Every finding on record at Sherman Village HCC

Based on observation, interview, and record review, the facility failed to provide necessary respiratory care (the medical treatment and support for the organs and structures in the body that allow a person to breathe) and services for one of three sampled residents (Resident 3) by failing to:Ensure Resident 3's nasal cannula (a flexible plastic tube that is connected to the oxygen tank and delivers oxygen to resident's nose) did not contain moisture that pooled inside the tubing.Ensure Resident 3 had an oxygen supplies bag to keep the oxygen tubing inside when not in use.Ensure Resident 3 received oxygen according to the physician orders. Resident 3's oxygen tank pressure gauge (a cylindrical metal container filled with pressurized oxygen gas with a device attached to the tank measuring the tank volume) indicated the tank was empty (arrow in red zone) and there was no air flow from Resident 3's nasal cannula.Ensure Resident 3 had an oxygen safety precaution signage posted on the door or wall of Resident 3's room.These deficient practices had the potential for Resident 3 to develop respiratory infections, exacerbate the resident's respiratory condition, and cause accidents and fire hazards (a potential threat to people or property from flammable materials or actions which are not fire safe).Findings:During a review of Resident 3's undated admission Record, the admission Record indicated the facility admitted Resident 3 on 6/5/2026 with diagnoses including chronic obstructive pulmonary disease (COPD - a progressive, long-term lung condition that damages the airways and air sacs, making it hard to breathe), interstitial pulmonary disease (a condition that cause swelling and scar tissues to form in the walls of the tiny air sacs in the lungs), asthma (inflammation and narrowing of the small airways in the lungs), and dependence on supplemental oxygen (a medical treatment that provides extra oxygen [a gas essential for living organisms] when the body cannot get enough from normal air).During a review of Resident 3's Clinical admission Progress Notes, dated 6/5/2026, the Clinical admission Progress Notes indicated Resident 3 had mild impaired cognitive skills (a condition in which a person has more memory or thinking problems than other people their age). The Clinical admission Progress Notes indicated Resident 3 was disoriented.During a review of Resident 3's Physician Order, dated 6/9/2026, the Physician Order indicated to administer oxygen at two liters per minute (L/Min - a unit of measurement) using a nasal cannula.During a review of Resident 3's Physician Order, dated 6/9/2026, the Physician Order indicated to change Resident 3's nasal cannula or mask as needed when soiled and every Sunday.During a review of Resident 3's Minimum Data Set (MDS - resident assessment tool), dated 6/22/2026, the MDS indicated Resident 3 required continuous oxygen therapy (a prescribed medical treatment that gives the body extra oxygen). During a review of Resident 3's Care Plan Report (CP) on oxygen therapy, initiated on 6/22/2026, the CP indicated interventions to apply continuous oxygen at two liters per minute (L/Min) using a nasal cannula every shift following a registered nurse assessment. The CP indicated intervention to explain the importance of keeping the oxygen at the prescribed setting.During a concurrent observation and interview on 8/5/2026 at 9:36 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 3 was observed sitting in a wheelchair in her room with oxygen administered via nasal cannula, connected to the oxygen tank located at the back of Resident 3's wheelchair. Resident 3's nasal cannula had visible moisture built up inside the tubing. LVN 2 stated that she did not know when Resident 3's oxygen supplies such as nasal cannula tubing were changed. LVN 2 stated Registered Nurses (RN) and the Respiratory Therapist (RT - a specialized healthcare professional who helps people with lung and breathing problems) checks and changes the residents' nasal cannula tubing.During a concurrent observation and interview on 8/5/2026 at 9:16 a.m. with Resident 3, Resident 3 was observed with a nasal cannula connected to the oxygen tank set at two L/Min. Resident 3 stated that she could not feel the oxygen flow in her nose. Resident 3's nasal cannula tip was placed near the resident's left cheek. Resident 3 stated she could not feel an oxygen flow on her left cheek. Resident 3 stated she was not in respiratory distress.During a concurrent observation and interview on 8/5/2026 at 9:48 a.m. with RN 1, RN 1 stated Resident 3's nasal cannula had visible moisture inside the tubing. RN 1 stated Resident 3's oxygen tank pressure gauge was on the red level which indicated the oxygen tank was empty. RN 1 tested the oxygen flow from Resident 3's nasal cannula on his right arm. RN 1 stated he could not feel an airflow from Resident 3's nasal cannula. RN 1 stated the oxygen concentrator