascular, Diabetic Venous open ulcer/s) or chronic non healing pressure ulcer stage 3/stage 4. A resident with Stage 1 or Stage 2 pressure ulcer/s will not be placed on EBP unless indicated and ordered by the attending physician. Any care activity where close contact with the resident is expected to occur such as bathing, peri-care, assisting with toileting, changing incontinence briefs, respiratory care. Changing bed linens. Any care activity involving contact with environmental surfaces is likely contaminated by the resident. Visitors and volunteers shall be educated and instructed in hand hygiene protocols, PPE use, and other infection control practices.

Based on interview and record review, the facility failed to implement their protocol for Antibiotic Stewardship (refers to a set commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use) for two of three sampled residents (Resident 54 and Resident 66).This deficient practice had the potential for Resident 54 and Resident 66 to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use.Findings:1. During a review of Resident 54's admission Record, the admission Record indicated Resident 54 was admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 54 was admitted with diagnoses including cerebral infarction (stroke, loss of blood flow to a part of the brain) and hypertension (HTN- high blood pressure).During a review of Resident 54's Minimum Data Set (MDS- a resident assessment tool) dated 2/28/2026, the MDS indicated Resident 54's cognition (ability to think, understand, learn, and remember) for daily decision making was intact. The MDS indicated Resident 54 was dependent (helper does all the effort) with toileting, bathing, and dressing.During a review of Resident 54's Order Details dated 2/25/2026, the Order Details indicated an order for Levaquin (medication to treat an infection) 250 milligrams (mg- unit of measurement) by mouth daily for a urinary tract infection (UTI- an infection in the bladder).During a review of Resident 54's Infection Surveillance Form dated 3/1/2026, the Infection Surveillance Form indicated Resident 54 had an antibiotic (medication to treat an infection) order for UTI. The Infection Surveillance Form indicated Resident 54 was asymptomatic and did not meet McGeer's criteria (a standardized set of rules used in nursing homes and long-term care facilities to consistently identify and track infections) for antibiotic usage. 2. During a review of Resident 66's admission Record, the admission Record indicated Resident 66 was admitted to the facility on [DATE] with diagnoses including HTN and Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities).During a review of Resident 66's MDS dated [DATE], the MDS indicated Resident 66's cognition was severely impaired. The MDS indicated Resident 66 required supervision (helper provides verbal cues) with activities of daily living (ADLs- routine tasks such as bathing, dressing, and toileting a person performs daily to care for themselves).During a review of Resident 66's Order Details dated 2/6/2026, the Order Details indicated an order for Macrobid (medication to treat an infection) 100mg twice a day for UTI.During a concurrent interview and record review on 3/25/2026 at 12:09 p.m., with the Infection Prevention Nurse (IPN), the IPN stated Resident 54 and Resident 66 did not meet McGeer's criteria and neither Resident 54 nor Resident 66's doctors were informed but should have been. IPN stated continuing an antibiotic when it does not meet McGeer's criteria puts Resident 54 and Resident 66 at risk for antibiotic resistance and developing multidrug resistant infections (MDROs- are microorganisms that have developed resistance to multiple classes of antibiotics).During an interview on 3/27/2026 at 1:07 p.m., with the Director of Nursing (DON), the DON stated when a resident does not meet McGeer's criteria the residents' doctor should be notified to possibly discontinue the antibiotic. DON stated residents on antibiotics without meeting McGeer's criteria could result in unnecessary usage and resistance to antibiotics.During a review of the facilities policy and procedure (P&P) titled, Antibiotic Stewardship, dated 10/2016, the P&P indicated, Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. The P&P indicated The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents. The P&P indicated Training of staff will emphasize the importance of antibiotic stewardship and will include how inappropriate use of antibiotics affects individual residents and the overall community.During a review of the facility's P&P titled, Surveillance for Infections, dated 9/2017, the P&P indicated, The criteria for such infections are based on current standard definitions of infections. The facility is using McGeer's criteria to determine infection. McGeer's criteria is a standardized evidenced based definitions used for surveillance of healthcare associated infections.

Based on observation, interview, and record review, the facility failed to:1. Ensure adequate room size and space to support the comfort and well being for one of six sampled residents (Resident 59).2. Ensure 6 of 26 residents' rooms (Rooms 21, 22, 23, 25, 26 and 27) met the requirements of 80 square feet for each resident.This failure had the potential to negatively impact Resident 59's quality of life by limiting his ability to move freely and safely within his living space and had the potential to result in inadequate provision of safe nursing care and a lack of privacy for residents.Findings:During a concurrent observation and interview on 3/26/2026 at 8:22 a.m. with Resident 59 at bedside, Resident 59's television (TV) stand was observed to be blocking Resident 59 from being able to maneuver his w/c to the left side of his bed. Resident 59 stated this room is way too small for him. Resident 59 TV stand had to be moved for him to get to the left side of his bed. Resident 59 stated there was nothing he could do about it, this was the room the facility gave him.During a review of Resident 59's admission Record (face sheet) dated 3/26/2026, the admission record indicated, Resident 59 was admitted to the facility with diagnosis including hemiplegia (paralysis of one side of the body), diabetes mellitus (a condition in which the body fails to process glucose (sugar) correctly) and difficulty walking.During a review of Resident 59's History and Physical (H&P) dated 4/30/2025, the H&P indicated, Resident 59's cognition was intact.During a review of Resident 59's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 12/18/2025, the MDS indicated Resident 59's cognition was intact. The MDS indicated Resident 59 needed substantial/maximal assistance (helper does more than half the effort) with activities of daily living (ADLs] daily self-care activities like toileting, bathing and dressing. The MDS indicated Resident 59 used a wheelchair (w/c) for mobility (moving around).During a review of the facility's Client Accommodation Analysis (CAA-room measurements) dated 3/25/2026, the CAA indicated room [ROOM NUMBER] (4 beds) was 292.87 sq. ft., room [ROOM NUMBER] (4 beds) was 306.40 sq. ft., room [ROOM NUMBER] (4 beds) was 308.81 sq. ft., room [ROOM NUMBER] (4 beds) was 307.20 sq. ft., room [ROOM NUMBER] (4 beds) was 310.22 sq. ft., and room [ROOM NUMBER] (4 beds) was 310.22 sq. ft.During an interview on 3/27/2026 at 8:31 a.m. with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated Resident 59's room was small. CNA 2 stated she had to move the TV stand every time she needed to get to the left side of Resident 59's bed. CNA 2 stated there were safety concerns with the small space.During an interview on 3/27/2026 at 8:46 a.m. with the plant supervisor (PS), the PS stated Resident 59's room was small and did not meet the 80 sq ft for each resident. The PS stated there were safety hazards and tripping concerns with a smaller room.During an interview on 3/27/2026 at 2:11 p.m. with the Administrator (ADM), the ADM stated she was aware of some of the rooms in the facility were smaller. The ADM stated there were safety concerns with small rooms. The ADM stated residents could bump into things if there is not enough space.

Based on interview and record review, the facility failed to notify the physician when Resident 2 presented a new wandering behavior for one of three sampled residents. This failure resulted in Resident 2's wandering behaviors not being addressed and a physical altercation between Resident 1 and Resident 2. Findings: 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 including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior)- bipolar (sometimes called manic-depressive disorder- mood swings that range from the lows of depression to elevated periods of emotional highs) type, and depression (persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities). During a review of Resident 2's History and Physical (H&P), dated 7/21/2025, the H&P indicated Resident 2 did not have the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 8/15/2025, the MDS indicated Resident 2 had severe cognitive (ability to learn, reason, remember, understand, and make decisions) impairment, required setup assistance when eating, required supervision for toileting and bathing, and required moderate assistance (helper does less than half the effort) for dressing and oral hygiene. During a review of Resident 2's Nursing Progress Note dated 8/25/2025 at 8:27 p.m., the Note indicated Resident 2 touched and removed Resident 1's belongings (a carton of milk and miscellaneous items) without permission resulting in Resident 2's aggressive behavior against Resident 1. During an interview on 9/9/2025 at 2:08 p.m., with Certified Nurse Assistant (CNA) 1, CNA 1 stated Resident 2 was a wanderer and would walk around and take food and hot chocolate off the snack carts. CNA 1 stated Resident 2 gets aggressive if he was not given the hot chocolate. During an interview on 9/9/2025 at 4:33 p.m. with CNA 3, CNA 3 stated Resident 2 had a history of wandering. CNA 3 stated Resident 2 was sneaky and would try to get hot cocoa and coffee off the carts. During an interview on 9/10/2025 at 2:51 p.m., with Resident 1, Resident 1 stated Resident 2 was known to walk around and grab waters, juices, and other items off of Residents (general) trays and carts. Resident 1 stated the staff knew about Resident 2's behavior. Resident 1 stated on 8/25/2025, Resident 2 grabbed his belongings from his table. Resident 1 stated he was so upset, he clenched his fist, waited for Resident 2 to walk back towards him, and attempted to punch Resident 2. During a concurrent interview and record review on 9/10/2025 at 11:47 a.m., with the Assistant Director of Nursing (ADON), Resident 2's medical record was reviewed. Resident 2's Nursing note dated 8/17/2025 at 6:43 p.m., indicated a nurse unknown) observed Resident 2 standing outside the facility. The ADON stated a Change of Condition where the physician is notified of a new behavior of attempting to leave the facility was not completed. The ADON stated the physician should have been notified when Resident 2 was found outside the facility on 8/17/2025. The ADON stated if the physician is not notified for a change of condition, the physician will not know to address it and there could be a delay of care. During a concurrent interview and record review on 9/10/2025 at 1:47 p.m. with the ADON, the facility's policy and procedure (P&P), titled Change in a Resident's Condition or Status, revised February 2021, was reviewed. The P&P indicated the nurse will notify the resident's attending physician or physician on call when there has been a(an) accident or incident involving the resident. The ADON stated the resident being found outside the facility is considered an incident that should have been communicated to the physician.

Based on observation, interview and record review, the facility failed to ensure Resident 1 and Resident 2 were free from abuse when Resident 1 and Resident 2 got into a physical altercation on 8/25/2025. The facility failed to ensure: A. Resident 1 received Trazadone (medication for depression [persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities] and insomnia) for three days (8/23/2025, 8/24/2025, and 8/25/2025).B. Resident 2's episodes of wandering (walking around without a specific goal or purpose) and behaviors of taking items from snack carts were communicated to the provider or addressed in a care plan.3.Implement the facility's policy and procedure titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021 which indicated residents have the right to be free from abuse. These deficient practices resulted in a physical altercation between Resident 1 and Resident 2 on 8/25/2025 at approximately 8:30 p.m. when:1. Resident 2 took milk and miscellaneous belongings from Resident 12. Resident 1 made a fist and swung at Resident 23. Resident 2 punched Resident 1 in the face4. Leaving Resident 1 with a bruise to the left nose bridgeFindings: A. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including urinary tract infection (UTI- an infection in the bladder/urinary tract), Heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and major depressive disorder (persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities). The admission Record indicated Resident 1's brother was the responsible party (RP-decision maker). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 8/7/2025, the MDS indicated Resident 3 had moderate cognitive (ability to learn, reason, remember, understand, and make decisions) impairment, required setup assistance when eating, required moderate assistance (helper does more than half the effort) for oral hygiene and upper body dressing, and was dependent for toileting hygiene, bathing, and lower body dressing. During a review of Resident 3's Physician Order Summary dated 9/19/2025, the Physican Order Summary indicated an order for Trazodone Hydrochloride (HCL), 50 Milligrams (MG - a unit of measurement) give 1 tablet by mouth at bedtime for depression manifested by (m/b) inability to sleep, start date 1/19/2025. During a concurrent interview and record review on 9/9/2025 at 3:26 p.m., with the Minimum Data Set Coordinator (MDSC), Resident 1's Medication Administration Record (MAR) for August 2025 was reviewed. The MDSC stated the MAR indicated Resident 3 had an order for Trazodone HCL Oral Tablet 50 MG to be given at bedtime for depression manifested by inability to sleep started on 1/9/2025. The MDSC stated there is no documentation indicating Resident 1 received the scheduled Trazodone 50 MG on 8/23/2025, 8/24/2025, and 8/25/2025. The MDSC stated the MAR did not indicate that adverse effects or side effects of Trazodone were being monitored for Resident 1. During a concurrent interview and record review on 9/9/2025 at 3:43 p.m., with licensed vocational nurse (LVN) 3, Resident 1's MAR for August 2025 was reviewed. LVN 3 stated the MAR did not indicate Resident 1 received the evening dose of Trazadone 50 mg on 8/23/2025, 8/24/2025, and 8/25/2025 for the evening shift, the documentation was blank. LVN 3 stated if the resident refused or the medication was held (not administered due to clinical judgment), the documentation would have indicated it. LVN 3 stated if a resident missed Trazadone for three days, it would affect a resident's ability to get enough sleep and could result in the resident becoming restless, agitated, or lead to falls or other safety concerns. During an interview on 9/9/2025 at 4:52 p.m., with Resident 1, Resident 1 stated about two weeks ago (unknown date), a nurse tried to give him his night time medications including the sleeping pill (Trazadone) in the afternoon around 4:30 p.m. Resident 1 stated he told the nurse it was too early, and was unsure if he received the medication. During an interview on 9/10/2025 at 11:47 a.m., with the Assistant Director of Nursing (ADON), the ADON stated it was important that the nurse documented medication administration after the medication was given. The ADON stated documentation is proof that the medication was administered to the resident, and the resident received it. The ADON stated it is important to monitor indicated behaviors such as hours of sleep and monitor adverse effects or side effects every shift to ensure that medications are effective for the resident. The ADON stated if the resident misses 3 consecutive doses of Trazadone for 3 days, the Resident 1 can become irritable and emotional due to lack of sleep. During a concurrent interview and record review on 9/10/2025 at 1:47 p.m. with the ADON, the facility's policy and procedure (P&P) titled Administering Medications, revised April 2019, was reviewed. The P&P indicated medications are administered in accordance with prescriber orders. The P&P indicated medication administration times are determined by resident need and benefit, not staff convenience. B. 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 including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior)- bipolar (sometimes called manic-depressive disorder- mood swings that range from the lows of depression to elevated periods of emotional highs) type, and depression During a review of Resident 2's History and Physical (H&P), dated 7/21/2025, the H&P indicated Resident 2 did not have the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 8/15/2025, the MDS indicated Resident 2 had severe cognitive (ability to learn, reason, remember, understand, and make decisions) impairment, required setup assistance when eating, required supervision for toileting and bathing, and required moderate assistance (helper does less than half the effort) for dressing and oral hygiene. During a review of Resident 2's Nursing Progress Note dated 8/25/2025 at 8:27 p.m., the Nursing Progress Note indicated Resident 2 touched and removed Resident 1's belongings without permission resulting in Resident 2's aggressive behavior against Resident 1. During an interview on 9/9/2025 at 2:08 p.m., with Certified Nurse Assistant (CNA) 1, CNA 1 stated Resident 2 was a wanderer and would walk around and take food and hot chocolate off snack carts. CNA 1 stated Resident 2 would get aggressive if he was not given the hot chocolate. During a concurrent interview and record review on 9/9/2025 at 3:05 p.m., with the MDSC, Resident 2's medical record was reviewed. The MDSC stated Resident 2 was known to walk around a lot and tried to leave of the facility once. During a concurrent interview and record review on 9/9/2025 at 3:43 p.m., with licensed vocational nurse (LVN) 3, LVN 3 stated Resident 2 was known to walk around the facility and made attempts to get hot chocolate. During an interview on 9/9/2025 at 4:33 p.m. with CNA 3, CNA 3 stated Resident 2 had a history of wandering. CNA 3 stated Resident 2 was sneaky and would try to get hot cocoa and coffee off the snack carts. concurrent observation and interview on 9/9/2025 at 4:52 p.m., with Resident 1, Resident 1 was observed with purple discoloration on the left side of his nose bridge. Resident 1 stated Resident 2 punched his face in the hallway. During an interview on 9/10/2025 at 2:15 p.m. with the ADON, the ADON stated when completing an abuse investigation it was important to review the resident's medications because medications could affect the physical body and their behaviors. During an interview on 9/10/2025 at 2:19 p.m. with the Social Services Director (SSD), the SSD stated Resident 2 likes to eat a lot, and forages for food and snacks a lot. The SSD stated because of Resident 2's mental health, it made sense that Resident 2 grabbed the milk from Resident 1. During an interview on 9/10/2025 at 2:51 p.m., with Resident 1, Resident 1 stated Resident 2 was known to walk around and grab waters, juices, and other items off of trays and snack carts. Resident 1 stated the staff knew about Resident 2's behavior. Resident 1 stated on 8/25/2025, Resident 2 grabbed his belongings from his table. Resident 1 stated he was so upset, he clenched his fist, waited for Resident 2 to walk back towards him, and attempted to punch Resident 2. During a review of facility hallway video footage with starting timestamp of 8/25/2025 7:23:45 p.m., the footage indicated:Received footage of [NAME]/[NAME] altercation from medical records. 8/25/2025 7:24:15 PM: Resident 1 makes left hand into a fist as Resident 2 and Staff Walk down the hallway toward Resident 1. 8/25/2025 7:24:20 PM: Resident 1 extends left fist and makes contact with the back of Resident 2 as Staff member and Resident 2 walk by. 8/25/2025 7:24:24 PM: Resident 2 uses right fist to punch left side of Resident 1's face making contact with Resident 1's glasses. During a review of the facilities P&P, titled Care Plans, Comprehensive Person-Centered, revised March 2022 the P&P indicated care plans are revised as information about the residents and the resident's conditions change. The P&P indicated the interdisciplinary team reviews and updates the care plan when there has been a significant change in the resident's condition. During a review of the facility's P&P, titled Safety and Supervision of Residents, revised July 2017 the P&P indicated the interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The P&P indicated the facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly. The P&P indicated risk factors and environmental hazards include unsafe wandering. During a review of the facility's policy and procedure (P&P), titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, the P&P indicated residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The P&P indicated the resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including other residents.