machine (a device that provides supplemental oxygen) located beside Resident 3's bed, belonged to Resident 3. RN 1 stated there were no plastic supply bags in Resident 3's room.During a concurrent observation and follow up interview on 8/5/2026 at 10:15 a.m. with RN 1, RN 1 stated there was no oxygen safety precaution signage posted on Resident 3's room door or wall. RN 1 stated Resident 3 was on oxygen therapy, and an oxygen safety precaution signage should be posted on resident's room door or wall. RN 1 acknowledged and stated that the absence of the posted oxygen signage could cause safety precautions to be missed.During an interview on 8/05/2026 at 12:15 p.m. with the Director of Nursing (DON), the DON stated the licensed nurses and RTs were responsible for monitoring Resident 3's oxygen set up, supplies, and administration. The DON stated an oxygen set up, which included a nasal cannula and a plastic supplies bag, should be changed every week and as needed when soiled. The DON stated Resident 3's oxygen supplies should be inside a dated and labeled oxygen supply bag when not in use. The DON stated the visible moisture inside Resident 3's nasal cannula tubing could be a vector for microorganisms that could cause Resident 3 to developing respiratory infections. The DON stated the licensed nurses should ensure Resident 3's oxygen tank was full. The DON stated the absence of a posted oxygen safety precaution signage on Resident 3's room could cause a fire hazard. The DON stated that using an empty oxygen tank could negatively affect Resident 3's respiratory status such as decreased oxygen saturation (the percentage of red blood cells carrying oxygen from the lungs to the rest of the body) and exacerbation of the resident's current respiratory diseases. The DON acknowledged and stated that the facility failed to ensure Resident 3 was provided with an oxygen supply bag and an oxygen tank that was not empty. The DON stated the facility failed to ensure Resident 3's nasal cannula was free from moisture that could cause infection. The DON further stated the facility failed to ensure an oxygen safety precaution sign was posted on Resident 3's room.During a review of the facility's policy and procedure (PnP) titled, Oxygen Administration, last reviewed on 4/30/2026, the PnP indicated the purpose . to provide guidelines for safe oxygen administration. The PnP indicated that a No Smoking/Oxygen in Use sign was a supply that .will be necessary when performing this procedure. The Steps in the Procedure section of the PnP indicated to . 2. Place an Oxygen in Use sign on the outside of the room entrance door. 3. Place an Oxygen in Use sign in a designated place on or over the resident's bed. 10. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered.12. Check the mask, tank.to be sure they are in good working order.

Based on observation, interview, and record review, the facility staff failed to ensure that the call light (a vital safety system in nursing homes that allows residents to signal staff members when they need help) request for assistance was answered promptly for one of the three sampled residents (Resident 1). This deficient practice had the potential not to meet Resident 1s' needs.Findings:During a review of Resident 1's undated Face Sheet (admission record), the Face Sheet indicated the facility admitted Resident 1 on 4/3/2026, with diagnoses including an acquired absence of right leg below the knee, bipolar disorder (a mental health condition defined by extreme shift in mood, energy, and activity levels involving emotional highs and lows), and hypertension (high blood pressure).During a review of Resident 1's History and Physical (H&P - a formal assessment of the resident to collect a resident's background information and perform a physical exam), dated 4/10/2026, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/13/2026, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact.During a concurrent observation and interview on 7/28/2026 at 10:20 a.m. with Resident 1, Resident 1 was observed in the room on a wheelchair. Resident 1 stated that the facility does not answer his call light when he calls the staff. Observed Resident 1 turned on the call light during an Interview, no staff came to Resident 1's room after the call was turned on for 20 minutes. During an interview, on 7/28/2026 at 2 p.m., with Director of Nursing (DON), the DON stated it is unacceptable for staff not to answer call light on time. The DON Stated the facility failed to follow its policy of answering call light immediately. The DON stated in-service will be done for answering the call lights.During a review of the facility policy and procedure (P&P) titled, Answering the Call Light, last reviewed and approved on 4/30/2026, the P&P indicated, The purpose of this procedure is to ensure timely responses to the resident's request and needs .1 Answer the resident call system Immediately.