Based on interview and record review, the facility failed to: 1. Ensure, a resident who was a Full Code (a medical term indicating a person's consent to receive all possible life-saving measures), received basic life support ([BLS], care healthcare professionals provide to anyone whose heart stops beating suddenly), including cardiopulmonary resuscitation ([CPR] an emergency life-saving procedure to restart a person's heart [chest compressions)]) per the resident's Physician Order for Life Sustaining Treatment ([POLST] a form that contains written medical orders for healthcare professionals regarding the residents wishes for specific medical treatments that can or cannot be done during life threatening emergencies where the resident is incapacitated) and facility's policy and procedure, for one of one sampled resident (Resident 1).2. Ensure registered nurse (RN) 1 honored and followed Resident 1's POLST dated [DATE], and provided the resident with CPR/BLS when Resident 1 was found unresponsive (does not react to verbal or physical cues) and without a pulse (heartbeat) on [DATE] at approximately 9:45 a.m. 3. Implement the facility policy and procedure (P&P) titled, Emergency Procedure-Cardiopulmonary Resuscitation, dated 2001, which indicated, if a resident is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: instruct a staff member to activate the emergency response system (code) and call 911. These failures resulted in RN 1 not administering CPR and not calling 911 when Resident 1 was found unresponsive and pulseless on [DATE]. Resident 1 expired on [DATE]. These failures placed 47 other residents in the facility, who have a Full Code status, at risk of not receiving life saving measures when needed.Based on interview and record review, the facility failed to: 1. Ensure, a resident who was a Full Code (a medical term indicating a person's consent to receive all possible life-saving measures), received basic life support ([BLS], care healthcare professionals provide to anyone whose heart stops beating suddenly), including cardiopulmonary resuscitation ([CPR] an emergency life-saving procedure to restart a person's heart [chest compressions)]) per the resident's Physician Order for Life Sustaining Treatment ([POLST] a form that contains written medical orders for healthcare professionals regarding the residents wishes for specific medical treatments that can or cannot be done during life threatening emergencies where the resident is incapacitated) and facility's policy and procedure, for one of one sampled resident (Resident 1).2. Ensure registered nurse (RN) 1 honored and followed Resident 1's POLST dated [DATE], and provided the resident with CPR/BLS when Resident 1 was found unresponsive (does not react to verbal or physical cues) and without a pulse (heartbeat) on [DATE] at approximately 9:45 a.m. 3. Implement the facility policy and procedure (P&P) titled, Emergency Procedure-Cardiopulmonary Resuscitation, dated 2001, which indicated, if a resident is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: instruct a staff member to activate the emergency response system (code) and call 911. These failures resulted in RN 1 not administering CPR and not calling 911 when Resident 1 was found unresponsive and pulseless on [DATE]. Resident 1 expired on [DATE]. These failures placed 47 other residents in the facility, who have a Full Code status, at risk of not receiving life saving measures when needed. On [DATE] at 7:10 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of the Director of Nursing (DON), Administrator (ADM) and consultant Administrator due to the facility's failure to provide basic life support (BLS) to Resident 1, including immediate initiation of CPR. On [DATE], the facility submitted an acceptable Immediate Jeopardy Removal Plan (IJRP). After onsite verification of IJRP implementation through observation, interview, and record reviews, the IJ was removed on [DATE] at 2:43 p.m., in the presence of the ADM, the DON and the consultant ADM. The IJRP included the following: 1. On [DATE], the DON provided in-service to Registered Nurse (RN 1) regarding POLST policy and procedure, honoring and following the Residents' POLST (if Full Code, start CPR and immediately call 911). 2. On [DATE], the DON and the Director of Staff Development (DSD) provided an in-service to licensed nurses and the Clinical Team members of the Inter-Disciplinary ([IDT] the residents health care team) composed of the Assistant Director of Nursing (ADON), Quality Assurance (QA) Nurse, Minimum Data Set (MDS)/Resident Assessment Coordinator, Social Service Designee (SSD), Activity Director, regarding honoring and following the Residents' POLST. 3. On [DATE], the DSD started providing in-service training to the Certified Nursing Assistants (CNAs) on procedures in administering CPR and calling 911. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease ([COPD] a chronic lung disease causing difficulty in breathing), chronic heart failure (heart disorder that causes the heart to not pump blood effectively) and ischemic heart disease (condition where poor blood flow causes heart tissue damage or death). During a review of Resident 1's History and Physical (H&P) dated [DATE], the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's POLST, dated [DATE], the POLST indicated if Resident 1 had no pulse and was not breathing to attempt resuscitation/CPR. The form indicated the POLST was discussed with Resident 1, who had capacity to understand. The form was signed and dated by Physician (MD) 2 and Resident 1 on [DATE].During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated [DATE], the MDS indicated Resident 1's cognition (ability to think, understand, learn, and remember) was moderately impaired and he had the ability to understand and be understood by others. The MDS indicated Resident 1 was fully dependent on staff (requiring two or more-person assistance to complete the activity) for toilet hygiene and putting on and taking off footwear, required partial assistance (helper does less than half the effort) for eating, oral hygiene and personal hygiene. During a review of Resident 1's IDT Meeting Document dated [DATE], the IDT Meeting Document indicated Resident 1 had the capacity to understand and represented himself during the meeting. The IDT Meeting Document indicated Resident 1 wished to be a Full Code. During a review of Resident 1's Nurses Progress Notes, documented by Licensed Vocational Nurse ( LVN) 1, dated [DATE], the Nurses Progress Notes indicated during medication pass on [DATE] at 9:45 a.m., LVN 1 could not obtain Resident 1's vital signs (measurements of the body's basic functions such as heart beat and breathing), RN 1 called to bedside to assess Resident 1. During a review of Resident 1's Nurses Progress Notes dated [DATE], the Nurses Progress Notes indicated when RN 1 assessed Resident 1, RN 1 found Resident 1's skin warm to the touch with no obtainable vital signs (no pulse and no breathing). The Nurses Progress Notes indicated RN 1 notified MD 1 who pronounced Resident 1 as expired. During a review of Resident 1's Physician's Discharge summary, dated [DATE], the Physician's Discharge Summary indicated Resident 1's date of death was [DATE]. During a review of Resident 1's Final Autopsy Report, dated [DATE], the Final Autopsy Report indicated Resident 1's date of death was [DATE] and the immediate cause of death was an acute myocardial infarct ( [heart attack] when blood flow to the heart muscle is blocked) likely associated with COPD induced hypoxia (lack of oxygen [gas needed to sustain life] in the body's tissues). During an interview on [DATE] at 3:27 p.m., RN 1 stated LVN 1 called her to Resident 1's bedside on [DATE], around 9:45 a.m. when LVN 1 found Resident 1 unresponsive. RN 1 stated Resident 1's skin was warm to the touch, he was not responsive, his chest did not rise and fall (indicating Resident 1 was not breathing) and did not have any detectable pulse. RN 1 stated she was CPR certified but she did not attempt CPR and instructed LVN 1 not to perform CPR nor call 911 because she thought Resident 1's POLST indicated Do Not Resuscitate ([DNR] if a person's heart or breathing stops, the person wishes the doctors and nurses not to restart it by doing CPR). During an interview on [DATE] at 2:46 p.m., the DON stated when a resident is found unresponsive, staff should immediately check for a pulse, if the resident does not have a pulse, then immediately start chest compressions, call for help, and immediately call 911. The DON stated, if chest compressions and/or CPR was not initiated immediately after the heart stops beating, the chances of the resident's survival decreases and the risk of permanent brain damage or death increases. The DON stated the resident's POLST must be honored.During a telephone interview on [DATE] at 5:46 p.m., the Facility Medical Director (MD 3) stated the facility must honor the residents' wishes as indicated in their POLST. During a review of the facility's Policy & Procedure (P&P) titled, Emergency Procedure-Cardiopulmonary Resuscitation, dated 2001, the P&P indicated if a resident is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: instruct a staff member to activate the emergency response system (code) and call 911, instruct a staff member to retrieve the automatic external defibrillator (an external defibrillator is a machine that helps restart a person's heart if it suddenly stops or beats the wrong way), verify or instruct a staff member to verify DNR or code status of the individual, initiate the basic life support (BLS- compressions, airway, breathing) sequence of events. During a review of an online article titled, American Heart Association 2020, CPR and Emergency Cardiovascular (anything that has to do with the heart and blood vessels) Care Committee Guidelines, the article indicated, the adult basic life support algorithm (a process or set rules to be followed) for healthcare providers included verifying for scene safety, check for responsiveness, shout for nearby help, look for no breathing or only gasping and check pulse simultaneously (at the same time). The guidelines further indicated if there was no breathing, or only gasping, with no pulse, to immediately begin CPR and perform cycles of thirty chest compressions and two breaths.AHH CPR Guidelines During a review of an online article titled, How to Perform CPR - Adult CPR Steps the article indicated, to check the scene for safety, check the person for responsiveness/breathing, if the person does not respond and is not breathing or only gasping, call 911, get equipment, or tell someone to do so, kneel beside the person, and place them on their back on a firm, flat surface. The guidelines indicated to begin chest compressions 30 at a time, give two breaths and to continue the cycle of 30 chest compression and two breaths.www.redcross.org During a review of the facility's P&P titled, POLST/ Advanced directive, undated 2001, the P&P indicated the purpose of the P&P was to specify the form to be used by the facility in documenting resident's preferred intensity of care. The P&P indicated the facility will honor a resident's completed POLST form from the hospital if there is no change to it. The facility must review the POLST with the resident / responsible party and document that this is in the resident's medical records.During a review of the POLST (in general) form, the form indicated the following: 1. First follow these orders, then contact the Physician/Nurse Practitioner/Physician Assistant.2. A copy of the signed POLST form is a legally valid physician's order. Any section not completed implies full treatment for that section.

Based on interview and record review, the facility failed to ensure the hand sink in a resident's bathroom was inspected during daily rounds by the maintenance staff and/or the facility's administrative staff, to ensure it was mounted securely to the bathroom wall and did not detach and fall off the wall causing a resident to fall and sustain injuries for one of three sampled residents (Resident 1). This deficient practice resulted in the hand sink in Resident 1's bathroom detaching from the wall and falling to the floor when Resident 1 placed her hands on it while washing her face. Resident 1 fell to the floor and sustained a left hip fracture, a bump with discoloration to her left eye and a bump with discoloration to the left side of the back of her head. This deficient practice had the potential for Resident 1 to sustain more critical injuries including death. Findings: During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including cerebral infarction [stroke] occurs when blood flow is disrupted to the brain) affecting Resident 1's left side, dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), glaucoma (chronic, progressive eye disease), and a history of failing. During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 12/28/2023, the MDS indicated Resident 1's cognitive (the ability to think, reason, and understood) skills for daily decision-making were severely impaired. The MDS indicated Resident 1 required moderate to maximal assistance for activities of daily living ([ADL] activities related to personal care that include, bathing, dressing, getting in/out of bed, walking, toileting and eating). The MDS indicated Resident 1 was 4'7' tall and weighed 100 pounds (lbs.) During a review of Resident 1's Change of Condition (COC) dated 3/10/2024 and timed at 8:29 a.m., the COC indicated Resident 1 sustained a fall and was noted with a bump and discoloration on her left eye and a bump and discoloration to the back left side of her head. During a review of the facility's Incident Investigation Summary, dated 3/10/2024 and timed at 5 a.m., the Incident Investigation Summary, indicated Resident 1 was washing up, while supervised by a Certified Nursing Assistant (CNA 1) when the toilet sink fell off the wall and Resident 1 lost her balance and slid on her left side. The Incident Investigation Summary indicated Resident 1 most likely hit her left orbital external side (the outer portion of the resident's left eye) on a paper towel dispenser, then hit her left mid upper parietal (back of her head) side on the wall, before she slid to the floor. The Incident Investigation Summary indicated at that time Resident 1 had no pain or injuries. On reassessment (time not indicated), Resident 1 was noted with red discoloration and bumps to her left exterior-lateral orbital region and left mid-upper parietal part of her head. Resident 1 complained of minimal tolerable pain on a scale of 3 out of 10 (an 11 point scale where pain is rated zero to 10; 0=no pain, 1-3=mild pain, 4-6=moderate pain, and 7-10=severe pain, and 10=worst imaginable pain). Later in the evening (time not indicated), Resident 1 complained of pain to her left hip when crossing her left leg above her right leg. During a review of Resident 1's Nursing Notes, dated 3/10/2024, the Nursing Notes indicated no documentation of Resident 1's fall or an assessment of Resident 1 after her fall. During a review of Resident 1's Nursing Note dated 3/10/2024 and timed at 2:31 p.m., the Nursing Note indicated Resident 1 verbalized pain to her left hip. The Nursing Note indicated Resident 1's physician was notified and an order for a Stat (immediate) X-ray (an imaging study that takes pictures of bones and soft tissues) was obtained. During a review of Resident 1's X-ray Results Report, dated 3/10/2024 and timed at 4:37 p.m., the X-ray Results Report indicated Resident 1 had an acute (a condition that is severe and has a sudden onset) left hip fracture. During a review of Resident 1's Physician's Order dated 3/10/2024 and timed at 5:16 p.m., the Physician's Order indicated to transfer Resident 1 to a General Acute Care Hospital (GACH) for evaluation related to her fall. During a review of Resident 1's GACH records dated 3/10/2024, the GACH records indicated Resident was admitted to the GACH on 3/10/2024 with a diagnosis of a left intertrochanteric femoral neck (region on top of the thigh bone that connects to the hip bone) fracture, secondary to a mechanical fall (a fall caused by an external force). During a review of the GACH's Hospital Course, dated 3/10/2024, the Hospital Course indicated given Resident 1's frailty, advanced age, poor baseline mobility, and dementia, Resident 1's Family Member (FM) and DPOA, requested conservative, nonoperative management. Resident 1 would return to custodial care for pain management and hospice consultation. Resident 1 was at high risk for mortality (death), either with surgery or without surgery. During a telephone interview on 3/27/2024 at 12 p.m., CNA 1 stated, she escorted Resident 1 to the bathroom (3/10/2024) in her wheelchair and placed her in front of the hand sink and stood her up so she (Resident 1) could wash her face. CNA 1 stated Resident 1 turned on the water in the sink and placed her hands on the sink when the sink fell to the ground. CNA 1 stated Resident 1 landed on her left hip and bumped the left side of her head. CNA 1 stated she could not recall if there was anything wrong with the hand sink prior to Resident 1 using it. During an interview on 3/27/2024 at 1:30 p.m., the Maintenance Supervisor stated it takes a lot of weight to force a sink off the wall and Resident 1 should not have been able to pull it from the wall. The Maintenance Supervisor stated the maintenance staff conducts daily rounds of the facility to identify any issues that the maintenance department needs to address. The Maintenance Supervisor stated he was not aware of any problems with the hand sink in Resident 1's bathroom. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 3/27/2024 at 2:56 p.m., LVN 1 stated she was summoned to Resident 1's room by CNA 1 and found Resident 1 on the floor, and the bathroom sink on the floor with water coming out of the pipes. LVN 1 stated she assessed Resident 1 and noticed discoloration to Resident 1's left eye and on the back of her head. During an interview with the Administrator (ADM) on 3/28/2024 at 12:44 p.m., the ADM stated, safety rounds are conducted daily by all staff to identify any hazards. The ADM stated he was not aware of any problems with the hand sink in Resident 1's bathroom and if there was a problem with the sink it should have been reported immediately to the maintenance department so it could have been repaired. During a review of the facility's policy and procedure (P/P) titled Safety and Supervision of Residents, revised 7/2017, the P/P indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. During a review of the facility's P/P title Maintenance Service, revised 12/2009, the P/P indicated the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Functions of the maintenance personnel include but are not limited to: maintaining the building in good repair and free from hazards.

Based on observation, interview, and record review, the facility failed to ensure the resident, who was walking 85 feet with moderate assistance (about 25-50 percent [%] physical assistance) with a platform walker ([PFW] a type of assistive device with forearm supports to provide extra support during walking), did not decline in walking and subsequently stopped walking, and failed to ensure the resident, who had limited ROM to both lower extremities received restorative nursing treatment to prevent potential decline in ROM for two of 15 sampled residents (Resident 3 and Resident 47). The facility failed to: 1. Assist Resident 47 with ambulation during Restorative Nursing Aide ([RNA] nursing aide program that help residents to maintain their function and joint mobility) treatment to maintain function and ability to move (walking) in accordance with the Physical Therapy ([PT], profession aimed in the restoration, maintenance, and promotion of optimal physical function) Discharge Recommendation and Treatment Note dated 1/3/24. 2. Ensure Resident 47's physician (MD 1) was notified of the resident's decline in his function to walk and subsequently stopped walking. 3. Ensure RNAs notified nursing and physical therapy staff of Resident 47's decline in walking. 4. Ensure RNA 1 and RNA 2 followed the facility's Policy and Procedure (P&P) titled, Resident Mobility and Range of Motion, by ambulating Resident 47 as ordered to maintain or improve mobility. 5. Ensure RNAs 1 provided Resident 3 with ROM to minimize decline in range of motion and mobility. 6. Ensure RNA 1 provided Active Range of Motion ([AROM] a movement at a given joint when the person moves voluntarily) to Resident 3 to both upper extremities (BUE) including shoulder, elbow, wrist, and hand and to both lower extremities (BLE) including hip, knee, ankle, and feet, five (5) times a week in February 2024 as ordered by the physician. These deficient practices resulted in: 1. Resident 47's significant decline in mobility from being able to walk 85 feet with moderate assistance with a PFW to not being able to walk. 2. Resident 3's potential further decline in ROM and physical function such as rolling, dressing, walking, and transferring. Findings: A. During a review of Resident 47's Admission Record, the record indicated Resident 47 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (condition in which the body does not metabolize blood sugar correctly), chronic kidney disease (gradual loss of kidney function to filter waste and excess fluid from the blood), unilateral primary osteoarthritis (loss of protective cartilage that cushions the ends of your bones) right knee and left knee, difficulty in walking, and muscle weakness. During a review of Resident 47's Joint Mobility Assessment ([JMA] assessment of joints to monitor joint range of motion) dated 10/10/23, the Joint Mobility Assessment indicated Resident 47 had both upper extremities (BUE) and both lower extremities (BLE) within functional limits and had no impairment in upper or lower extremities. The Joint Mobility Assessment indicated, recommendation for Resident 47 to ambulate with RNA using a platform walker. During review of Resident 47's Minimum Data Set ([MDS] a standardized assessment and care-screening tool) dated 12/19/23 indicated Resident 47 had no impairment in cognitive skills (ability to think, understand, learn, and remember) for daily decision making and did not exhibit behavior of rejection of care. The MDS indicated Resident 47 did not have any functional limitations in range of motion ROM on either side of the upper or lower extremities. The MDS also indicated Resident 47 required partial or moderate assistance (helper does less than half the effort) from staff for eating, oral hygiene, upper and lower body dressing, and lying to sitting on side of the bed. The MDS indicated Resident 47 was dependent on two staff assistance (staff does all the effort or the assistance for the resident to complete the activity) to walk 10 feet, walk 50 feet with two turns and walking 150 feet was not attempted. During a review of Resident 47's care plan titled The Resident is at Risk for Injury, Pain and Discomfort related to right knee chondrocalcinosis (condition in which calcium crystals (mineral) deposit in joints causing pain), right knee osteoarthritis, back pain with bilateral sciatica (type of pain that radiates down both legs from the back), right knee joint effusion (extra fluid around the joint), left knee osteoarthritis, chronic midline low back pain with left sided sciatica, left great toe amputation (surgical removal of a limb), history of laminectomy (surgical procedure that remove a portion of the spinal bone to relieve pressure on nerves) dated 6/15/23 with target date of 3/18/24 indicated the goal for Resident 47 was to be able to participate in daily activities. The care plan's intervention included the following: 1. RNA to perform AROM exercises to BUE daily five times a week for four weeks (5x/wk for 4 wks.) as tolerated. 2. RNA to perform AROM to BLE daily 5x/wk for 4 weeks as tolerated. 3. Encourage exercise as well as rest periods, monitor medication (unspecified) effectiveness and for medication adverse effects (undesirable harmful effect resulting from medication). 4. Notify MD 1 as needed, monitor presence of pain during daily care, transfer, or positioning. During a review of Resident 47's care plan titled Resident Has Alteration in Physical Functioning Related to Disease Condition .at Risk for Decline in Joint Mobility .Decline in Activities of Daily Living ([ADL] basic activities such as eating, dressing, toileting), dated 6/15/23 with a target date of 3/18/24, indicated a goal for Resident 47 was to develop some area in physical function and achieve some degree of independence and be able to meet ADL needs with staff assistance. During a review of Resident 47's Physician's Order Summary Report dated 2/14/24 indicated an order dated 7/30/23 for RNA to perform AROM exercises to Resident 47's BUE once a day 5x/wk for 4 weeks as tolerated and an order dated 8/1/23 for RNA to perform BLE AROM daily 5x/wk for 4 weeks as tolerated. During a review of Resident 47's physician's order discontinued on 2/12/24, indicated an order for RNA program for assisted ambulation using platform walker once a day, five times a week for 4 weeks or as tolerated. This order was entered on 2/13/24 with no start date indicated. During a review of Resident 47's Physical Therapy (PT) Evaluation and Plan of Treatment dated 12/4/23 indicated Resident 47's prior level of function (before PT's evaluation on 12/4/23) was independent with rolling, sit to lying, lying to sitting on side of bed, supervision or touching assistance with sit to stand, bed to chair transfer, and walking 10 feet. The PT Evaluation and Plan of Treatment indicated Resident 47's discharge plan was to live at home with support from others. The PT Evaluation and Plan of Treatment indicated Resident 47 required substantial/maximal assistance to roll from left to right, sit to lying, lying to sitting on side of bed, sit to stand, bed to chair transfers, and walking was not attempted due to environmental limitations. During a review of Resident 47's PT Treatment Encounter Note dated 12/29/23 indicated Resident 47 required contact guard (physical steadying assistance) minimal assistance (less than 25% physical assistance) with bed mobility, moderate assistance for transfers and that the resident was able to ambulate 85 feet with moderate assistance and PFW. During a review of Resident 47's PT Treatment Encounter Note dated 1/2/24 indicated Resident 47 required contact guard/minimal assistance with bed mobility, moderate assistance for transfers, and that the resident was able to ambulate 85 feet with moderate assist with PFW. During a review of Resident 47's PT Treatment Encounter Note dated 1/3/24 (last PT treatment) indicated Resident 47 required moderate assistance for transfers, was able to ambulate 85 feet with two persons moderate assistance using PFW and with one person following with a wheelchair (WC) behind. The PT Treatment Encounter Note indicated Resident 47's gait (ambulation) training with RNA was completed using PFW with moderate assistance and required another person following with WC due to resident having episodes of knee buckling (knees feel weak) but resident was able to self-correct and maintain proper base of support (contact points beneath a person and supporting surface to provide balance when walking), step length (how far each step is), and continuity of steps. The PT Treatment Encounter Note indicated Resident 47 was very cooperative and tolerated the treatment session well. During a review of Resident 47's PT Discharge Summary dated 1/3/24 indicated the discharge reason was the resident achieved highest practical level of functioning. The PT Discharge Summary indicated discharge recommendations to see RNA order. During a review of Resident 47's Joint Mobility assessment dated [DATE] indicated Resident 47's BUE and BLE were within functional limits without. The Joint Mobility Assessment indicated the recommendation for RNA for ambulation using platform walker. During a review of Resident 47's January 2024 Documentation Survey Report (record of nursing assistant tasks) for RNA, the report indicated for RNA to ambulate Resident 47's with PFW 5x/wk for 4 weeks as tolerated. Resident 47's January 2024 Documentation Survey Report indicated on 1/10/24 Resident 47 ambulated 20 feet for 15 minutes and on 1/12/24 Resident 47 ambulated 50 feet for 20 minutes. The January 2024 Documentation Survey Report indicated RNAs did not ambulate Resident 47 from 1/13/24 through 1/31/24, a total of 18 days. During a review of Resident 47's RNA Weekly Summary dated 1/11/24, the Weekly Summary indicated RNA walked Resident 47 five times a week from 1/3/24 to 1/10/24, used PFW as the assistive device and walked 25 feet. During a review of Resident 47's RNA Weekly Summary dated 1/18/24, the Weekly Summary indicated Resident 47 was seen by RNA five times the week of 1/11/24 to 1/17/24, and provided the resident with ambulation, AROM of BUE and BLE treatment, used a front-wheeled walker ([FWW] a device to assist with walking that has a wheel on each of the front legs) as the assistive device and walked zero feet. The RNA Weekly Summary also indicated Resident 47 Complains of pain. Not able to walk with the RNA after medicine (unspecified) given. During a review of Resident 47's RNA Weekly Summary dated 1/25/24, the Weekly Summary indicated Resident 47 was seen by RNA five times the week of 1/18/24 to 1/24/24, provided the resident with ambulation, AROM of BUE and BLE treatment, used FWW and walked zero feet. The RNA Weekly Summary also indicated the resident Complains of pain. Not able to walk with the RNA after medicine (unspecified) given. During a review of Resident 47's RNA Weekly Summary dated 2/1/24, the Weekly Summary indicated Resident 47 was seen by RNA five times the week of 1/25/24 to 1/31/24, provided the resident with ambulation, AROM of BUE and BLE treatment, used FWW platform and walked zero feet. The RNA Weekly Summary indicated the resident Complains of pain. Not able to walk with RNA. During a review of Resident 47's RNA Weekly Summary dated 2/8/24, the Weekly Summary indicated Resident 47 was seen by RNA five times the week of 2/1/24 to 2/7/24, provided the resident with ambulation, AROM of BUE and BLE RNA, used PFW as the assistive device and walked zero feet. The RNA Weekly Summary indicated the resident Complains of pain. Not able to walk after standing up. During a review of Resident 47's February 2024 Documentation Survey Report for RNA to perform Resident 47's ambulation with PFW, 5x/wk for 4 weeks as tolerated, the report indicated Resident 47 did not walk with any RNA from 2/1/24 to 2/14/24, a total of 14 days. During a review of Resident 47's medical record, the record indicate there were not any change of condition (COC) reports or reports of Resident 47's inability to ambulate with RNA, or any assessment of Resident 47's decline and interventions to address Resident 47's decline during January 2024 and February 2024. During a concurrent observation and interview on 2/13/24 at 10:15 a.m., in Resident 47's room, Resident 47 was in bed and was observed able to move a little bit both legs underneath the blankets. Resident 47 stated he was walking using a walker with PT, but it had been about a month since the last time he walked. Resident 47 stated no staff had been walking with him since physical therapy stopped on 1/3/2024. During a concurrent observation and interview on 2/14/24 at 10:06 a.m., in Resident 47's room, Resident 47 was in bed. Resident 47 stated he had not walked and wanted to walk again. Resident 47 stated he was walking before but now he was not walking. Resident 47 stated he had not done any walking with RNA and performed exercises (unspecified) on his own in the bed. During a concurrent observation and interview on 2/14/24 at 3:13 p.m., in Resident 47's room, Resident 47 was in bed on his back and stated he did not receive any RNA treatment today (2/14/24). During a concurrent observation and interview on 2/15/24 at 10:49 a.m., in Resident 47's room, RNA 1was observed to conduct treatment session to Resident 47. Resident 47 was observed sitting at the edge of the bed. RNA 1 was observed standing in front of the resident demonstrating the exercise movement to Resident 47 and the resident was following RNA 1's demonstration without any physical assistance from RNA 1. RNA 1 was observed counting the number of exercise repetition until Resident 47 completed the exercise. Resident 47 was observed able to move the right arm up and down to the resident's ear, bend and straighten the right elbow, roll both shoulders backward, touch the left shoulder with right hand, and open and close the right fingers without limitation. Resident 47 was able to lift the left arm to below shoulder level, touch the right shoulder with left hand, able to bend and straight left elbow, and open and close left fingers. Resident 47 was able to bend and straighten right knee but could not fully straighten the right knee, move the right ankle up and down. Resident 47 was able to bend and straighten the left knee but could not fully straighten the left knee and able to move left ankle up and down. RNA 1's was observed not ambulating Redesign 47 during observed treatment session on 2/15/24 at 10:49 a.m. During a concurrent interview and record review on 2/15/24 at 11:01 a.m. with RNA 1, the RNA's January 2024 and February 2024 treatment records and RNA's Weekly Summary were reviewed. RNA 1 stated Resident 47 currently had orders for RNA to provide AROM exercises to BUE and BLE and did not have an order for ambulation with RNA. RNA 1 stated she was not sure when the RNA's ambulation order was discontinued but it was recent. RNA 1 stated Resident 47 was previously on physical therapy and was transferred to RNA program for walking, but Resident 47 was not able to walk much. RNA 1 stated Resident 47 has to walk with a platform walker with two staff next to him on either side and one staff walking behind with a wheelchair. RNA 1 stated Resident 47 had not been walking with RNAs. RNA 1 reviewed the RNAs Weekly Summary dated 1/25/24, 2/1/24, 2/8/24, and stated Resident 47 did not walk with RNA due to pain (location not specified). RNA 1 stated she did not remember the last time she was able to walk with Resident 47. RNA 1 stated there were errors on the January 2024 RNA task documentation and confirmed Resident 47 had not walked for a while. During a concurrent interview and record review on 2/15/24 at 11:59 a.m. with PT 1, Resident 47's PT's records were reviewed. PT 1 stated if residents were discharged from PT with recommendations for RNA program, then orders for RNA were completed and RNAs were trained on how much assistance to provide during transfers, average distance for walking, and how to monitor ambulation. PT 1 reviewed Resident 47's PT's Treatment Notes and Discharge summary and stated, on 1/3/24 Resident 47 was able to ambulate 85 feet with moderate assistance and PFW. PT 1 stated there should have been an order for RNA for ambulation with PFW and leg (BLE) exercises. PT 1 stated Resident 47 should be able to walk 85 feet with moderate assistance, PFW and RNA, because that was the distance Resident 47 was able to walk upon discharge from PT therapy on 1/3/2024. PT 1 stated if Resident 47 could walk and did not receive ambulation exercises, then Resident 47 would decline in walking. PT 1 stated RNAs or nurses would report to physical therapy if a resident stopped walking with RNA or if a resident refused RNA. PT 1 stated PT would try to reassess the resident to see if they could benefit from therapy or assess if the resident really did not want to do any RNA. PT 1 stated walking 85 feet was a functional distance and a good distance so it would not be good if the resident was no longer able to walk this distance anymore. PT 1 stated that if a resident, who could previously ambulate, was no longer ambulating, the resident was at risk for getting weaker which may affect his ability to transfer. PT 1 stated Resident 47 would need to be reassessed by PT. PT 1 stated she was not aware Resident 47 was no longer walking with RNA. During a concurrent interview and record review on 2/15/24 at 1:51 p.m. the Director of Staff Development (DSD) stated she was the RNAs supervisor. DSD reviewed Resident 47's medical records and stated there was an order dated 11/15/23 for RNA program for assisted ambulation using PFW once a day 5x/wk for 4 weeks or as tolerated and she discontinued the RNA ambulation order on 2/12/24. DSD stated she discontinued the order due to Resident 47 was not able to ambulate. DSD stated Resident 47 was doing well with ambulation with RNA, then had a slow decline and complained of pain. DSD stated Resident 47 was walking a little less and then he did not walk at all. DSD stated if Resident 47, who was able to walk when discharged from physical therapy on 1/3/24, no longer able to walk, it considered a change of condition, and a COC should have been completed immediately so that nursing staff could notify the MD to see if there were any interventions or new orders to address the issue. DSD stated if the resident refused to walk with RNA, then RNAs should attempt treatments three times, and then complete a COC. DSD stated she reviewed Resident 47's medical records and there was no documentation indicating RNA staff or DSD reported the decline in ambulation with RNA to nursing staff, therapy staff, or the resident's physician. DSD stated there were no interventions or assessment completed by nursing or physical therapy to address Resident 47's significant decline in mobility. DSD stated if the MD was notified earlier and Resident 47 received an assessment and interventions to address the reason(s) for Resident 47's inability to walk, Resident 47's current inability to walk could have been avoided. During a phone interview on 2/15/24 at 3:07 p.m., with Medical Doctor (MD 1) stated he did not receive any notification from the facility regarding Resident 47's decline in mobility and inability to ambulate with RNA. During a concurrent interview and record review on 2/15/24 at 3:16 p.m. with DSD, the RNA Weekly Summaries was reviewed. DSD stated on 1/11/24 RNA's Weekly Summary indicated Resident 47 ambulated 25 feet with RNA assistance. DSD stated Resident 47 ambulated zero feet as indicated on RNA's Weekly Summaries dated 1/18/24, 1/25/24, 2/1/24, and 2/8/14. DSD stated she reviewed Resident 47's medical record again and confirmed there were no documented evidence of RNAs reporting to nursing, physical therapy, or MD 1 of Resident 47's inability to walk. DSD stated there were no nursing assessment, interventions, or COCs completed for Resident 47 to address the resident's decline in functional mobility and inability to ambulate. During a concurrent observation and interview on 2/16/24 at 9:20 a.m. with Resident 47, in Resident 47's room, the resident was observed in bed on his back. Resident 47 stated he would love to walk. Resident 47 stated he felt great and stronger when he walked and felt like he could move his body more when he walked. Resident 47 stated now he was in bed and felt like it took a lot of time for his body to get going to do anything since he had not walked. Resident 47 stated he felt like he could not walk right now and would have to get stronger to be able to walk again. During a phone interview on 2/16/24 at 10:53 a.m. RNA 2, stated Resident 47 did not walk that much with RNAs. RNA 2 stated Resident 47 did not walk 50 feet with RNA 2 on 1/13/24 and 1/14/24 (as documented by RNA 2) and it must have been an error. During an interview on 2/16/24 at 11:41 a.m., the Director of Nursing (DON) stated a COC was a form of communication about any alteration in a resident's condition and would include a decline in function. The DON stated a COC includes notification of a resident's MD, family, or responsible party, and interventions to improve a resident's condition. The DON stated the nurses must complete a COC. The DON stated if Resident 47 was walking while on RNA program and declined in mobility, and then stop walking, it should have been reported. The DON stated the nurses had to complete an assessment and refer Resident 47 to a higher level of care such as physical therapy to reassess the resident. During an interview on 2/16/24 at 2:38 p.m., the Registered Nurse Supervisor (RN 1) stated the licensed nurses were supposed to complete a COC as soon as possible when there was a decline in Resident 47's physical functioning. RN 1 stated waiting two weeks or four weeks was too long to complete a COC. RN 1 stated it was important to complete a COC immediately or the function of the resident would get worse, and the resident could decline and have contractures. RN 1 reviewed Resident 47's medical record and confirmed Resident 47 was previously able to ambulate and that there was no COC completed for Resident 47's decline in ambulation. RN 1 stated she was not notified about Resident 47 not being able to ambulate. During a concurrent interview and record review on 2/16/24 at 2:54 p.m., with the DON, Resident 47's medical record was reviewed. The DON stated no one from the facility's staff informed about Resident 47's had not been walking with RNAs. The DON stated walking 10 feet and taking a few steps with nursing staff considered a decline from walking 85 feet with moderate assistance. The DON stated Resident 47 should continue to walk 85 feet with RNAs because that was the distance the resident was walking with PT. The DON stated there was no documentation regarding RNAs reporting Resident 47 was not walking with RNAs. The DON stated RNAs should have reported to the licensed nurses and PT about Resident 47 was not walking. B. During a review of Resident 3's Admission Record indicated Resident 3 originally was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cellulitis (infection of the skin) of left lower limb and right lower limb, acute respiratory failure (any condition that affects breathing function and result in lungs not functioning properly) with hypoxia (low oxygen level in tissues), and muscle weakness. During a review of Resident 3's MDS dated [DATE] indicated Resident 3 had the ability to express ideas and wants and had the ability to understand others. The MDS also indicated Resident 3 had no functional limitations in range of motion in both upper extremities and had impairments on both sides of the lower extremities. The MDS indicated Resident 3 was dependent on staff for position from sit to lying, lying to sitting on side of a bed, and chair to bed transfers. The MDS indicated Resident 3 required substantial/maximal assistance from staff with eating, oral hygiene, and upper body dressing. During a review of Resident 3's Joint Mobility Assessment (JMA) dated 1/7/24 indicated Resident 3 was within functional limits (variance due to normal aging) for BUE and both ankle flexion (bend). The JMA indicated Resident 3 had minimal limitations (75 percent [%] to 100%) in both hip flexion and both knee flexion. During a review of Resident 3's Physician's Order Summary Report dated 2/14/24 indicated an order dated 7/26/23 for RNA to perform AROM exercises to BUE once a day five (5) times a week for four (4) weeks (5x/wk for 4 wks) as tolerated and an order dated 7/26/23 for RNA to perform BLE AROM (5x/wk for 4 wks) once a day as tolerated. During a review of Resident 3's care plan titled Alteration in Physical Functioning dated 3/10/23, the care plan indicated Resident 3 was at risk for decline in joint mobility and ADL decline. During a review of Resident 3's the February 2024 RNA Task Documentation Survey Report, the Survey Report indicated RNA provided to Resident 3 AROM exercises to BUE and BLE daily on 2/8/24, 2/9/24, 2/10/24, 2/11/24, 2/12/24, 2/13/24. During a concurrent observation and interview on 2/13/24 at 3:59 p.m., in Resident 3's room, observed Resident 3 was lying in bed on her back and wearing a hospital gown. Resident 3 stated she had not started doing any exercises with facility staff due to having an infection. Resident 3 was observed able to move both arms with minimal limitations and able to move a little both lower extremities underneath the blankets. During a concurrent observation and interview on 2/14/24 at 3:16 p.m., in Resident 3's room, Resident 3 was observed lying in bed with eyes closed and arousable to verbal cues. Resident 3 stated no staff came on 2/14/24 to do any exercises with her. During a concurrent interview and record review on 2/15/24 at 11:30 a.m., of Resident 3's February 2024 RNA Documentation Survey Report for RNA tasks, RNA 1 stated she did not provided ROM exercises to Resident 3. RNA 1 stated she has helped a Certified Nursing Assistants (CNA) to complete Resident 3's activity of daily living care and counted those encounters as RNA's treatment. RNA 1 stated the RNAs documented that Resident 3 completed RNA treatment when performed ADL care and not specific RNA ROM exercises to BUE and BLE. RNA 1 stated she should not have counted ADL care as RNA treatment because ROM exercises were different and that during ADL care provided to Resident 3, the resident did not move her arms and legs through a full range of motion. During an interview on 2/15/24 at 11:59 a.m., PT 1 stated joint mobility helps with function such as rolling, dressing, walking, transfers. PT 1 stated it was important to maintain Resident 3's joint mobility. During a concurrent interview and record review on 2/15/24 at 1:16 p.m., the DSD stated she was the RNA supervisor. DSD stated RNA orders for treatments were different than CNA or ADL care. DSD stated RNA orders for ROM was more intentional, more purposeful than just ADL care. DSD stated ADL care was not considered an RNA treatment. During an interview on 2/15/24 at 11:24 a.m., the DON stated an RNA program was a restorative program to maintain or improve a resident's ROM ability because residents could have ROM decline without the RNA program. The DON stated the facility should provide the RNA program to resident so that the residents maintained their function and quality of life. The DON stated RNA was different than CNA, because RNA was a special program that provides exercises to residents as recommended by PT and ordered by a resident physician. During a review of the facility's policies and procedures (P&P) revised 7/2017 titled, Resident Mobility and Range of Motion, indicated residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility. The policy indicated, documentation of the resident's progress toward the goals and objectives will include attempts to address any changes or decline in the resident's condition or needs. During a review of the facility's P&P revised 7/2017 titled, Restorative Nursing Services, indicated restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services. During a review of the facility's P&P revised 10/2020 titled, Range of Motion Exercises, indicated, the purpose of this procedure is to exercise the resident's joints and muscles .move each joint through its range of motion three (3) times unless otherwise instructed. Cross reference F580, F842 44898 49131