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (is a form that summarizes a person's health conditions and current treatments for their care) for one of three sample residents (Resident 3) for Resident 3's risk for falls. This failure had the potential to place Resident 3 at risk for an avoidable fall.Findings: During a review of Resident 3's admission Record (AR), the AR indicated the facility admitted the resident on 5/5/2026 with diagnoses that included difficulty in walking, fall on same level, dementia (a progressive state of decline in mental abilities), unspecified, muscle weakness (generalized), and dizziness. During a review of Resident 3's Fall Risk Evaluation, dated 5/5/2026 at 8:35 p.m., the Fall Risk Evaluation indicated Resident 3 had one to two falls in the past three months, had intermittent confusion and had poor vision. Resident 3 fall risk score was 12 (a score of 10 or greater resident should be considered at high risk for potential falls). During a review of Resident 3's History and Physical (H&P- a comprehensive, formal medical document created by a clinician during an initial patient encounter or hospital admission), dated 5/6/2026 at 5:22 p.m., the H&P indicated Resident 3 was cognitively impaired and required monitoring for safety functions. During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 6/2/2026, the MDS indicated Resident 3's cognition was moderately impaired. The MDS indicated Resident 3 required supervision (helper provides verbal cues and or touching steading and or contact guard assistance as resident completes activity) with showering and was independent (resident completes activity by themselves with no assistance from a helper) with eating, oral hygiene, toileting, upper and lower body dressing and putting on and taking off footwear. During a review of Resident 3's Change of Condition (COC) Assessment Form dated 6/21/2026 at 7:19 a.m. the COC Assessment Form indicated Resident 3 was found on the floor sitting upright. During a review of Resident 3's Fall Risk Evaluation dated 6/21/2026 at 8 a.m., the Fall Risk Evaluation indicated Resident 3 had no falls in the past three months, was alert and oriented times three (they are awake and aware of their own name, know where they are, and they know the current day of the week). The Fall Risk Evaluation indicated Resident 3 had a fall risk score of 8 (not a high risk for falls). During a review of Resident 3's Care plan Report (CP) initiated on 6/21/2026, the CP indicated falling star program at risk for falls related to history of falls with interventions that included floor mats (a thick, soft foam pad placed on the floor next to a bed or chair), place resident close to nursing station for close observation and frequent visual monitoring. During a review of Resident 3's Order Summary Report (OSR) dated 6/23/2026, the OSR indicated Resident 3 was on the super star program with frequent visual monitoring due to high risk for fall and injury document per shift every shift for super star program. During a review of Resident 3's CP initiated on 6/23/2026, the CP indicated superstar falling star program at risk for falls related to balance deficit, cognitive impairment, decrease strength and endurance, history of falls and non-compliant with requests for assistance of call light. The CP interventions included frequent visual monitoring, falling start if indicated and floor mats. During a concurrent interview and observation on 7/6/2026 at 11:06 a.m. with Resident 3, Resident 3 stated is able to walk on own but does get dizzy. In Resident 3's room observed no landing mats on either side of Resident 3's bed. During a concurrent interview and observation on 7/6/2026 at 1:22 p.m. of Resident 3's room with the Director of Staff Development (DSD) the DSD stated Resident 3 did not have a landing mat in her room. The DSD stated floor mats are contraindicated for Resident 3 due to Resident 3 being ambulatory would be a trip hazard. During a concurrent interview and record review on 7/6/2026 at 4:20 p.m. of Resident 3's care plans with the Director of Nursing (DON), the DON stated the care plans for falls indicated the interventions of using floor mats but would not be applicable to Resident 3 as she ambulates and is high functioning. The DON stated this is contraindicated because the landing mat would be a potential trip hazard. The DON stated if the care plan has it listed as an intervention it should be implemented. The DON stated the care plan is not accurate because it is contraindicated for Resident. The DON stated care plans should be resident-centered, the care plan for Resident 3 is not resident-centered and can potentially cause Resident 3 to have a fall if the care plan was implemented as written. During a review of the facility's Policy and Procedures (P&P) titled, Care Plans, Comprehensive Person-Centered, last reviewed on 3/26/2026, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetable to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.