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who had a history of multiple falls, was supervised, monitored, and provided with a Mat alarm (an alarm used on top of a mattress or in a wheelchair to help monitor residents when they rise from the bed or wheelchair to reduce falls and unnecessary injury) in his wheelchair as recommended the Interdisciplinary Team ([IDT] a group of health care professionals with various areas of expertise who work together toward the goals of a resident) to prevent Resident 1 from falling and sustaining an injury. The facility failed to: 1. Ensure Resident 1's care plan was revised to include IDT's recommendations made after Resident 1's fall on 11/13/2023 that included continued use of the Mat alarm, frequent visual checks, and placing Resident 1 in front of or close to the nursing station. 2. Ensure Resident 1's care observation was endorsed to the nursing staff at the nursing station when Resident 1 was placed next to a nursing station on 12/12/2023 and was left unsupervised. Resident 1 without staff knowledge self-propelled himself in his wheelchair to the facility's dining/activity room where there was no staff present, stood up from his wheelchair unassisted and fell . 3. Ensure licensed staff followed the facility's P&P titled, Care Plans, Goals and Objectives, that indicated care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. 4. Ensure the licensed nurses and the IDT followed the facility's P&P, titled, Safety and Supervision of Residents in implementing interventions to reduce Resident 1's accident risks and hazards by communicating specific interventions to all relevant staff, assigning responsibility for carrying out interventions and ensuring interventions are implemented and documented. These deficient practices resulted in: Resident 1 sustaining seven falls on 4/16/2023, 5/9/2023, 5/12/2023, 5/30/2023, 11/13/2023 and twice on 12/12/2023. On 12/12/2023 at 8:45 p.m., Resident 1 was taken to a nursing station by CNA 6 without alerting nursing staff that she was leaving Resident 1 there and to watch him. Resident 1 left the nursing station without staff knowledge and entered the facility's dining/activity room where he stood up from his wheelchair unassisted and unsupervised, and fell . After the fall at the dinning/activity room, Resident 1 was taken to the nursing station and approximately 20 minutes later, in the presence of Licensed Vocational Nurse (LVN 1), Resident 1 stood up from his wheelchair unassisted and unsupervised, and fell to the floor again. Resident 1 sustained fracture (break) to his distal coccygeal (tailbone). Findings: During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including dementia (progressive loss of memory and impaired ability to remember or make decisions) and difficulty walking. During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care-screening tool), dated 3/10/2023, the MDS indicated Resident 1's cognitive skills for daily decision-making were severely impaired. The MDS indicated Resident 1 was not steady when moving from a seated to a standing position and could only stabilize with staff assistance. The MDS indicated Resident 1 required extensive one-person physical assist to move on/off the unit. During a review of Resident 1's Morse Fall Scale (a method for determining a resident's likelihood of falling) Reports for 2023, the reports indicated Resident 1 had falls on 4/16/2023, 5/9/2023, 5/12/2023, 5/30/2023, 11/13/2023 and 12/12/2023. During a review of Resident 1's IDT meeting note, dated 11/14/2023, the IDT note indicated Resident 1 had poor safety awareness, forgetfulness, and disorientation. The IDT note indicated Resident 1 needed constant redirection and reorientation of location. The IDT's recommendations were to continue the Mat alarm, frequent visual checks, and place Resident 1 in front of or close to the nursing station. During a review of Resident 1's Care Plan dated 11/13/2023, the Care Plan indicated the IDT's recommended interventions, to continue the use the Mat alarm, frequent visual checks, or to place Resident 1 in front of or near the nursing station, were not included. During a review of Resident 1's Tracking Record for Improving Patient Safety Report, dated 12/14/2023, the Tracking report indicated on 12/12/2023 at 8:21 p.m., Resident 1 wheeled himself to the dining room. The Tracking report indicated Resident 4, who was in the dining room, witnessed Resident 1 get out of his wheelchair and fall to the floor. The Tracking report indicated Resident 4 called for assistance and LVN 1, a certified nursing assistant (CNA 2) and CNA 3 arrived to find Resident 1 on the floor. The Tracking report indicated Resident 1's fall was unwitnessed by staff and Resident 1's wheelchair alarm was not in use. During a review of Resident 1's Tracking Record for Improving Patient Safety Report, dated 12/14/2023, the Tracking report indicated on 12/12/2023 at 8:45 p.m., after Resident 1 experienced an unwitnessed fall a few minutes prior (8:21 p.m.) and was taken in his wheelchair to the nursing station. The Tracking report indicated while LVN 1 was on the phone, Resident 1 got up from his wheelchair and fell again. During a review of Resident 1's Health Status Note dated 12/13/2023, the Health Status Note indicated Resident 1's physician ordered a STAT (urgent) X-ray of Resident 1's sacrum (triangular bone near buttocks). During a review of Resident 1's Radiology (X-ray) Report dated 12/13/2023, the Radiology Report indicated Resident 1 sustained a distal coccygeal fracture. During an interview on 12/29/2023, at 1 p.m., LVN 1 stated, on 12/12/2023, CNA 2 called her to attend to Resident 1. LVN 1 stated she went to the activity room to see what was going on and observed Resident 1 lying on the floor outside the activity room. LVN 1 stated, she, CNA 2, and CNA 3 assisted Resident 1 back into his wheelchair. LVN 1 stated, 15 minutes after she assisted Resident 1 back into his wheelchair, she (LVN 1) observed Resident 1, at the nursing station, getting up from his wheelchair and falling onto the floor on his buttocks. LVN 1 stated Resident 1 needed to be closely supervised. During a concurrent interview and record review on 1/2/2024 at 2:05 p.m., with the Director of Staff Development (DSD), Resident 1's Morse Fall Score Reports dated 3/4/2023, 4/16/2023, 5/9/2023, 5/12/2023 and 11/13/2023 were reviewed. The Morse Fall scores indicated Resident 1 scored between 55-75 indicating Resident 1 was at high risk for falls. The Morse Fall Score Report indicated Resident 1 would overestimate or forget limits of his ability to ambulate safely. The DSD stated the purpose of the Morse Fall Scale Report was to determine Resident 1's risk for falls and to develop a care plan with interventions to prevent falls and injuries. The DSD stated Resident 1's Morse Fall Score Report indicated Resident 1 was at high risk for falls due to his diagnosis of dementia and poor safety awareness and his care plans should be revised to reflect effective goals and interventions after each fall. During an interview on 1/12/2023 at 11a.m., CNA 6 stated she was assigned to Resident 1 on 12/12/2023 during the evening shift (3 p.m. - 11 p.m.). CNA 6 stated on 12/12/2023 at approximately 8 p.m., she wheeled Resident 1 to the nursing station. CNA 6 stated during that time there were staff present in the hallway and at the nursing station, so she thought Resident 1 was being supervised. CNA 6 stated she did not tell anyone that Resident 1 was there or to watch him as she left him there. CNA 6 stated Resident 1 propels himself in a wheelchair independently and often tries to get out of the wheelchair unassisted. During an interview on 1/12/2023 at 4:35 p.m., the DON stated she reviewed Resident 1's care plan dated 11/13/2023 and confirmed Resident 1's care plan was not revised to reflect specific interventions such as conducting frequent visual checks and placing a w/c alarm in Resident 1's wheelchair as discussed during the IDT meeting held after Resident 1's fall on 11/13/2023. During a review of the facility's P/P titled, Safety and Supervision of Residents dated 7/2017, the P/P indicated Resident safety, supervision, and assistance to prevent accidents are facility-wide priorities. The P/P indicated the IDT care team shall analyze information obtained from assessments and observation to identify any specific accident hazards or risks for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. The P/P indicated the facility will implement interventions to reduce accident risks and hazards including the following: Communicating specific interventions to all relevant staff, assigning responsibility for carrying out interventions, providing training as needed, ensuring that interventions are implemented and documented. The P/P indicated how the facility will monitor the effectiveness of interventions to include ensuring interventions are implemented correctly and consistently, evaluating the effectiveness of interventions, modifying, or replacing interventions as needed, and evaluating the effectiveness of new or revised interventions. During a review of the facility's P/P, titled Care Plans, Goals and Objectives, revised 4/2009, the P/P indicated care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. Care plan goals and objectives are defined as desired outcome for a specific resident problem. When goals and objectives are not achieved, the resident's clinical record will be documented as to why the results were not achieved and what new goals and objectives have been established. Care plans will be modified accordingly.

Based on interview and record review the facility failed to ensure a resident, who was a high risk for falls, was transferred from a wheelchair to the bed by two persons for one of two sampled residents (Resident 1). The facility failed to: 1. Ensure a certified nursing assistant (CNA 1) and CNA 4 did not transfer Resident 1 from a wheelchair to bed without another staff assistance as indicated in the resident ' s untitled care plan. 2. Ensure CNA 1, CNA 4, and CNA 5 followed the facility ' s policy and procedure (P/P) titled Falls and Fall Risk, Managing by trying to prevent Resident 1 from falling during transfer from a wheelchair to bed by implementing the care plan intervention to have two person physical assistance for the resident ' s transfer. These deficient practices resulted in Resident 1 falling during transfer from a wheelchair to bed and sustaining a right femur (thighbone) fracture (broken bone) requiring transfer to a general acute care hospital (GACH) for right hip repair surgery. Findings: During a review of Resident 1 ' s Admission Records the Admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted to the facility 11/19/2023 with diagnoses including unspecified fracture of the right femur, aftercare following right hip replacement surgery, difficulty walking, muscle weakness and hemiplegia (paralysis [loss of the ability to move] on one side of the body). During a review of Resident 1 ' s Minimum Data Set ([MDS], a standardized assessment and care-screening tool) dated 10/11/2023, the MDS indicated Resident 1 was able to make herself understood and understood others. The MDS indicated Resident 1 was not experiencing any pain or hurting during the time of assessment (5 day look back period (period of time within which the resident ' s condition is captured by the MDS assessment). The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort of activities for the resident) on staff for assistance with bathing, dressing, and using the toilet. During a review of Resident 1 ' s Fall Risk assessment dated [DATE], the Fall Risk Assessment indicated Resident 1 was rated 75 indicating a high fall risk (0-24 low fall risk, 25-44 moderate fall risk, above 45 a high fall risk). During a review of Resident 1 ' s Health Status Note dated 3/25/2023, the Health Status Note indicated Resident 1 had an assisted fall on 3/25/2023 while CNA 4 attempted to transfer the resident to a wheelchair. The Health Status Note indicated Resident 1 was being assisted by CNA 4 into her wheelchair and Resident 1 ' s knee gave out. Resident 1 was assisted to the floor, landing on her buttocks. During a review of Resident 1 ' s untitled care plan dated 3/25/2023 (initiated after the witnessed fall), the care plan indicated Resident 1 had an assisted fall by CNA 4 with a goal for Resident 1 to not have any injuries status post (s/p) fall. Resident 1 ' s care plan interventions included assessing for the root cause and risk factors that may have resulted in Resident 1 ' s fall and facility staff to utilize two-person physical assistance for Resident 1 ' s transfers between surfaces and bed mobility. This care plan was active when Resident 1 sustained a fall on 11/15/2023. During a review of Resident 1 ' s Joint Mobility Assessment, dated 7/12/2023, the Joint Mobility Assessment indicated Resident 1 had functional impairment to both lower extremities including hip, knee, ankle, foot. During a review of Resident 1 ' s History and Physical report (H&P) dated 9/26/2023, the H&P indicated Resident 1 required assistance with walking, had right sided hemiplegia, and was able to exercise her rights regarding care (able to understand and be involved in care). During a review of Resident 1 ' s Health Status Note dated 10/4/2023, the Health Status Note indicated Resident 1 was assessed and required extensive two-person assistance for activities of daily living (ADL) and had limited mobility. During a review of Resident 1 ' s Health Status Note written by the licensed vocational nurse (LVN 1) dated 11/15/2023 and timed at 7:09 p.m., the Health Status Note indicated at approximately 3 p.m., Resident 1 sustained a sprain (twist of connective tissue that connects two bones of a joint) on right thigh during incontinence brief change. The Health Status Note indicated LVN 1 applied Rest, Ice, Compression, and Elevation (RICE). During a review of the Change of Condition ([COC] documentation of vital medical information when a resident experiences a change from their normal state of being) evaluation dated 11/16/2023 at 9 a.m., the COC indicated Resident 1 was experiencing right knee and right hip pain rated a nine out of 10. The COC indicated Resident 1 had a witnessed fall on 11/15/2023 (the second fall in 2023 while being assisted by one person). The COC indicated the pain was acute (new) musculoskeletal (involving both muscles and bones) pain. The COC indicated Resident 1 reported the following: 1. Right hip pain was acute, intolerable (unable to endure), sharp, throbbing pain rated nine out of10. 2. Right thigh pain was acute, intolerable, sharp, throbbing pain rated eight out of 10. 3. Right knee pain was acute intolerable, sharp, throbbing pain rated seven out of 10. The COC indicated the movement of the right leg made the pain worse and immobilization (the process of stopping something from moving) that was applied by the registered nurse supervisor (RN 1), made the pain better. During a review of Resident 1 ' s Health Status Note dated 11/16/2023 (the day after the fall) at 9 a.m., the Health Status Note indicated at approximately 9 a.m. Resident 1 complained of right hip and right knee pain. The Health Status Note indicated Resident 1 was assessed by RN 1 and LVN 2, who was a charge nurse. Resident 1 ' s physician (MD1) was notified of Resident 1 ' s severe pain. The Health Status Note indicated MD1 ordered the following: 1. Obtain an X-ray (a photographic or digital image of the internal composition of a part of the body) of the right hip and knee. 2. Administer Ultracet (a combination of Tramadol [pain medication] 37.5 ([mg] unit of weight measurement) and 325 mg Tylenol (a pain medication ) for pain level of six out of 10. 3. Administer Norco (narcotic pain medication) 10/325mg for a pain scale of seven out of 10. 4. Apply an ice pack to the right knee for swelling and pain. During a review of Resident 1 ' s COC dated 11/16/2023 and timed at 9:15 a.m., the COC indicated Resident 1 ' s change of condition was a fall, and Resident 1 had a decline in function and mobility, with uncontrollable pain. The COC indicated Resident 1 had a fall that was associated with a suspected serious injury (e.g., fracture) and hip pain. During a review of Resident 1 ' s X-ray results report dated 11/16/2023 and timed at 12:14 p.m., the X-ray report indicated the following: An acute interochanteric fracture (upper portion of femur, a type of hip fracture or broken hip) of the right femur with superior (top) and medial (middle) displacement (femur bone was forced out of alignment) without dislocation (bones separated where they meet at the joint). During a review of Resident 1 ' s Health Status Note dated 11/16/2023 at 2:47 p.m., the Health Status Note indicated Resident 1 was transferred to GACH via ambulance at 2:45 p.m. on 11/16/2023. During a review of Resident 1 ' s H&P report from the GACH dated 11/16/2023, Resident 1 was admitted to the GACH due to a right hip fracture after sustaining a fall at the facility the day prior (11/15/2023). The GACH record indicated Resident 1 was to undergo an Open Reduction Internal Fixation ([ORIF], a type of surgery used to stabilize and heal a broken bone) for the right hip fracture. During an interview on 11/30/2023 at 11 a.m., Resident 1 stated on 11/15/2023 around 4 p.m. CNA 1 was assisting her to go to the bathroom. Upon returning from the bathroom CNA1 was assisting her (Resident 1) to get back to bed by transferring her from a wheelchair to bed. CNA 1 was transferring her alone without the assistance of another staff. Resident 1 stated when she stood up to initiate the transfer her leg gave out and she (Resident 1) fell to the floor straight on her knees. Resident 1 stated she immediately felt excruciating pain and began yelling and screaming in pain. Resident 1 stated CNA 1 and CNA 2 got her (Resident 1) off the floor and back into bed. Resident 1 stated she was having excruciating pain. Resident 1 stated the next day (11/16/2023) the X-ray was done which showed a fracture and she was sent to the GACH for surgery. During an interview on 11/30/2023 at 1 p.m., a restorative nursing assistant ([RNA 1] a trained CNA that interacts with the resident and provides skilled practice and exercises with walking and mobility) stated Resident 1 could be very unsteady on her feet and her legs were shaky. RNA 1 stated when RNAs walk Resident 1 they would use a front wheeled walker (a mobility device with two front wheels that offers stability and support while walking) and have two to three RNAs for assistance, one on the left side, one on the right side, and one walking behind Resident 1 with a wheelchair in case Resident 1 ' s legs gave out or she became tired. During an interview on 12/1/2023 at 12:21 p.m., CNA 1 stated on 11/15/2023 around 4 p.m. she was helping Resident 1 to transfer from a wheelchair back to bed. When Resident 1 stood up from the wheelchair to get transfer, her leg gave out so she fell on her right side, hitting the mattress with the right side of the body then slid down to her knees. CNA1 stated, Resident 1 immediately started screaming in pain, so she called CNA 2 for help and her (CNA 1) and CNA 2 placed Resident 1 back to bed. CNA1 stated after dinner time (between 5 p.m. to 6 p.m.) she (CNA 1) went to check on Resident 1 and change her incontinence briefs. CNA1 stated Resident 1 was okay when she was just lying in bed but as soon as she (Resident 1) was moved to be changed or repositioned, Resident 1 was yelling and screaming in pain. CNA 1 stated Resident 1 had her face scrunched up and was grimacing (a facial expression of pain) due to the amount of pain she was in. During an interview on 12/1/2023 at 12:58 p.m., LVN 1 stated on 11/15/2023 CNA 1 reported Resident 1 was in pain, she did not mention that Resident 1 fell . During an interview on 12/1/2023 at 1:15 p.m., Resident 1 ' s Family Member (FM1) stated on 11/15/2023 around 7 p.m. Resident 1 called her and was hysterically crying due to having pain in her leg. FM1 stated Resident 1 informed her of the fall. FM1 stated she was frustrated to learn that only one CNA was helping Resident 1 with the transfer from a wheelchair to bed leading to Resident 1 ' s fall. FM1 stated Resident 1 had a history of falls at the facility. FM1 stated she had a meeting with the facility after previous falls, and she was assured that two people would be assisting Resident 1 during care and transfer. FM1 stated she visited Resident 1 frequently and Resident 1 was unsteady on her feet so it was unbelievable to her the facility would have one CNA transferring Resident 1 alone. During an interview on 12/1/2023 at 5:08 p.m., the Director of Nursing (DON) stated when a fall occurs, the facility staff were to follow the facility ' s Falls and Fall Risk policy. The DON stated the licensed nurses must immediately assess the resident prior to moving the resident incase the resident has injuries that can get worse with movement. The DON stated the resident ' s physician should have been notified immediately so the physician could give timely orders for tests to treatment. The DON stated it was important for the facility staff to carry out interventions outlined in Resident 1 ' s untitled care plan for falls, dated 3/25/2023, because the care plan was a guideline for Resident centered care and Resident 1 ' s fall prevention. During an interview on 12/7/2023 at 10:15 a.m., RN 1 stated that on the morning of 11/16/2023, she first learned of Resident 1 ' s right hip pain at around 9 a.m. from LVN 2. RN 1 stated when she went to assess Resident 1, the resident was lying comfortably in bed but as soon as she (RN 1) touched the resident ' s right leg, the resident screamed in pain. RN 1 stated Resident 1 informed her that she had fallen the night prior (11/15/2023) on her right side. RN 1 stated she placed an immobilizer on Resident 1 ' s right leg to relieve Resident 1 ' s pain. RN 1 stated MD1 was notified of Resident 1 fall and right hip pain for the first time on 11/16/2023 around 9 a.m. During a review of the facility ' s P/P titled Falls and Fall Risk, Managing dated 3/2018, the P/P indicated the facility staff was to identify interventions related to the resident ' s specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The P/P indicated facility staff was to implement a resident-centered fall prevention care plan to reduce the specific risk factors of falls for each resident at risk or with history of falls. The P/P indicated if falling recurs despite initial interventions, staff will implement additional or different interventions.