Based on interview and record review, the facility failed to maintain medical records in accordance with acceptable professional standards and practices for one of three sampled residents (Resident 1) when Resident 3 had a fall on 6/21/2026 and the Fall Risk Evaluation (a simple check-up by a healthcare provider to see how likely an older adult is to fall) was inaccurate. This failure resulted in inaccurate documentation of Resident 3's records. Findings: During a review of Resident 3's admission Record (AR), the AR indicated the facility admitted the resident on 5/5/2026 with diagnoses that included difficulty in walking, fall on same level, dementia (a progressive state of decline in mental abilities), unspecified, muscle weakness (generalized), and dizziness. During a review of Resident 3's Fall Risk Evaluation dated 5/5/2026 at 8:35 p.m., the Fall Risk Evaluation indicated Resident 3 had one to two falls in the past three months, had intermittent confusion and had poor vision. Resident 3 fall risk score was 12 (a score of 10 or greater resident should be considered at high risk for potential falls). During a review of Resident 3's History and Physical (H&P- a comprehensive, formal medical document created by a clinician during an initial patient encounter or hospital admission), dated 5/6/2026 at 5:22 p.m., the H&P indicated Resident 3 was cognitively impaired and required monitoring for safety functions. During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 6/2/2026, the MDS indicated Resident 3's cognition was moderately impaired. The MDS indicated Resident 3 required supervision (helper provides verbal cues and or touching steading and or contact guard assistance as resident completes activity) with showering and was independent (resident completes activity by themselves with no assistance from a helper) with eating, oral hygiene, toileting, upper and lower body dressing and putting on and taking off footwear. During a review of Resident 3's Change of Condition (COC) Assessment Form dated 6/21/2026 at 7:19 a.m. the COC Assessment Form indicated Resident 3 was found on floor sitting upright. During a review of Resident 3's Fall Risk Evaluation dated 6/21/2026 at 8 a.m., the Fall Risk Evaluation indicated Resident 3 had no falls in the past three months, was alert and oriented times three (they are awake and aware of their own name, know where they are, and they know the current day of the week). The Fall Risk Evaluation indicated Resident 3 had a fall risk score of 8 (not a high risk for falls). During a review of Resident 3's Care plan Report (CP) initiated on 6/21/2026, the CP indicated falling star program at risk for falls related to history of falls with interventions that included floor mats (a thick, soft foam pad placed on the floor next to a bed or chair), place resident close to nursing station for close observation and frequent visual monitoring. During a review of Resident 3's Order Summary Report (OSR) dated 6/23/2026, the OSR indicated Resident 3 was on the super star program with frequent visual monitoring due to high risk for fall and injury document per shift every shift for super star program. During a review of Resident 3's CP initiated on 6/23/2026, the CP indicated superstar falling star program at risk for falls related to balance deficit, cognitive impairment, decrease strength and endurance, history of falls and non-compliant with requests for assistance of call light. The CP interventions included frequent visual monitoring, falling start if indicated and floor mats. During a concurrent interview and observation on 7/6/2026 at 11:06 a.m. with Resident 3, Resident 3 stated is able to walk on own but does get dizzy. In Resident 3's room observed no landing mats on either side of Resident 3's bed. During a concurrent interview and record review on 7/6/2026 at 4:20 p.m. with the Director of Nursing (DON), the DON stated fall risk assessments are done on admission, readmission and when there is a fall. The DON reviewed Resident 3's AR and stated Resident 3 had a fall prior to admission. The DON reviewed Resident 3's Fall Risk Evaluation dated 5/5/2026 and stated Resident 3 had a fall risk score of 12 indicating a risk for a fall. The DON reviewed Resident 3's Fall Risk Evaluation dated 6/21/2026 and stated that Resident 3's fall risk score was 8 and indicates Resident 3 has no history of falls in the last three months. The DON stated the 6/21/2026 Fall Risk Evaluation should indicate there is a history of falls because it has not been more than three months since Resident 1's initial fall and the fall on 6/21/2026 should be counted as well. The DON stated this fall risk is not accurate, potential for not providing the correct care for resident safety from fall. During a review of the facility's Policy and Procedures (P&P) titled, Charting and Documentation last reviewed on 3/26/2026, the P&P indicated documentation will be objective, complete and accurate.

Based on interview and record review, the facility failed to respect one of the three sampled residents (Resident 1) rights by failing to ensure Resident 1's Physician Orders for Life Sustaining Treatment (POLST- document that acts as a set of binding medical orders for people with serious illnesses or advanced frailty which is intended for immediate use by emergency responders to honor a patient's wishes for care during a medical crisis) was followed.This failure violated Resident 1's and Resident 1's Representative (RR 1) rights.Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on [DATE], with diagnoses that included unspecified (unconfirmed) chronic respiratory failure (a long-term, serious condition where the lungs cannot properly exchange gases, leading to low oxygen or high carbon dioxide in the blood), unspecified coma (a state of deep, prolonged unconsciousness where a person is alive but unable to wake up, move, or respond to their environment, light, or sound), tracheostomy (a surgically created hole [stoma] in the neck leading directly into the windpipe [trachea] to provide an airway, often using a tube to help with breathing) and dependent on ventilator (a medical device to help support or replace breathing). The admission Record indicated RR 1 was Resident 1's primary decision maker and Family Member 1 (FM 1) was the first emergency contact person.During a review of Resident 1's POLST, dated [DATE], the POLST indicated a physician order for do not resuscitate (DNR- a medical order written by a doctor to instruct health care providers not to do cardiopulmonary resuscitation (CPR) if breathing stops or the heart stops beating) if Resident 1 was found with no pulse and not breathing. The POLST indicated a physician order for comfort focused treatment and no hospitalization transfer if Resident 1 was found with a pulse and was breathing. The POLST indicated RR 1 was Resident 1's legally recognized decision maker.During a review of Resident 1's Physician Order, dated [DATE], the Physician Order indicated, DNR, comfort measures only, no hospitalization.During a review of Resident 1's Care Plan, dated [DATE], about advance directive (AD-a legal document indicating resident preference on end-of-life treatment decisions), the Care Plan indicated no CPR, no hospitalization and comfort focused treatment with an intervention to respect residents and or family wishes.During a review of Resident 1's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated [DATE], the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool) dated [DATE], the MDS indicated Resident 1's was on persistent vegetative state (a condition following severe brain damage where a patient is awake but shows no sign of consciousness or awareness of themselves or their surroundings).During a review of Resident 1's Change of Condition (COC- a document used to record and report any significant changes in a resident's physical, mental, or psychosocial status), dated [DATE], the COC indicated on [DATE], at 12:25 a.m., Resident 1 had elevated temperature at 100 degrees Fahrenheit, respiratory distress and vomited three times. The COC indicated Registered Nurse 1 (RN 1), called Respiratory Therapist, and called FM 1 who did not pick up the phone. The COC indicated Resident 1 got worse and RN 1 called 911 (emergency medical response). The COC indicated when paramedics arrived, RN 1 called FM 1 again and requested to transfer Resident 1 to the hospital.During an interview on [DATE], at 8:41 a.m., with the Complainant, the Complainant stated Resident 1 was transferred to General Acute Care Hospital (GACH) on [DATE], even with a POLST order of no hospitalization.During an interview on [DATE], at 9:20 a.m., with RN 2, RN 2 stated Resident 1's code status (a set of instructions that tell medical professionals what, if any, life-saving measures you want them to take if your heart or breathing stops) was DNR. RN 2 stated RR 1 should have been notified first and if he (RR1) did not respond then FM 1 should be called after.During an interview on [DATE], at 9:37 a.m., with the Director of Nursing (DON), the DON stated Resident 1's POLST indicated RR 1 as Resident 1's legal decision maker. The DON stated the POLST are directives for healthcare if in case the residents cannot decide for themselves. The DON stated when Resident 1 was transferred to GACH on [DATE], Resident 1 and RR 1's rights were violated. The DON stated that the facility should have a meeting with FM 1 and RR 1 to check if RR 1 can give power of attorney (POA- a legal document that appoints a trusted person to manage the legal, financial, or medical affairs) to FM 1 since RR 1 was from out of the country. The DON stated as of today ([DATE]), FM 1 does not have a POA. The DON stated Resident 1's POLST was not followed. The DON stated the facility did not respect Resident 1 and RR 1's rights and violated Resident 1 and RR1's autonomy.During an interview on [DATE], at 11:19 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated on [DATE], Resident 1 had a fever, medicated with acetaminophen (medication used to treat pain and fever) but was not effective. LVN 1 stated Resident 1's breathing became abnormal, so she (LVN 1) reported to RT and RN 1. LVN 1 stated Resident 1's code status was a DNR and no hospitalization. LVN 1 stated Resident 1 was transferred to GACH because the facility could not control Resident 1's vital signs, causing an elevated temperature and heart rate. LVN 1 stated RN 1 called FM 1, but RR 1 was the