Based on interview and record review, the facility failed to manage pain for one of two sampled residents (Resident 1). The facility failed to: 1. Ensure the licensed vocational nurse (LVN 1) did not let Resident 1 experience excruciating pain without receiving pain medication for 17 and half hours after a fall. 2. Ensure LVN 1 notified Resident 1's physician of Resident 1 experiencing excruciating pain in the right leg after the resident fell ; and obtain orders for pain medication. 3. Ensure LVN 1 assessed Resident 1 for pain location and pain severity when Resident 1 complained of pain after a fall. 4. Ensure Resident 1's physician was notified of the resident's fall for the physician to provide orders for timely treatment and transfer to a general acute care hospital (GACH). These deficient practices resulted in Resident 1 experiencing excruciating pain without receiving pain medication for 17 and half hours after the fall. Resident 1 was sent to the GACH on 11/16/2023 where the resident was diagnosed with right femur (thighbone) fracture and underwent an Open Reduction Internal Fixation ([ORIF] a type of surgery used to stabilize and heal a broken bone) surgery of the right hip fracture. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including fracture of the right femur, aftercare following right hip joint replacement surgery, difficulty walking, muscle weakness, and hemiplegia (paralysis [loss of the ability to move] on one side of the body). During a review of Resident 1's Minimum Data Set ([MDS], a standardized assessment and care-screening tool) dated 10/11/2023, the MDS indicated Resident 1 was able to make herself understood and understood others. The MDS indicated Resident 1 was not experiencing any pain or hurting during the time of assessment (5 day look back period (period of time within which the resident's condition is captured by the MDS assessment). The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort of activities for the resident) on staff for assistance with bathing, dressing, and using the toilet. During a review of Resident 1's Care Plan initiated on 8/24/2018, and last revised on 1/11/2023, the Care Plan focus indicated Resident 1 was at risk for pain. The Care Plan goal was for Resident 1 to maintain her comfort level and to be free from pain with interventions that included assessing Resident 1 for changes in pain that may have indicated new pain, assessing Resident 1's characteristics of pain, and administer as needed pain medication as ordered. During a review of Resident 1's Health Status Note, written by licensed vocational nurse (LVN 1) dated 11/15/2023 and timed at 7:09 p.m., the Health Status Note indicated that at approximately 3 p.m., Resident 1 sustained a sprain (a twist of the ligaments [connective tissue that connects two bones] such as in the ankle, the wrist, or other joint violently as to cause pain and swelling) on a left thigh. (however, it was Residetn 1's right leg). The Health Status Note documentation indicated that per a certified nursing assistant (CNA 1), Resident 1 was experiencing pain in the right leg during incontinence brief change . The note indicated the Rest, Ice, Compression, and Elevation (RICE, a method of self-care to care for an injury, usually for soft tissue injuries [sprains, strains, and bruising]) protocol was initiated. During a review of Resident 1's Medication Administration Report (MAR) for the month of 11/2023, the MAR indicated Resident 1 was not given any medication for pain on 11/15/2023 (the day of the fall). During a review of Resident 1's Change of Condition ([COC] documentation of vital medical information when a resident experiences a change from their normal state of being) Evaluation form dated 11/16/2023 and timed at 9 a.m., the COC indicated Resident 1 had a witnessed fall (Resident 1 fell while CNA1 was assisting her from the wheelchair back to bed) on 11/15/2023. The COC indicated the resident had acute (new) musculoskeletal (involving both muscles and bones) pain. The COC indicated Resident 1 complained of right hip pain described as intolerable (unable to endure), sharp and throbbing. Resident 1 rated pain as nine out of 10 on a pain scale from zero to 10 (a tool used to assess a person's pain where zero is no pain, 1-4 was mild pain, 5-7 was moderate pain, and 8-10 was severe pain). The COC indicated that Resident 1 also complained of acute right thigh pain which was described as intolerable, sharp, throbbing, and rated eight out of 10 on the pain scale. The resident also complained of acute right knee pain, which was described as intolerable, sharp, throbbing pain and rated a seven out of 10 on a pain scale. The COC indicated movement of Resident 1's right leg made the pain worse and not moving Resident 1's leg made the pain better. During a review of Resident 1's Health Status Note dated 11/16/2023 (the day after the fall) and timed at 9 a.m., the Health Status Note indicated at approximately 9 a.m. on 11/16/2023 Resident 1's physician (MD 1) was notified of Resident 1's severe pain. MD 1 ordered the following: 1. Obtain an X-ray (a photographic or digital image of the internal composition of a part of the body) of the right hip and knee. 2. Administer Ultracet (a combination of Tramadol [pain medication] 37.5 ([mg] unit of weight measurement) with 325 mg Tylenol for pain level of six out of 10. 3. Administer Norco (narcotic pain medication) 10/325mg for a pain scale of seven out of 10. 4. Apply an ice pack to the right knee for swelling and pain. A review of Resident 1's order summary report dated 11/2023, indicated MD 1 placed an order on 10/31/19 for Tylenol 325 mg, two tablets by mouth every four hours as needed for joint pain scale level one out of 10. During a review of the MAR dated 11/2023, the MAR indicated on 11/16/2023, Resident 1 received Tylenol 650 mg at 9:30 a.m. for pain level of six out of 10 and again at 1 p.m. for pain level of six out of 10. The MAR indicated Resident 1 did not receive Ultracet for a pain level of six out of 10 as ordered. During a review of Resident 1's X-ray results report dated 11/16/2023 and timed at 12:14 p.m., the X-ray report indicated the following: 1. No acute fracture or dislocation of the right knee. 2. Acute interochanteric fracture (upper portion of femur, a type of hip fracture or broken hip) of the right femur with superior (top) and medial (middle) displacement (femur bone was forced out of alignment) without dislocation (bones separated where they meet at the joint). During a review of Resident 1's Health Status Note dated 11/16/2023 and timed at 2:47 p.m., the Health Status Note indicated Resident 1 was transferred to the GACH via ambulance at 2:45 p.m. (22 hours and 45 minutes after Resident 1's fall). During a review of Resident 1's History and Physical (H&P) report from the GACH dated 11/16/2023, the H&P indicated Resident 1 was admitted to the GACH due to a right hip fracture after sustaining a fall at the facility the day prior (11/15/2023). During a review of Resident 1's Discharge Summary report from the GACH dated 11/19/2023, the Discharge Summary indicated Resident 1 underwent ORIF surgery for a right hip fracture. During an interview on 11/30/2023 at 11 a.m., Resident 1 stated on 11/15/2023 around 4 p.m. CNA 1 was assisting her to go to the bathroom. Upon returning from the bathroom CNA1 was assisting her (Resident 1) to get back to bed by transferring her from a wheelchair to bed. CNA 1 was transferring her alone without the assistance of another staff. Resident 1 stated when she stood up to initiate the transfer her leg 'gave out' and she fell straight to the floor on her knees. Resident 1 stated she immediately felt excruciating pain and started yelling and screaming in pain. Resident 1 stated CNA 1 and CNA 2 got her off the floor and placed her back into bed. Resident 1 stated she was having excruciating pain, but LVN 1 just applied an ice pack on her leg. Resident 1 stated she was in excruciating pain all night every time the CNAs tried to change her incontinence briefs. Resident 1 stated she uses incontinence briefs at night. Resident 1 stated around 7 p.m. on 11/15/2023 she was in so much pain she called a family member (FM 1) crying that she could not tolerate the pain and kept begging the facility's staff for medication, but all she got was an ice pack. Resident 1 stated she felt pissed off that she had fallen, and staff was not taking her pain complaints seriously. Resident 1 stated she was waiting for pain medication until the next day. During an interview on 12/1/2023 at 12:21 p.m., CNA 1 stated on 11/15/2023 around 4 p.m. she was helping Resident 1 transfer from a wheelchair back to bed and when Resident 1 stood up to get transferred she fell to her side, hitting the mattress with the right side of her body and then slid down to the floor on her knees. CNA1 stated Resident 1 immediately started screaming in pain. CNA 1 stated she called CNA 2 for help and together they lifted Resident 1 from the floor and placed the resident back into the bed. CNA1 stated she immediately reported to LVN 1 what had happened. CNA 1 stated LVN 1 went to check Resident 1 and told the resident she (LVN 1) would get an ice pack for her (Resident 1's) pain. CNA1 stated after dinner time (between 5 p.m. and 6 p.m.), she (CNA1) went to check on Resident 1 and change her incontinence briefs. CNA1 stated Resident 1 was okay when she was just lying in bed but as soon as she (Resident 1) was moved to be changed or repositioned, Resident 1 was yelling and screaming in pain. CNA 1 stated Resident 1 had her face scrunched up and was grimacing (a facial expression of pain) due to the amount of pain she was in. CNA 1 stated she informed LVN 1 again about Resident 1 having pain and LVN 1 brought more ice to apply on Resident 1's leg. CNA 1 stated she informed LVN 1 three times that day that Resident 1 was screaming in pain. During an interview on 12/1/2023 at 12:58 p.m., LVN 1 stated on 11/15/2023 CNA 1 reported that Resident 1 was in pain, but not that Resident 1 had a fall. LVN 1 stated Resident 1 informed her it was a leg sprain, therefore she treated it as a leg sprain and performed RICE. LVN 1 stated she gave Resident 1 an ice pack and elevated the leg. LVN 1 stated she did not call the physician on 11/15/2023 to report Resident 1's change of condition after the resident complained of pain. During a review of Resident 1's Pain Tool Evaluation form for the month of 11/2023, the Pain Tool Evaluation form indicated LVN 1 did not assess Resident 1's pain location and characteristics on 11/15/2023 (the day of Resident 1 fall) as care planned. During an interview on 12/1/2023 at 1:15 p.m., FM 1 stated on 11/15/2023 at around 7 p.m. Resident 1 called her hysterically crying where she could barely even make out what Resident 1 was saying but she could understand that her leg was hurting her. FM 1 stated she called the facility and spoke to LVN 1 who informed her everything was going to be okay and Resident 1 just sprained her leg. FM1 stated she found it odd that LVN 1 was calling it a sprain just by looking at it without an X-ray, but she was the nurse, so I did not question it. FM 1 stated LVN 1 informed her she did a knee massage for Resident 1 and gave the resident some ice and the resident was okay. FM 1 stated she was worried about Resident 1 and her pain, but the nurse assured her the resident was okay, so she (FM 1) tried not to worry about her that night. FM 1 stated she was very upset and believed the facility downright neglected Resident 1 because they left her in pain all night and did not address the resident's fall or pain until the next day. FM 1 stated Resident 1 was in bad pain all night. FM 1 stated Resident 1 was a very strong lady and does not complain often so the nurses should have known something was seriously wrong when Resident 1 was crying in pain. During an interview on 12/1/2023 at 5:08 p.m., the director of nursing (DON) stated when a fall occurs, the facility staff must follow the facility's policy on Incidents and report the fall, and the resident must immediately be assessed by a licensed nurse prior to moving the resident incase the resident has injuries that can get worse with movement. The DON stated staff cannot make medical diagnoses because it is not within their scope of practice and LVN 1 should not have assumed Resident 1 just had a sprain. The DON stated the physician should have been notified immediately so the physician could give orders for tests and treatment for the resident and get a true medical diagnosis, and to treat the pain. The DON stated LVN1 failed to document a pain assessment (including pain location, intensity, and other characteristics of pain) for Resident 1 on 11/15/2023. The DON stated appropriate pain assessment and management was important because pain affects the resident's quality of life and pain is an indicator that something is wrong with the resident. The DON stated it was important for the facility staff to carry out interventions outlined in Resident 1's untitled care plan for falls, dated 3/25/2023, because the care plan was a guideline for Resident centered care and Resident 1's fall prevention. During an interview on 12/7/2023 at 10:15 a.m., Registered Nurse supervisor (RN 1) stated on the morning of 11/16/2023, she first learned of Resident 1's pain at around 9 a.m. from LVN 2. RN 1 stated when she went to assess Resident 1 on 11/16/2023, the resident was lying comfortably in bed but as soon as she (RN 1) touched the resident's right leg, Resident 1 complained of pain. RN 1 stated Resident 1 informed her that she (Resident 1) had fallen the night prior and had a sprain on her leg. RN 1 stated LVN 2 gave Resident 1 Tylenol 650 mg for pain on 11/16/2023 at around 9:30 a.m., because that was what was available. During an interview and concurrent record review on 12/7/2023 at 10:24 a.m., the DON reviewed Resident 1's MAR record for 11/15/2023 and 11/16/2023. The DON stated that on 11/15/2023 (the day of Resident 1's fall), Resident 1 did not receive any pain medications. The DON stated Tylenol was documented as given on 11/16/2023 at around 9:30 a.m. (17.5 hours after the fall). The DON stated Resident 1 was requesting more powerful pain medications than Tylenol on the morning of 11/16/2023 but by time they received the new orders from MD 1 and the stronger pain medications were authorized, Resident 1 had already been sent out to the GACH. During a review of the facility's policy and procedure (P/P) titled Incidents dated 12/2007, the P/P provided guidelines for facility staff to follow in the case of an actual fall. The P/P indicated to prevent further injury, do not move the resident after fall until complete range of motion (ROM) was done. The P/P indicated a complete head to toe check was required and the physician and responsible party was to be notified of the fall. During a review of the facility's P/P titled Pain Assessment and Management dated 10/2022, the P/P indicated acute pain should be assessed every 30 to 60 minutes after the onset and reassessed as indicated until relief is obtained. The P/P indicated facility staff was to monitor the resident for the presence of pain and the need for further assistance when there was a change of condition. The P/P indicated the physician was to be notified immediately if the resident's pain was not adequately controlled the physician needed to be notified for significant changes in the level of the resident's pain. The P/P indicated the documentation regarding the resident's pain should be documented with adequate detail (i.e., enough information to gauge the status of pain and the effectiveness of interventions for pain).