decision maker.During an interview on [DATE], at 11:26 a.m., with RN 1, RN 1 stated on [DATE], he (RN 1) was rounding when he (RN 1) saw the RT at Resident 1's bedside and reported that Resident 1 had respiratory distress, with elevated temperature and heart rate and the staff cannot stabilize her (Resident 1). RN 1 stated he (RN 1) called FM 1 and FM 1 said to transfer to the hospital. RN 1 stated he (RN 1) called FM 1 because she (FM 1) was the first emergency contact person listed in the admission Record. RN 1 stated based on his (RN 1) understanding if Resident 1 was found unresponsive with no pulse and not breathing then they follow the POLST for DNR and no hospitalization but on [DATE], Resident 1 had vital signs but in respiratory distress so he (RN 1) can still call 911 to transfer Resident 1 to GACH. RN 1 stated he (RN 1) did not want to keep Resident 1 at the facility on respiratory distress.During a review of facility's policy and procedure (P&P) titled, Resident Rights, dated 2/2021, and last reviewed on [DATE], the P&P indicated, Employees shall treat all residents with kindness, respect, and dignity.1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to:a. a dignified existence;b. be treated with respect, kindness, and dignity; .e. self-determination ;.h. be supported by the facility in exercising his or her rights; .k. appoints a legal representative of his or her choice, in accordance with state law; .During a review of facility's P&P, titled, Change in a Resident's Condition or Status, dated 2001, and last review on [DATE], the P&P 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.Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: .b. there is a significant change in the residents' physical, mental, or psychosocial status; .e. it is necessary to transfer the resident to a hospital/treatment center.During a review of Resident 1's POLST, dated [DATE], the POLST indicated, POLST must be completed by a health care provider based on patient preferences and medical indications. A legally recognized decisionmaker may include a court-appointed conservator or guardian, agent designated in an Advance Directive, orally designated surrogate, spouse, registered domestic partner, parent of a minor, closest available relative, or person whom the patient's physician/ nurse practitioner/ physician assistant believes best knows what is in the patient's best interest and will make decisions in accordance with the patient's expressed wishes and values to the extent known. A legally recognized decisionmaker may execute the POLST form only if the patient lacks capacity or has designated that the decisionmaker's authority is effective immediately.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received proper care in accordance with professional standards of practice, by: 1. Failing to accurately complete comprehensive assessment for Resident 1 after readmission from the General Acute Care Hospital (GACH) on 10/15/2025.2. Failing to implement treatment consistent with physician orders by not holding hydralazine (a medication to treat high blood pressure) oral tablet when systolic blood pressure was less than 110 millimeters of mercury (mmHg - standard unit of measurement for pressure) on 9/6/2025 and 9/7/2025 during morning shift.These deficient practices had the potential to result in harm to Resident 1 and increased Resident 1's risk for adverse outcome related to blood pressure management.Cross reference F755. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 9/13/2021 and was readmitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), dysphagia (difficulty swallowing), and heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 1's Minimum Data Set ([MDS] - a resident assessment tool), dated 10/25/2025, the MDS indicated Resident 1 had severe cognitive impairment (significant trouble with thinking, memory, concentration, and decision-making). The MDS indicated Resident 1 was dependent on staff for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a concurrent interview and record review on 5/6/2026 at 12:46 p.m. with Treatment Nurse (TXN) 1, Resident 1's clinical admission assessment dated [DATE] and skin reassessment dated [DATE] were reviewed. TXN 1 stated that nursing staff completed the clinical admission assessment inaccurately because the assessment did not indicate Resident 1's skin issues upon admission to the facility. TXN 1 further stated that Resident 1 was admitted to the facility with a pressure injury to sacrum extending to right and left buttocks. TXN 1 stated staff (registered nurses) left many questions unanswered and incomplete, resulting in an inaccurate clinical assessment. TXN 1 stated that staff must complete clinical assessment accurately to ensure Resident 1's needs are properly identified and addressed.During a concurrent interview and record review on 5/6/2026 at 2:41 p.m. with Registered Nurse (RN) 1, RN 1 stated that the registered nurses in the facility are responsible for completing the initial clinical assessments for all new admissions. RN 1 stated that Resident 1's Clinical assessment dated [DATE] was incomplete and not accurate because no skin issues were identified and when the treatment nurse reassessed Resident 1 the next day, they identified multiple skin problems. RN 1 stated that if the clinical assessment was not done accurately it looks like Resident 1 skin issues were developed at the facility. During a review of Resident 1's Order Summary Report, dated 8/10/2025, the Order Summary Report indicated Hydralazine HCI oral tablet 50 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) to be given one tablet by mouth three times a day for hypertension (HTN-high blood pressure) and hold if systolic blood pressure (SBP-top number in blood pressure reading) less than 110 mmHg.During a review of Resident 1's Medication Administration Record (MAR- flowsheet that indicates medication given to a resident), dated 9/2025, the MAR indicated that on 9/6/2025 and 9/7/2025, during the morning shift, hydralazine was given when systolic blood pressure was less than 110 mmHg. During a concurrent interview and record review on 5/6/2026 at 2:41 p.m. with RN 1, Resident 1's MAR dated 9/2025 was reviewed. RN 1 stated that the MAR indicated that on 9/6/2025 at 1 p.m. Resident 1's blood pressure was 95/63 mmHg, on 9/7/2025 at 9 a.m. Resident 1's blood pressure was 86/60 mmHg, and on 9/7/2025 at 1 p.m. Resident 1's blood pressure was 86/60 mmHg. RN 1 stated that nursing staff did not follow doctors' order because the systolic blood pressure was less than 110 and giving the dose of hydralazine will lower Resident 1's blood pressure even more. RN 1 further stated that it is important to follow doctors' orders to prevent any side effects and cause harm to Resident 1. During a concurrent interview and record review on 5/6/2026 at 4:02 p.m. with the Director of Nursing (DON), the DON stated that nursing staff failed to follow the physicians order and administered hydralazine to Resident 1 when the medication should have been held. The DON stated that the nurses must follow physicians orders to prevent harm to the residents. The DON stated that Registered Nurses (RN) are responsible for completing clinical assessment upon admission. The DON further stated that RNs should perform thorough clinical assessment to ensure the assessment accurately reflects each residents current needs. During a review of facility's policy and procedure (P&P) titled, Comprehensive Assessments, revised on 3/2022, the P&P indicated, Comprehensive assessment are conducted and coordinated by a registered nurse with appropriate participation of other health professionals on the interdisciplinary team. Comprehensive assessments are conducted to assist in developing person-center care plans.During a review of facility's P&P titled, Administering Medication, revised on 4/2021, the P&P indicated, Medications are administered in accordance with prescriber orders, including any required time frames.

Based on interview and record review, the facility failed to hold the hydralazine (a medication to treat high blood pressure) oral tablet when systolic blood pressure was less than 110 millimeters of mercury (mmHg - standard unit of measurement for pressure) on 9/6/2025 and 9/7/2025 during morning shift in accordance with the physician order for one of three sampled residents (Resident 1).This deficiency practice had the potential to result in increased risk for adverse outcome related to blood pressure management to Resident 1. Cross reference F684. Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 9/13/2021 and was readmitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), dysphagia (difficulty swallowing), and heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 1's Minimum Data Set ([MDS] - a resident assessment tool), dated 10/25/2025, the MDS indicated Resident 1 had severe cognitive impairment (significant trouble with thinking, memory, concentration, and decision-making). The MDS indicated Resident 1 was dependent on staff for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's Order Summary Report, dated 8/10/2025, the Order Summary Report indicated Hydralazine HCI oral tablet 50 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) to be given one tablet by mouth three times a day for hypertension (HTN-high blood pressure) hold if systolic blood pressure (SBP-top number in blood pressure reading) less than 110 mmHg.During a review of Resident 1's Medication Administration Record (MAR- flowsheet that indicates medication given to a resident), dated 9/2025, the MAR indicated that on 9/6/2025 and 9/7/2025, during the morning shift, hydralazine was given when systolic blood pressure was less than 110 mmHg. During a concurrent interview and record review on 5/6/2026 at 2:41 p.m. with RN 1, Resident 1's MAR dated 9/2025 was reviewed. RN 1 stated that the MAR indicated that on 9/6/2025 at 1 p.m. Resident 1's blood pressure was 95/63 mmHg, on 9/7/2025 at 9 a.m. Resident 1's blood pressure was 86/60 mmHg, and on 9/7/2025 at 1 p.m. Resident 1's blood pressure was 86/60 mmHg. RN 1 stated that nursing staff did not follow the doctors' order because the systolic blood pressure was less than 110 mmHg and giving the dose of hydralazine will lower Resident 1's blood pressure even more. RN 1 further stated that it is important to follow doctors' orders to prevent any side effects and cause harm to Resident 1. During a concurrent interview and record review on 5/6/2026 at 4:02 p.m. with the Director of Nursing (DON), the DON stated that nursing staff failed to follow the physicians order and administered hydralazine to Resident 1 when the medication should have been held. The DON stated that the nurses must follow physician's orders to prevent harm to the residents.During a review of facility's Policy and procedures (P&P) titled Administering Medication, revised on 4/201, the P&P indicated, Medications are administered in accordance with prescriber orders, including any required time frames.