Based on interview and record review, the facility failed to immediately inform and consult with the physician when Resident 1 who had Covid-19 (a potentially severe respiratory illness caused by a coronavirus and characterized by fever, coughing and shortness of breath) experienced a significant change of condition, for one of four residents (Resident 1). The facility failed to: Ensure Licensed Vocational Nurse 1 (LVN 1) assessed Resident 1 and notified Resident 1's physician when Certified Nursing Assistant 1 (CNA 1) informed her (LVN 1) Resident 1 was weak, had slow and shallow breathing, and the resident's oxygen saturation (oxygen saturation refers to the level of oxygen carried by red blood cells through the arteries and delivered to internal organs) rate was 88 percent [(%) reference range rate is 95%-100%] on room air. This deficient practice resulted in a delay of necessary medical interventions for Resident 1 when the resident had a COC leading to respiratory failure (a person exhibiting no effort to breathe or has stopped breathing altogether) manifested by slow and shallow breathing requiring cardio-pulmonary resuscitation Resident 1 expired on [DATE] at the facility. On [DATE] Resident 1 tested positive for COVID-19 (a potentially severe respiratory illness caused by a coronavirus and characterized by fever, coughing and shortness of breath) and was transferred to an isolation (an area where a possibly infectious resident is separated while receiving medical care) room in the facility. On [DATE] at approximately 8 a.m., CNA 1 found Resident 1 being weak, with slow, shallow breathing and an oxygen saturation (the level of oxygen carried by blood through blood vessels and delivered to internal organs) rate of 88% on room air. CNA 1 reported Resident 1's status to LVN 1 right away. However, LVN 1 did not go to Resident 1's room to assess him, did not call Resident 1's physician to report Resident 1's COC, and did not conduct ongoing assessments of Resident 1. At 10:45 a.m., (2 hours and 30 minutes later) CNA 1 found Resident 1 unresponsive, without a pulse (heart beat) and breathless. The Registered Nurse Supervisor (RNS 1) was called to Resident 1's room who began Resident 1's CPR by placing a non-rebreather ([NRM] a medical device that helps provide oxygen for people who can still breathe on their own). oxygen mask at 15 liters per minute [(lpm) a unit of measurement of the oxygen flow]. Resident 1 was pronounced dead at the facility at 11:21 a.m., by paramedics (assess a patient's condition and administer emergency medical care). During an anonymous complaint investigation conducted on [DATE] at 9:40 a.m., 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 to a resident) was called in the presence of the facility's Administrator (ADM) and the Director of Nursing (DON) due to the facility's failure to ensure Resident 1 was assessed and monitored during a COC and failure to ensure nursing staff were competent to provide effective CPR. On [DATE] at 2:47 p.m., the ADM submitted an acceptable IJ removal plan ([IJRP] an intervention to immediately correct the deficient practices). After review and verification that the IJRP was implemented through observation, interview, and record review, the IJ was removed while onsite on [DATE] at 2:47 p.m., in the presence of the ADM, the DON, the Operational Consultant (OC), the MDS Coordinator, the Director of Staff Development (DSD), and the Director of Medical Records. The IJRP included the following: 1. In-service (staff education) was provided by the Director of Nursing (designee) on [DATE] & [DATE] on the following topics: a. Identification of worsening signs and symptoms of Covid-19. b. Identification of respiratory distress. c. Identification of COC and when to call the physician. d. Immediate notification of a resident's change of condition to their attending physician. 2. In-services will be on going until all licensed nurses have attended and fully demonstrate knowledge competency. 3. The Interdisciplinary Team ([IDT] a resident's health care team from various specialties) will discuss all change of conditions during daily clinical meetings. During the huddle, CNAs and Licensed Nurses will report any changes and concerns to RN Supervisor and/or the DON immediately and to the incoming shift nurses. Huddles are conducted every shift. 4. The DON (or Nursing Supervisor if DON is unavailable) will review the change of conditions daily and will validate compliance in notifying the physician and through completion of documentation. 5. Medical Records will audit the change of conditions daily and will communicate the outcome of the change of conditions report to the DON and the Administrator for further follow-up. The audit log will be given by the Medical Records to the DON (or Nursing Supervisor if DON is unavailable) on a daily basis. 6. Knowledge competency on worsening change of conditions such as respiratory distress, cardiopulmonary distress and when to notify the MD of COCs started on [DATE] and is ongoing until all nursing staff have been taught and provide a return demonstration to show competence. If the MD is unavailable, the Licensed nurses will contact the Medical Director. 7. CNAs were provided in-services and training education on [DATE] and [DATE] to document any resident changes via the Stop and Watch form located in each station hallway and in each shower room. The Stop and Watch form will be immediately submitted to the Licensed Nurses on duty. The DON (or the Nursing Supervisor if DON is unavailable) will validate for completion daily. The in-services will be on-going until all staff have been in-serviced. 8. Identify all residents who are at risk for respiratory distress to monitor for compliance by reading through the 24 hours report and/or the 72 hours report on electronic health record software Point Click Care (PCC). 9. New hires will be oriented on how to identify COC and when to notify the attending physician. On a daily basis, the DON (or Nursing Supervisor) will ensure that for every COC, the MD will be notified. 10. Knowledge and skills competencies on identification of worsening signs and symptoms of COVID-19 and Identification of respiratory distress will be incorporated and completed in the orientation program for newly hired licensed nurses, quarterly and as needed. Findings: During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including Covid 19, diabetes ([DM] a chronic condition associated with abnormally high levels of sugar in the blood), acute kidney failure (when kidneys are unable to filter waste products from the blood) and hypertension ([HTN] high blood pressure). During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care-screening tool), dated [DATE] the MDS indicated Resident 1's cognitive (relating to the mental process of knowing, learning, and understanding things) skills for daily decision-making were severely impaired. The MDS indicated Resident 1 required an extensive one-person physical assistance with transfers, bed mobility, locomotion on/off the unit and activities of daily living ([ADL] tasks such as eating, bathing, dressing, grooming and toileting). During a review of Resident 1's Laboratory Report (LR) dated [DATE], the LR indicated Resident 1 tested positive for Covid-19 on [DATE]. During a review of Resident 1's Physician's Order dated [DATE], the physician's order indicated to transfer Resident 1 to the Red Zone (a designated area in the facility where Covid 19 positive residents are located). During an interview on [DATE], at 2:20 p.m., with CNA 1, CNA 1 stated on [DATE] Resident 1's appetite was decreased, and he did not want anything to eat. CNA 1 stated on [DATE] at 7:30 a.m., when she took Resident 1's vital signs ([v/s] measurements of temperature, pulse, blood pressure, and oxygenation and rate of respiration )) she observed Resident 1 was weak, his breathing was slow and shallow. CNA 1 stated Resident 1 opened his eyes a little bit but when she tapped his shoulder he did not move much. CNA 1 stated Resident 1 was usually confused but usually conversant. CNA 1 stated she reported Resident 1's new condition status right away to LVN 1. During an interview on [DATE], at 8:25 a.m., with LVN 1 and subsequent interviews on the same day at 11:39 a.m., and 1:48 p.m., LVN 1 stated on [DATE] she was assigned to Resident 1 as his charge nurse (assigned to provide nursing care such as assessment, administering medications and treatments, maintaining files and charts). LVN 1 stated at approximately 8 a.m., CNA 1 reported to her that Resident 1's oxygen saturation rate was 88% and he was weak. LVN 1 stated she did not go to Resident 1's room to administer oxygen to the resident after receiving CNA 1's report. LVN 1 stated she did not go into Resident 1's room to assess him and she did not notify Resident 1's physician of Resident 1's COC. LVN 1 stated she should have gone to Resident 1's room, assessed his condition, rechecked his v/s including his oxygen saturation and called Resident 1's physician to let him know about Resident 1's COC, because Resident 1 was medically unstable and further medical interventions and orders were needed. During a telephone interview with Registered Nurse Supervisor 1 (RNS 1) on [DATE], at 12:05 p.m., RNS 1 stated if Resident 1's oxygen saturation was low and he was weak, Resident 1 should have been administered oxygen, a COC should have been documented, and the physician should have been informed right away. During a review of facility's policy and procedure (P/P) titled Change in Resident's Condition of Status revised ,d+[DATE], the P/P indicated the facility will promptly notify resident's Attending Physician and representative of changes in the resident's medical condition. The P/P also indicated the Nurse Supervisor/ Charge Nurse will notify resident's Attending Physician or On-Call Physician when there has been a significant change in the resident's physical/ emotional/ mental conditions, or a need to transfer the resident to a hospital/treatment center.

Based on interview and record review, the facility failed to ensure a resident, who was experiencing a change of condition (COC), was assessed, and monitored for one of four residents (Resident 1). The facility failed to: 1. Ensure Licensed Vocational Nurse 1 (LVN 1) assessed Resident 1 when she was made aware of the resident's change of condition (COC). 2. Ensure Resident 1 was frequently monitored following a report that he was weak, had slow and shallow breathing with oxygen saturation rate (oxygen saturation refers to the level of oxygen carried by blood through the blood vessels and delivered to internal organs) rate was 88 percent [(%) normal range rate 95%-100%] on room air. This deficient practice resulted in Resident 1 experiencing respiratory failure (a person exhibiting no effort to breathe or stop breathing altogether) manifested by slow and shallow breathing requiring cardio-pulmonary resuscitation ([CPR] emergency life-saving procedure that is done when someone's breathing, or heartbeat has stopped). Resident 1 expired on [DATE] at the facility. On [DATE] Resident 1 tested positive for COVID-19 (a potentially severe respiratory illness caused by a coronavirus and characterized by fever, coughing and shortness of breath) and was transferred to an isolation (an area where a possibly infectious resident is separated while receiving medical care) room in the facility. On [DATE] at approximately 8 a.m., Certified Nursing Assistant (CNA 1) found Resident 1 being weak, with slow and shallow breathing with an oxygen saturation (the level of oxygen carried by blood through blood vessels and delivered to internal organs) rate of 88% (normal reference range 95%-100%) on room air. CNA 1 reported Resident 1's status to LVN 1. However, LVN 1 did not go to Resident 1's room to assess him, did not call Resident 1's physician to report Resident 1's COC and did not conduct ongoing assessments of Resident 1 status. On [DATE] at 10:45 a.m., CNA 1 found Resident 1 unresponsive, without a pulse (heart beat) and breathless. A Registered Nurse Supervisor (RNS 1) was called to Resident 1's room who began CPR on Resident 1 by placing a non-rebreather ([NRM] a medical device that helps provide oxygen for people who can still breathe on their own) oxygen mask on him at 15 liters per minute [(lpm) a unit of measurement of oxygen flow]. Resident 1 was pronounced dead at the facility at 11:21 a.m., by paramedics (assess a patient's condition and administer emergency medical care). During an anonymous complaint investigation conducted on [DATE] at 9:40 a.m., 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 to a resident) was called in the presence of the facility's Administrator (ADM) and the Director of Nursing (DON) due to the facility's failure to ensure Resident 1 was assessed and monitored during a COC and failure to ensure nursing staff were competent to provide effective CPR. On [DATE] at 2:47 p.m., the ADM submitted an acceptable IJ removal plan ([IJRP] an intervention to immediately correct the deficient practices). After review and verification that the IJRP was implemented through observation, interview, and record review, the IJ was removed while onsite on [DATE] at 2:47 p.m., in the presence of the ADM, the DON, the Operational Consultant (OC), the MDS Coordinator, the Director of Staff Development (DSD), and the Director of Medical Records. The IJRP included the following: 1. In-service (staff education) was provided by the Director of Nursing (designee) on [DATE] & [DATE] on the following topics: a. Identification of worsening signs and symptoms of Covid-19. b. Identification of respiratory distress. c. Identification of COC and when to call the physician. d. Immediate notification of a resident's change of condition to their attending physician. 2. In-services will be on going until all licensed nurses have attended and fully demonstrate knowledge competency. 3. The Interdisciplinary Team ([IDT] a resident's health care team from various specialties) will discuss all change of conditions during daily clinical meetings. During the huddle, CNAs and Licensed Nurses will report any changes and concerns to RN Supervisor and/or the DON immediately and to the incoming shift nurses. Huddles are conducted every shift. 4. The DON (or Nursing Supervisor if DON is unavailable) will review the change of conditions daily and will validate compliance in notifying the physician and through completion of documentation. 5. Medical Records will audit the change of conditions daily and will communicate the outcome of the change of conditions report to the DON and the Administrator for further follow-up. The audit log will be given by the Medical Records to the DON (or Nursing Supervisor if DON is unavailable) on a daily basis. 6. Knowledge competency on worsening change of conditions such as respiratory distress, cardiopulmonary distress and when to notify the MD of COCs started on [DATE] and is ongoing until all nursing staff have been taught and provide a return demonstration to show competence. If the MD is unavailable, the Licensed nurses will contact the Medical Director. 7. CNAs were provided in-services and training education on [DATE] and [DATE] to document any resident changes via the Stop and Watch form located in each station hallway and in each shower room. The Stop and Watch form will be immediately submitted to the Licensed Nurses on duty. The DON (or the Nursing Supervisor if DON is unavailable) will validate for completion daily. The in-services will be on-going until all staff have been in-serviced. 8. Identify all residents who are at risk for respiratory distress to monitor for compliance by reading through the 24 hours report and/or the 72 hours report on electronic health record software Point Click Care (PCC). 9. New hires will be oriented on how to identify COC and when to notify the attending physician. On a daily basis, the DON (or Nursing Supervisor) will ensure that for every COC, the MD will be notified. 10. Knowledge and skills competencies on identification of worsening signs and symptoms of COVID-19 and Identification of respiratory distress will be incorporated and completed in the orientation program for newly hired licensed nurses, quarterly and as needed. Findings: During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included Covid 19, diabetes ([DM] a chronic condition associated with abnormally high levels of sugar in the blood), acute kidney failure (when kidneys are unable to filter waste products from the blood) and hypertension ([HTN] high blood pressure). During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated [DATE] the MDS indicated Resident 1's cognitive (relating to the mental process of knowing, learning, and understanding things) skills for daily decision-making were severely impaired. The MDS indicated Resident 1 required extensive one-person physical assistance with transfers, bed mobility, locomotion on/off the unit and activities of daily living ([ADL] task such as eating, bathing, dressing, grooming and toileting. During a review of Resident 1's Laboratory Report (LR) dated [DATE], the LR indicated Resident 1 tested positive for Covid-19 on [DATE]. During a review of Resident 1's Physician's Order dated [DATE], the physician's order indicated to transfer Resident 1 to the Red Zone (an isolation area in the facility where Covid 19 positive residents are located). During an interview on [DATE], at 2:20 p.m. with CNA 1, CNA 1 stated on [DATE] Resident 1's appetite was poor, and he did not want anything to eat. CNA 1 stated on [DATE] at 7:30 a.m., when she took Resident 1's vital signs ([v/s] measurements of temperature, pulse, blood pressure, and oxygenation and rate of respiration) she observed Resident 1 was weak, his breathing was slow and shallow, Resident 1 slightly opened his eyes. CNA 1 tapped the resident on the shoulder, but the resident did not move much. CNA 1 stated Resident 1 was usually confused but conversant. CNA 1 stated she reported these findings right away to LVN 1. During an interview on [DATE], at 8:25 a.m. with LVN 1 and subsequent interviews on the same day at 11:39 a.m., and 1:48 p.m., LVN 1 stated on [DATE] she was assigned to Resident 1 as his charge (assigned to provide nursing care such as assessment, administering medications and treatments, maintaining files and charts) nurse. LVN 1 stated at approximately 8 a.m., CNA 1 reported to her that Resident 1's oxygen saturation rate was 88% on room air and he was weak but stated she did not go to Resident 1's room to administer oxygen to him after receiving CNA 1's report. LVN 1 stated Resident 1 needed to be assessed in person to get an accurate picture of his status and she should have gone to Resident 1's room, assessed his condition, rechecked his v/s including his oxygen saturation. LVN 1 stated she did not go into Resident 1's room to assess him when it was reported to her the resident had slow and shallow breathing and his oxygen saturation was 88% on room air. LVN 1 stated ADM and the DON told them (Licensed Vocational Nurses{LVN's}) not to go into the red zone rooms until the end of the shift so as not to spread the virus. LVN 1 stated during her morning rounds on [DATE] she called Resident 1's name as she stood outside of his door, and she charted based on what CNA 1 reported to her. LVN 1 stated she failed to assess Resident 1 until Resident 1 went into cardiopulmonary arrest (sudden, unexpected loss of heart function, breathing, and consciousness). During a telephone interview on [DATE], at 12:05 p.m. with Registered Nurse Supervisor 1(RSN 1), RNS 1 stated on [DATE] she was working as the charge nurse at Nursing Station 1 until 11 a.m., when another nurse was supposed to relieve her. RNS 1 stated she overhead an immediate STAT (immediate) page was called to Resident 1's room at around 10:45 a.m., (2 hours and 30 minutes after CNA 1 reported of Resident 1's COC) she responded right away. RNS 1 stated she was not aware Resident 1's oxygen saturation was low, and the resident had slow and shallow breathing. RNS 1 stated LVN 1 did not notified her of Resident 1's COC status until CPR started. RNS 1 stated LVN 1 should have notified her about Resident 1's weakness, slow and shallow breathing and low oxygen saturation because she was still the Nursing Supervisor even though she was working as a charge nurse. RNS 1 stated if Resident 1's oxygen saturation was low and he was weak, Resident 1 should have been provided oxygen, a COC should have been documented, and the physician should have been informed. RNS 1 stated Resident 1's vital signs and oxygen saturation rate should have been assessed and monitored to make sure the necessary effective medical interventions were provided to ensure a significant change of condition was treated effectively. During an interview on [DATE], at 5 p.m., with the DON, the DON stated LVN 1 should have assessed Resident 1 regardless of whether the resident was in an isolation area (the red zone) or not when he had a COC. The DON stated LVN 1, and other staff members could still enter the red zone as long as they practiced hand hygiene and wore full personal protective equipment ([PPE] specialized clothing or equipment worn by healthcare workers for protection against infectious materials). During a review of facility's policy and procedure (P/P) titled Change in Resident's Condition or Status, revised ,d+[DATE], the P/P indicated the Nurse Supervisor/ Charge Nurse will notify the attending physician or on call physician promptly about changes in resident's condition. A significant change of condition is a decline or improvement in the resident's condition that will not normally resolve by itself without intervention of staff or implementing standard disease-related clinical interventions.

Based on observation, interview, and record review, the facility failed to ensure the licensed nurses had the necessary training, knowledge, and skills to perform effective cardiopulmonary resuscitation ([CPR] emergency lifesaving procedure when the heart stops beating consisting of chest compressions and artificial breathing) to a resident who had a significant change of condition for one of four sampled residents (Resident 1). The facility failed to: 1. Ensure the registered nurse supervisor (RNS 1) provided rescue breathing to Resident 1 by using an AMBU ([artificial manual breathing unit] a hand-held device commonly used to provide ventilation to patients who are not breathing or not breathing adequately) bag or delivered rescue breaths by mouth when the resident was found unresponsive, without a pulse (heart beat) and not breathing. RNS 1 instead of using an AMBU bag applied 15 liters per minute ([lpm] a unit of measurement) of oxygen via non-rebreather mask ([NRM] a medical device that helps provide oxygen for people who can still breathe on their own). This deficient practice resulted in Resident 1 not being adequately ventilated (mechanically move air in and out of the lungs) by nursing staff who performed CPR incorrectly, after Resident 1 experienced a severe change of condition (COC) leading to his death and placed other residents at risk for not receiving proper and effective CPR causing death. Resident 1 expired at the facility. On [DATE] Resident 1 tested positive for COVID-19 (a potentially severe respiratory illness caused by a coronavirus and characterized by fever, coughing and shortness of breath) and was transferred to an isolation (an area where a possibly infectious resident is separated while receiving medical care) room in the facility. On [DATE] at approximately 8 a.m., CNA 1 found Resident 1 being weak, with slow, shallow breathing and an oxygen saturation (the level of oxygen carried by blood through blood vessels and delivered to internal organs) rate of 88% on room air. CNA 1 reported Resident 1's status to LVN 1 right away. However, LVN 1 did not go to Resident 1's room to assess him, did not call Resident 1's physician to report Resident 1's COC, and did not conduct ongoing assessments of Resident 1. At 10:45 a.m., (2 hours and 30 minutes later) CNA 1 found Resident 1 unresponsive, without a pulse (heart beat) and breathless. The Registered Nurse Supervisor (RNS 1) was called to Resident 1's room who began Resident 1's CPR by placing a non-rebreather ([NRM] a medical device that helps provide oxygen for people who can still breathe on their own). oxygen mask at 15 liters per minute [(lpm) a unit of measurement of the oxygen flow]. Resident 1 was pronounced dead at the facility at 11:21 a.m., by paramedics (assess a patient's condition and administer emergency medical care). On [DATE] at 9:40 a.m., 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 to a resident) was called in the presence of the facility's Administrator (ADM) and the Director of Nursing (DON) due to the facility's failure to ensure Resident 1 was assessed and monitored during a COC and failure to ensure nursing staff were competent to provide effective CPR. On [DATE] at 2:47 p.m., the ADM submitted an acceptable IJ removal plan ([IJRP] an intervention to immediately correct the deficient practices). After review and verification that the IJRP was implemented through observation, interview, and record review, the IJ was removed while onsite on [DATE] at 2:47 p.m., in the presence of the ADM, the DON, the Operational Consultant (OC), the MDS Coordinator, the Director of Staff Development (DSD), and the Director of Medical Records. The IJRP included the following: 1. In-service (staff education) was provided by the Director of Nursing (designee) on [DATE] & [DATE] on the following topics: a. Identification of worsening signs and symptoms of Covid-19. b. Identification of respiratory distress. c. Identification of COC and when to call the physician. d. Immediate notification of a resident's change of condition to their attending physician. 2. In-services will be on going until all licensed nurses have attended and fully demonstrate knowledge competency. 3. The Interdisciplinary Team ([IDT] a resident's health care team from various specialties) will discuss all change of conditions during daily clinical meetings. During the huddle, CNAs and Licensed Nurses will report any changes and concerns to RN Supervisor and/or the DON immediately and to the incoming shift nurses. Huddles are conducted every shift. 4. The DON (or Nursing Supervisor if DON is unavailable) will review the change of conditions daily and will validate compliance in notifying the physician and through completion of documentation. 5. Medical Records will audit the change of conditions daily and will communicate the outcome of the change of conditions report to the DON and the Administrator for further follow-up. The audit log will be given by the Medical Records to the DON (or Nursing Supervisor if DON is unavailable) on a daily basis. 6. Knowledge competency on worsening change of conditions such as respiratory distress, cardiopulmonary distress and when to notify the MD of COCs started on [DATE] and is ongoing until all nursing staff have been taught and provide a return demonstration to show competence. If the MD is unavailable, the Licensed nurses will contact the Medical Director. 7. CNAs were provided in-services and training education on [DATE] and [DATE] to document any resident changes via the Stop and Watch form located in each station hallway and in each shower room. The Stop and Watch form will be immediately submitted to the Licensed Nurses on duty. The DON (or the Nursing Supervisor if DON is unavailable) will validate for completion daily. The in-services will be on-going until all staff have been in-serviced. 8. Identify all residents who are at risk for respiratory distress to monitor for compliance by reading through the 24 hours report and/or the 72 hours report on electronic health record software Point Click Care (PCC). 9. New hires will be oriented on how to identify COC and when to notify the attending physician. On a daily basis, the DON (or Nursing Supervisor) will ensure that for every COC, the MD will be notified. 10. Knowledge and skills competencies on identification of worsening signs and symptoms of COVID-19 and Identification of respiratory distress will be incorporated and completed in the orientation program for newly hired licensed nurses, quarterly and as needed. Findings: During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including Covid 19, diabetes ([DM] a chronic condition associated with abnormally high levels of sugar in the blood), acute kidney failure (when kidneys are unable to filter waste products from the blood) and hypertension ([HTN] high blood pressure). During a review of Resident 1's Minimum Data Set ([MDS] standardized assessment and care screening tool), the MDS indicated Resident 1's cognitive (relating to the mental process of knowing, learning, and understanding things) skills for daily decision-making were severely impaired. The MDS indicated Resident 1 required extensive one-person physical assistance with transfers, bed mobility, locomotion on/off the unit and activities of daily living ([ADL] tasks such as eating, bathing, dressing, grooming and toileting. During a review of Resident 1's Progress Report (PR) dated [DATE], at 11:46 a.m., the PR indicated on [DATE], at 10:46 a.m. Certified Nursing Assistant (CNA 1) called Licensed Vocational Nurse (LVN 1) to report Resident 1 was unresponsive, not breathing and without a pulse. The PR indicated, CPR was begun, and Resident 1 was attached to 15 lpm of oxygen via an NRM. The PR indicated Resident 1 died at 11:21 a.m. on [DATE]. During an interview on [DATE], at 8:30 a.m., and a subsequent interview on the same day at 12:35 p.m., with CNA 1, CNA 1 stated on [DATE] at 10:46 a.m., she found Resident 1 unresponsive, without a pulse and not breathing. CNA 1 stated she did not perform CPR on Resident 1 right away, instead she called LVN 1 who was in the hallway to come and check Resident 1. CNA 1 stated it was her first-time performing CPR and stated she was sorry she did not begin CPR immediately. During an interview on [DATE], 8:25 a.m., with LVN 1, LVN 1 stated she was caring for another resident in another room and heard CNA 1 saying Resident 1 was unresponsive, had no pulse and was not breathing. LVN 1 stated CPR was started, and a staff member called 911. LVN 1 stated she did not use the automated external defibrillator ([AED] a device used in emergency situations to restart the heart when someone is experiencing sudden cardiac arrest) because she did not know how to use it. During an observation on [DATE] at 8:15 a.m., an AED was noted in a glass case that was mounted on the wall near Resident 1's room. During a telephone interview on [DATE], at 12:05 p.m., and a subsequent interview on the same day at 3:45 p.m., with RNS 1, RNS 1 stated she heard on [DATE] 10:46a.m. an emergency page to go to Resident 1's room. RNS 1 stated she brought the crash cart (a wheeled container carrying medicine and equipment for use in emergencies) and an NRM to Resident 1's room where CPR was being performed by staff (LVN1 and CNA1). RNS 1 stated, Resident 1 was unresponsive, was not breathing and had no pulse, she set up the NRM and placed it on Resident 1's face. RNS 1 stated she applied 15 lpm of oxygen via a NRM on Resident 1's face during CPR because it was the protocol of the facility to use a NRB mask on residents who have a low oxygen saturation (the level of oxygen carried by blood through the blood vessels and delivered to internal organs) rate. RNS 1 stated she forgot to use an AMBU bag and acknowledged that a NRM was not the appropriate device to deliver oxygen to a resident who was not breathing, unresponsive and had no pulse. RNS 1 stated she needed a refresher course and training in CPR to manage an airway properly because she was dealing with resident's lives. During a review of facility's policy and procedure (P/P) titled Cardiopulmonary Resuscitation (CPR) and Basic Life Support (BLS), revised ,d+[DATE], the P/P indicated if the victim is unresponsive, no pulse or no respirations, call a code, designate a staff person to call 911, open the airway, check breathing and administer rescue breaths. During a review of an online article titled, American Heart Association 2020 CPR and Emergency Cardiovascular Care Committee ECC Guidelines, the article indicated maintaining a patent (unobstructed) airway and providing adequate ventilation and oxygenation are priorities during CPR. The guidelines indicated for patients without an advanced airway (medical devices inserted through the mouth or nose to provide a stable way of providing breaths during CPR), it is reasonable to deliver breaths either by mouth or by using bag-mask ventilation (AMBU bag). Patients should be monitored continuously to verify airway patency, adequate ventilation, and oxygenation while CPR is being administered. The guidelines indicated delivery of chest compressions without assisted ventilation for prolonged periods could be less effective than conventional CPR (compressions plus ventilation) because arterial oxygen (oxygen level in the blood) content decreases as CPR duration increases. https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-gudelines

Based on interview and record review, the facility failed to ensure a Certified Nursing Assistant (CNA 1) did not physically and verbally abuse a resident (Resident 1) when Resident 1 refused to have her wet adult brief changed and peri-care (cleaning the private area) performed by CNA 1 for one out of two sampled residents (Resident 1). As a result of this deficient practice, Resident 1 felt helpless, useless, and like CNA 1 was going to kill her, following CNA 1's disparaging (words meant to belittle the value or importance of someone or something) comments about her that is why you are blind, you cannot walk, and you are going to be in that bed for the rest of your life, and when CNA 1 physically assaulted Resident 1 by grabbing her wrist tightly, pulling and pushing her from side to side in her bed, hitting and smashing her face on the bed rail, then using a threatening tone when she told Resident 1's (Resident 2) not to use the call light again. Findings: During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated, Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including heart failure (a condition in which the heart cannot pump enough blood to meet the body's needs), type 2 diabetes ([DM] a condition that affects how the body processes sugar), and hypertension ([HTN] high blood pressure). During a review of Resident 1's History and Physical (H&P), dated 11/15/2022, the H&P indicated, Resident 1 was alert and oriented (aware of) to person, place, time, and event, was cooperative and had an appropriate mood and affect (the outward expression of emotion). During a review of Resident 1's Minimum Data Set ([MDS], a standardized assessment and care-screening tool), dated 2/4/2023, the MDS indicated, Resident 1 had the ability to express ideas and wants, had clear comprehension (capability of understanding something), required extensive one-person physical assist to complete toileting, personal hygiene, dressing, and was totally dependent and required a two-person physical assist with transfers and bed mobility. During a review of Resident 1's Care Plan (CP), dated 8/23/2019, the CP indicated, Resident 1 preferred to be changed at specific times by certain CNAs. The CP's goal was to meet Resident 1's needs through the next CP review date, 5/26/2023. The CP's interventions included always respecting Resident 1's rights and letting Resident 1 make choices regarding what time she wanted to be changed instead of staff telling the resident what to do. During a review of a Report of Abuse and Neglect of an Elder or Dependent Adult (SOC 341), dated 3/10/2023, the SOC 341 indicated Resident 1 reported that CNA 1 was physically and verbally abusive. The SOC 341 indicated Resident 1 did not want her buttocks cleaned and CNA 1 ignored Resident 1's preference. The SOC 341 indicated CNA 1 grabbed Resident 1's arm very strongly and forced Resident 1 to have her buttocks cleaned after the resident refused. During a review of Resident 1's Health Status Note (HSN), dated, 3/10/2023, the HSN indicated Resident 1 had episodes of screaming during incontinence (involuntary voiding of urine and stool) care. The HSN indicated Resident 1 did not like her assigned CNA (CNA 1) and after a moment of exchanging words, managed to change the bottom sheet with a dry sheet, but Resident 1 was still upset. It took a while to calm Resident 1 down. During an interview on 3/15/2023 at 2:05 p.m., with the Social Services Director (SSD), the SSD stated on 3/10/2023, she (the SSD), the Administrator (ADM), and the Director of Nursing (DON) interviewed Resident 1, who reported she had been physically and verbally abused on the night shift (3/10/2023), by CNA 1, who was from a registry (a nurse who works on a temporary basis through an agency in a variety of settings rather than a permanent role or in one fixed place). During a concurrent observation and interview on 3/15/2023, at 2:50 p.m., with Resident 1, Resident 1 stated when she refused to allow CNA 1 to change her wet brief, CNA 1 insisted on changing her anyway. Resident 1 stated she asked her roommate (Resident 2) to put on her (Resident 2's) call light, but CNA 1 responded in a loud and aggressive tone of voice, you better not turn on the call light. Resident 1 stated, CNA 1 said to her, that is why you are blind, you cannot walk, and you are going to be in that bed for the rest of your life. Resident 1 stated, she continued to refuse to have her brief changed several times and CNA 1 grabbed her wrist tightly, pulled and pushed her from side to side and hit and smashed her face on the bed rail. Resident 1 stated, she yelled and screamed for help and Licensed Vocational Nurse 1 (LVN 1) came running into her room and she immediately informed LVN 1, that CNA 1 was abusing her. Resident 1 stated she felt helpless and useless, and thought CNA 1 was going to kill her. Resident 1 was observed with glossy eyes, her voice crackled and between long pauses stated, she wished her son had been there to protect her. During an interview on 3/15/2023 at 3:10 p.m., with Resident 2, Resident 2 stated, she was awake and witnessed the incident with Resident 1 and CNA 1. Resident 2 stated, she did not see the physical stuff, but stated she heard CNA 1 tell Resident 1 that she (Resident 1) was blind and could not walk. Resident 2 stated, she heard Resident 1 tell CNA 1 that she (Resident 1) did not want to be changed, then she heard Resident 1 yell, stop treating me so rough! Resident 2 confirmed, Resident 1 asked her (Resident 2) to put on her call light, then stated she heard CNA 1 say in a loud aggressive tone, do not put on that call light again! that was when Resident 1 started screaming for help. Resident 2 stated, CNA 1's statement about not putting the call light on again, made her (Resident 2) afraid to turn on the call light for the rest of the night. During a review of Resident 2's Admission Record (Face Sheet), the Face Sheet indicated, Resident 2 was admitted to the facility on [DATE] with diagnoses including heart failure and major depression (persistent feeling of sadness and loss of interest). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had adequate hearing, clear speech, was usually able to understand and make herself understood by others. During an interview on 3/15/2023 at 4:30 p.m., with the Director of Staff Development (DSD), the DSD stated, on 3/10/2023, Resident 1 reported she had been physically and verbally abused by a night shift CNA (CNA 1) The DSD stated, she did not investigate the allegation of abuse made by Resident 1 but reported the allegation of abuse to the Administrator (ADM). The DSD stated, CNA 1 was a registry staff, and worked on 3/9/2023 from 10:30 p.m.,., to 3/10/2023 at 7 a.m. During a telephone interview on 3/15/2023 at 4:45 p.m., with LVN 1, LVN 1 stated, on 3/10/2023 around 4 a.m., to 5 a.m., he was at the other end of the facility when he heard Resident 1 was screaming for help. LVN 1 stated, when he entered Resident 1's room he heard a heated discussion between Resident 1 and CNA 1, but he could not remember what was said. LVN 1 stated, Resident 1 reported that CNA 1 abused her by grabbing her arm tight, pushing, and pulling her and smashing her face against the bed rail. LVN 1 stated, Resident 1 reported that she told CNA 1 she did not want to be changed, but CNA 1 changed her anyway and handled her roughly. During an interview on 3/15/2023 at 5:10 p.m., with the Director of Nursing (DON), the DON stated, on 3/10/2023 the ADM informed her of Resident 1's allegation of abuse. The DON stated, she, the ADM, and the SSD interviewed Resident 1. The DON stated, Resident 1 reported she was physically and verbally abused by her night shift CNA (CNA 1). The DON stated, Resident 1 reported that CNA 1 grabbed her arm and squeeze her tight, hurting her arm. The DON stated the nursing registry was notified of the abuse allegation and CNA 1 was put on the do not return list. During an interview on 3/15/2023 at 5:25 p.m., with the ADM, the ADM stated, on 3/10/2023 she was informed of Resident 1's allegation of abuse. The ADM stated, Resident 1 reported she was handled roughly by the CNA 1 on the night shift. The ADM stated the investigation of the alleged abuse was ongoing. During an interview on 3/16/2023 at 12:43 p.m., with CNA 1, CNA 1 stated, on 3/10/2023 at 4 a.m., she entered Resident 1's room and explained to Resident 1 that she was there to change her wet brief. CNA 1 stated, Resident 1 started arguing with her and refused to be changed. CNA 1 stated, Resident 1 initially told her several times she did not want to be changed but stated eventually Resident 1 agreed to be changed. CNA 1 stated, while changing Resident 1 she (Resident 1) began to scream and would not allow her to finish changing her (Resident 1). CNA 1 stated, LVN 1 came into the room and Resident 1 told LVN 1 that she (CNA 1), was abusing her (Resident 1). CNA 1 stated, Resident 1's sheets and brief were wet, and she could not leave Resident 1 like that even though Resident 1 refused to be changed. CNA 1 acknowledged and stated, Resident 1 had the right to refuse, and staff must honor residents' rights. CNA 1 stated, she did not physically or verbally abuse Resident 1. During an interview on 3/16/2023 at 2:30 p.m., with CNA 2, CNA 2 stated, on the morning of 3/10/2023, Resident 1 was quiet, she was not happy, or talkative, and social like she normally was. CNA 2 stated, she asked Resident 1 if she was ok and Resident 1 told her, she had a rough night and stated, that CNA 1 on the night shift handled her roughly, squeezed her arm, pushed her hard against the bed rail, and was verbally abusive towards her and then told her roommate (Resident 2), in an intimidating manner she better not turn on the call light again. CNA 2 stated she reported the allegation to the DSD. During a review of the facility's policy and procedure (P/P) titled, Abuse Prevention Program, dated 12/2016, the P/P indicated, residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. As part of the resident abuse prevention, the administration will protect residents from abuse by anyone including, but not limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual.

Based on interview and record review, the facility failed to ensure hemodialysis ([HD] removing of waste, salt, and extra water to prevent build up in the body for residents who have loss of kidney function) treatment was provided as ordered by the physician and adequate monitoring was provided by facility staff for one of two sampled residents (Resident 1) by failing to: 1) Implement the physician's order and plan of care for Resident 1 to receive HD treatment and services every, Monday, Wednesday, and Friday from an off-site HD center. 2) Notify Resident 1's physician of a missed HD treatment on [DATE]. 3) Ensure Resident 1 had transportation to and from an off-site HD center per facility's policy and procedure. 4) Ensure licensed staff provided ongoing oversight of Resident 1's dialysis treatment. 5) Have ongoing communication and collaboration with the dialysis center. These deficient practices resulted in Resident 1 missing HD treatment on [DATE] and [DATE]. Resident 1's last dialysis treatment was [DATE]. On [DATE] at 9:47 a.m., Resident 1 became unresponsive enroute to the dialysis center transported by FM 1, 911 (emergency services) was called and found Resident 1 in pulseless electrical activity ([PEA] a condition where your heart stops because the electrical activity in your heart is too weak to make your heartbeat). Cardiopulmonary Resuscitation (CPR, a lifesaving technique that's useful in many emergencies such as heart attack) was started. Resident 1 was transferred to the general acute care hospital (GACH) and expired approximately six hours later. On [DATE], at 1:28 p.m., an Immediate Jeopardy ([IJ]) a situation in which the facility's noncompliance with one or more requirements of participation had cause, or is likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility's failure to implement the physician order and plan of care for Resident 1 to receive HD treatment every Monday, Wednesday, and Friday from an off-site HD center. The facility's failure to notify Resident 1's physician of a missed HD treatment on [DATE], ensure Resident 1 had transportation to and from an off-site HD center per facility's policy and procedure, ensure licensed staff provided ongoing oversight of Resident 1's dialysis treatment and have ongoing communication and collaboration with the dialysis center treating Resident 1. On [DATE], at 4:43 p.m., the facility submitted an acceptable IJ removal plan (IJRP) with interventions to immediately correct the deficient practices. The acceptable IJRP included the following corrective actions: 1.The facility will ensure residents received HD as ordered and licensed staff will document in residents' progress notes and on the dialysis communication sheet. 2. The facility will ensure transportation was set up to transport residents to and from the dialysis center as scheduled. 3. The facility will ensure communication between nursing staff and dialysis center for any refusals and/or re-scheduling of the dialysis treatment. 4. Physician will be informed, and staff will document status of the resident post dialysis. If dialysis is not done due to transportation issues the facility staff will inform the physician and resident representative and will suggest transferring resident to the general acute care hospital (GACH) to be dialyzed. If the physician refused to transfer resident to GACH this information will be documented. 5. The facility will call the dialysis center to re-schedule the missed dialysis treatment. 6. Care plan will be developed and implemented. 7. Residents will be placed on monitoring every shift after any missed dialysis treatments. 8. In-service all nursing staff on dialysis management including the following: a. Dialysis must be done as ordered by the physician and according to the plan of care. b. Nursing Supervisor will communicate the dialysis status (missed dialysis and refusal) of the resident to the physician and resident representative. c. Document the dialysis status of the resident in the progress notes, in the electronic health record (EHR), on the 24-hour report, and the tracking log. d. Dialysis communication sheet must be completed after every dialysis treatment. If the resident did not receive dialysis treatment, document the reasons why in the dialysis communication sheet. e. If the resident refused dialysis, Change of Condition ([COC] sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional status) form will be done and the Nursing Supervisor will communicate with the physician, resident representative, and dialysis center immediately. g. If dialysis was missed due to transportation issues, the physician will be informed and suggest transferring to resident to GACH to be dialyzed. Inform the DON and the administrator immediately for further action. h. Any refusals of dialysis treatment for any reasons or dialysis are missed for any reasons, the license nurse will personally communicate this with the DON and/or Administrator for further follow up. 9. Nursing Supervisor will call the Dialysis Center to ensure that the resident has arrived at dialysis and will ensure that the resident will return to the facility safely from dialysis. 10. DON and Medical Records Supervisor will review other residents (if any) receiving dialysis treatment to validate for compliance. 11. Social Services Director will oversee timely dialysis transportation. 12. Facility maintains an agreement with two ambulance companies, Med Reach and Blue Ribbon, which will be utilized as back-up transportation. 13. DON (or Supervisor if DON is not available) will review the 24-hour communication record in EHR and documentation in the progress notes for residents with orders for dialysis treatment, 7x/week. The administrator was informed the IJ was removed on [DATE] at 4:43 p.m. after verifying and confirming on site the IJRP was implemented through observations, interviews, and record reviews. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included end stage renal disease (ESRD, permanent loss of kidney function), dependence on renal (kidney) dialysis (treatment to filter waste, salts, and fluid from blood for those with kidney failure), primary hypertension (abnormally high blood pressure that's not the result of a medical condition), and cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body). During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated [DATE], the MDS indicated, Resident 1's cognition (ability to think and reason) was intact. The MDS indicated Resident 1 required extensive assistance with one staff for bed mobility, transfer, dressing, and toilet use. During a review of Resident 1's Physician's Order, dated [DATE] the physician's orders indicated HD treatments on Mondays, Wednesdays, and Fridays. During a review of Resident 1's care plan titled, Dialysis, dated [DATE], the care plan indicated Resident 1 needed dialysis every Monday, Wednesday, and Friday with transportation. The goal was that Resident 1 will have no complications related to hemodialysis daily. The staff interventions included to have Resident 1 ready at least one hour prior to transportation (pick up) for dialysis services. During an interview on [DATE], at 10:46 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on [DATE] (Friday scheduled dialysis appointment) at 8:30 a.m., Resident 1 was observed sitting in the wheelchair and singing. LVN 1 stated she completed the dialysis communication form prior to Resident 1 leaving the facility. LVN 1 stated FM 1 arrived at the facility at 9:00 a.m. and picked up Resident 1 to go to her dialysis treatment center. During an interview on [DATE], at 11:31 a.m., with the Registered Nurse Supervisor (RNS) 1, RNS 1 stated she received a phone call from FM 2, on [DATE], FM 2 informed RNS 1 that Resident 1 became unresponsive enroute to the dialysis center and Resident 1 was dying. RNS 1 called the Director of Staff Development (DSD) who assisted her (RNS 1) with calling the dialysis center and was told Resident 1 was not there and was taken to the GACH per FM 1. During an interview on [DATE], at 9:44 a.m., with the Director of Nursing (DON), the DON stated, she was unable to find Resident 1's dialysis records, nurses notes, or Change of Condition (COC) notes for the missed dialysis treatment on [DATE]. The DON stated FM 1 provided transportation to the dialysis center. The DON also stated the last dialysis note was for [DATE]. The DON also stated, if Resident 1 missed dialysis, the physician should be notified, and it should be documented on the COC notes. During an interview on [DATE] at 10:06 a.m., with the dialysis center administrator (ADM) 2, ADM 2 stated according to the nurses' notes, dated [DATE], Resident 1 did not show up for her scheduled dialysis treatment. ADM 2 stated when a patient missed dialysis treatment, dialysis provider will call the nephrologist (medical doctor specialize in the care of kidneys) and reschedule dialysis treatment the following day. ADM 2 stated there was no documentation the facility was called regarding the missed dialysis on [DATE]. During an interview on [DATE] at 10:06 a.m., with dialysis center Registered Nurse (DCRN) 1, DCRN 1 stated she was not aware Resident 1 was a nursing home resident. DCRN 1 stated, Resident 1 was rescheduled on [DATE] when she missed her dialysis treatment on [DATE]. FM 1 rescheduled the new dialysis appointment for [DATE]. DPRN stated, Resident 1 did not show up on [DATE]. DCRN 1 stated there was no documentation if Resident 1's nephrologist was notified of the missed dialysis treatment on [DATE] and [DATE]. DPRN stated any missed dialysis treatment can cause fluid overload (a condition where you have too much fluid volume in your body), and hyperkalemia (high potassium in the blood). During a review of the dialysis center progress notes report, dated [DATE] at 3:20 p.m., the progress notes indicated Resident 1 dialysis treatment was reschedule to [DATE]. Resident 1 last dialysis treatment was on [DATE]. During a review of the dialysis center progress notes report, dated [DATE], the progress notes indicated Resident 1 dialysis treatment was missed due to unknown reason. During an interview on [DATE] at 11:43 a.m., with RNS 1, RNS 1 stated Resident 1 missed her dialysis treatment on [DATE]. RNS 1 stated Resident 1's attending physician was not informed of the missed dialysis. RNS 1 stated there was no documentation on Resident 1's progress notes or change in condition notes regarding a missed dialysis treatment. RNS 1 stated, the facility forgot Resident 1 had a dialysis appointment on [DATE], since FM 1 did not come to the facility to pick up Resident 1. RNS 1 stated, the reason for Resident 1 missed dialysis should have been documented and facility staff should reschedule the missed dialysis appointment and not FM 1. RNS 1 stated the RN or LVN assigned to Resident 1 on [DATE] should have called the dialysis center to reschedule the missed dialysis treatment. During an interview on [DATE] at 11:43 a.m., with RNS 1, stated, Resident 1 has no transportation arrangements to and from the dialysis center when she was readmitted to the facility on [DATE]. RNS 1 stated there was no documentation indicating the Social Services (SW) made arrangements for Resident 1's transportation to dialysis center. RNS 1 stated, no documentation means it was not done. During an interview on [DATE], at 4:18 p.m., with FM 1, FM 1 stated on [DATE] Resident 1 called him (FM 1) to inform him she (Resident 1) was not feeling well and does not want to go for her dialysis treatment. FM 1 stated Resident 1 told him she informed the facility staff that she was not feeling well. FM 1 stated he did not receive a call from facility regarding Resident 1's missed dialysis treatment. FM 1 also stated the facility did not have transportation arranged for Resident 1 and the social worker called and gave phone numbers for FM 1 to call the County Access transportation program to arrange transportation. FM 1 stated on [DATE], he was taking Resident 1 to dialysis for treatment and Resident 1 became unresponsive. FM 1 pulled over his car and called 911. The paramedics arrived at the scene and started CPR. During a review of the GACH record Emergency Department (E.D.) Documentation, dated [DATE], the E.D. documentation indicated, Resident 1 suddenly became unresponsive in the car and emergency medical services (EMS) was called and found in PEA arrest. Chest compressions (pressing on the chest to restore blood flow to vital organs) were administered. Resident 1 last dialysis was four days ago ([DATE]). Laboratory results in the emergency department includes: potassium (a mineral in your body that helps your heartbeat stay regular, nerves to function and muscles contract) level was 7.5 millimole/liter ([mmol] unit of measure{(normal range 3XXX,d+[DATE].1 mmol/L}), blood urea nitrogen ([BUN] measures the amount waste product that your kidneys remove from your blood) of 108 mg/dL (normal range ,d+[DATE] mg/dL), creatinine (a compound excreted from the body) at 11.00 mg/dL (normal 0XXX,d+[DATE].3 mg/dL), lactic acid (organic acid) at 5.1mmol/L, elevated troponin (type of protein found in the muscles of your heart) 274 ng/ L and a positive Covid 19 (a highly contagious infection, caused by a virus that can easily spread from person to person) test on [DATE]. According to the ED Documentation, all resuscitative measures were stopped, and the patient was given comfort measures and expired in the E.D. During a review of the GACH record titled Death Documentation dated [DATE], the death documentation indicated, date and time of death was [DATE] at 3:34 p.m., with a diagnosis of Cardiac arrest (occurs when the heart suddenly and unexpectantly stops pumping) related to hyperkalemia (high potassium level in the blood) versus primary cardiac process. During a review of the facility's policy and procedure titled, Dialysis Care, [undated], indicated, Facility will provide consistent, appropriate quality care for residents receiving dialysis. Facility staff will arrange transportation to and from the dialysis clinic for the resident. Facility will maintain open communication with the dialysis clinic regarding changes in the resident's condition. During a review of the facility's policy and procedure titled, Change in a Resident's Condition or Status, dated revised ,d+[DATE], indicated, our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. The nurse will notify the resident's attending physician or physician on call when there has been a (an): need to alter the resident's medical treatment significantly. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR (situation, background, assessment, and recommendation. An easy-to-use structured form of communication that enables information to be transferred accurately between individuals) communication form.

Based on interview, and record review, the facility failed to ensure one of one sample residents, Resident A, who had decreased mobility and a history of [MEDICAL CONDITION], was assessed and monitored for amount and consistency of bowel movement (BM) as indicated in the plan of care to prevent fecal impaction (the formation of a large mass of hard stool in the rectum. While this stool may be too large to pass, loose, watery stool may be able to get by, leading to diarrhea or leakage of fecal material. Prolonged fecal impaction can lead to an enlargement or obstruction of the colon, and may be life-threatening). On June 14, 2012, at 12 p.m., Resident A vomited undigested food and had fluctuating low oxygen saturation of 80 to 91 percent (oxygen saturation is the percentage of oxygen in the blood - the normal range is 95 to 100 percent (%)). The physician was notified and Resident A was transferred to a general acute care hospital (GACH) by paramedics at 3:25 p.m., admitted and was diagnosed with [REDACTED]. Findings: The Department received a complaint on June 18, 2012, that Resident A was not continuously assessed for bowel motility ( moving) and/or need of medication to promote bowel motility and prevent constipation. On June 21, 2012, at 8 a.m., an unannounced visit was conducted to the facility. According to the admission record, Resident A was admitted from a psychiatric hospital on June 6, 2012, with [DIAGNOSES REDACTED]. The Minimum Data Set, an assessment care screening tool, dated June 12, 2012, indicated the resident was moderately impaired in her cognitive skills for daily decision-making, required extensive assistance from staff with activities of daily living and was totally dependent for toilet use. The resident was assessed as frequently incontinent (loss of control) of bowel. Resident A had a physician's orders [REDACTED]. A plan of care dated June 6, 2012, for prone to constipation related to decline in mobility and history of [MEDICAL CONDITION], status [REDACTED]. The approaches included to monitor BM for amount and consistency, to monitor the effectiveness of medication, and to notify the physician accordingly. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]" Y " (yes) indicating the resident had a BM and " N " (no) indicating the resident did not have a BM. The monitoring documentation did not include the amount and consistency of the resident's BM in order to assess the effectiveness of the laxative.. A review of the certified nurse assistant (CNA) Daily Documentation from June 6 to 14, 2012, revealed the CNAs ' documented " Y " (yes) or " N " (no) for BM every shift. The CNAs ' documentation reflected the resident had a BM daily, and at times twice a day. However, there was no documentation of the amount or size (large, medium, and small) and/or the consistency (hard, soft, formed, ribbon-like, and watery) of the BM to identify if the resident was emptying her bowel completely, as indicated in the plan of care. The Daily Licensed Nurses note dated June 11, 2012, for the 7 a.m. to 3 p.m. shift, indicated the resident complained of mild to moderate lower abdominal pain, and the pain scale level was 5 (on a scale of 1 to 10, with 10 being the worst pain). The note indicated Tylenol was given and it was effective. There was no documentation as to why the resident was complaining of abdominal pain and no documentation that the resident was checked for fecal impaction. Also, there was no documentation the physician was notified that the resident was complaining of abdominal pain, in accordance with the plan of care. Further review of the Daily Licensed notes from June 11 to 14, 2012, revealed in the bowel incontinent section, a box was checked for abdomen-soft and non-tender with normal active bowel sounds in all quadrants. There was no other documentation aside from the check mark in the box. On June 14, 2012, at 12 p.m. the Licensed Nurses Notes indicated the resident appeared weak, and vomited a large amount of undigested food. The note indicated Resident A's oxygen saturation was fluctuating between 80 to 86 % while receiving 3 liters per minute (L/min) of oxygen (O2). There was no documentation the resident's abdomen was assessed nor the resident was checked for fecal impaction. The physician was notified with orders to continue to monitor the resident. The Licensed Nurses Notes on the same date at 1 p.m., indicated Resident A's O2 saturation was 87 and 90 %, while receiving (increased O2) at 10 liters per minute, and she was complaining of vaginal pain of 4 out of 10 (0 is no pain and 10 is severe pain). Tylenol 325 milligram, 2 tablets, were given without relief. At 3:05 p.m., the resident was receiving 10 L/min. of oxygen and her O2 saturation reading was 80 to 84 %, the resident continued to complain of vaginal pain, and was transferred by paramedics to the GACH at 3:25 p.m. A review of the Emergency Department Admission Note dated June 14, 2012, obtained from GACH revealed the resident had evidence of fecal impaction with hard stool at the rectal vault (the opening). The resident was disimpacted and admitted to the GACH with [DIAGNOSES REDACTED]. Symptoms of fecal impaction include abdominal or back pain and difficulty urinating. (http://www.localhealth.com/article/fecal-impaction/symptoms). During an interview and record review on June 21, 2012 at 8:40 a.m., with the Certified Nurse Assistant (CNA 1), she said she took care of Resident A every day she worked. A review of the Nurses ' Aides Notes from June 7 through 14, 2012, CNA 1 documented the resident had a BM on June 7, 10, 11, 12, and 13, 2012. Further interview revealed the resident wore an incontinent pad. CNA 1 stated she assisted the resident to the bathroom, but the resident did not have a formed BM, only smears of stool on the incontinent pad for June 7, 10, 11, 12, and 13, 2012. However CNA 1 documented the smear as a BM on the nurses ' aides ' notes and did not report the BM results (smear) to the licensed staff. During an interview with a licensed vocational nurse (LVN) on June 22, 2012 at 9 a.m., she said the facility's policy is to record the number of stools, record if the stool has a foul odor, or if it is a diarrhea stool. She was not able to explain the assessment method used by the facility to monitor a BM for amount or consistency as described in the plan of care. The facility's policy and procedure revised December 2011, titled " Bowel Monitoring " indicated the CNA was to record if the resident had a bowel movement or no bowel movement by charting "Yes" for a BM or , "No" for no BM. If the resident had no BM for two days, the CNA was to report this condition to the charge nurse for proper intervention. The CNA failed to record the BM accurately and report to the licensed nurse.