Based on interview and record review, the facility failed to update a resident's care plan for one of three sampled residents (Resident 1) to reflect Resident 1's current wound treatment orders for sacrococcyx (the large triangular bone at the base of the spine and the tailbone) pressure ulcer (damage to the skin and underlying soft tissue caused by prolonged pressure).This deficient practice had the potential for Resident 1's need not being met.Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 9/13/2021 and was readmitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), dysphagia (difficulty swallowing), and heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 1's Minimum Data Set ([MDS] - a resident assessment tool), dated 10/25/2025, the MDS indicated Resident 1 had severe cognitive impairment (significant trouble with thinking, memory, concentration, and decision-making). The MDS indicated Resident 1 was dependent on staff for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's care plan titled, Actual pressure sore. Resident is noted with sacrococcyx extending right and left buttocks, dated 10/16/2025, the care plan goal indicated to minimize risk of complications and decline and will show signs and symptoms of improvement through appropriate interventions through the next assessment. The care plan intervention indicated to Administer treatment as ordered.During a concurrent interview and record review on 5/6/2026 at 12:46 p.m. with Treatment Nurse (TXN) 1, Resident 1's care plan titled, Actual pressure sore. Resident is noted with sacrococcyx extending right and left buttocks, was reviewed. TXN 1 stated that Resident 1's wound care plan was not resident-centered because it failed to include the treatment Resident 1 was receiving for Sacrococcyx pressure ulcer. TXT 1 further stated that care plan should include the current treatment orders so nursing staff would know how to properly care for Resident 1.During a concurrent interview and record review on 5/6/2026 at 4:02 p.m. with the Director of Nursing (DON), the DON stated that nursing staff should have updated Resident 1's wound care plan to reflect Resident 1's current wound order. The DON stated that without an updated care plan, the nurses will not have a guide on how to provide appropriate care for Resident 1.During a review of facility's policy and procedures (P&P) titled, Care Plans, Comprehensive Person-Centered, revised on 3/2022, the P&P indicated, Assessments of resident are ongoing, and care plans are revised as information about the residents and the resident condition changes. Care plan interventions are derived from thorough analysis of the information gathered as part of the comprehensive assessment.

Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for one of three sampled residents (Residents 1) by failing to hold Eliquis (a blood thinner-medication used to prevent and treat blood clots [gel-like clumps of blood that forms inside the body when blood vessels [a tube through which the blood circulates in the body] are injured or damaged] by slowing down the body's clotting process and increase the risk for bleeding) as ordered by the physician. This failure had the potential for Resident 1 to experience hemorrhage (rapid, excessive loss of blood from damaged blood), negatively affecting Resident 1's well-being. Findings:a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted originally admitted Resident 1 on 1/26/2016 and readmitted on [DATE] with diagnoses including age related osteoporosis (bone disease that causes bones to become weak, brittle, and fragile, significantly increasing the risk of fractures) with current pathological fracture of right humerus (a break in the upper arm bone caused by an underlying disease that has weakened the bone), epilepsy (a chronic brain disorder characterized by sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares and loss of consciousness), and type two diabetes mellitus (DM II-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 1's History and Physical (H&P - a comprehensive assessment of a resident's medical condition), dated 9/24/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 3/9/2026, the MDS indicated Resident 1's had severely impaired cognitive skills for daily decision making. The MDS indicated Resident 1 was dependent (helper does all the effort) on facility staff for personal hygiene, toileting hygiene, showers, upper and lower body dressing. During a review of Resident 1's Change of Condition (COC -major decline or improvement in a resident's status that will not resolve without intervention) form, dated 4/12/2026, the COC form indicated that on 4/12/2026, at 9:50 p.m., Resident 1 was observed with bluish discoloration on the inner upper right arm. During a review of Resident 1's Order Summary Report, the report indicated the following physician's order:-11/7/2025: Eliquis Oral tablet 2.5 milligram (mg-unit of measurement). Give one tablet via gastrostomy tube (G-tube-a medical device inserted through the abdomen into the stomach to deliver food, liquids, and medication directly, bypassing the mouth) every 12 hours for deep venous thrombosis (DVT- a condition where a blood clot forms in a deep vein, typically in the legs or thigh, causing swelling, pain, warmth, and redness) prophylaxis. -4/13/2026: Hold on blood thinners for three days. During a concurrent interview and record review on 4/22/2026 at 11:06 a.m. with Registered Nurse (RN) 1, Resident 1's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated April 2026 was reviewed. The MAR indicated, on 4/13/2026, at 9a.m. and 9 p.m. administration time, Resident 1 received 1 tablet of 2.5mg Eliquis. RN 1 stated the failure to hold Eliquis 2.5 mg as ordered by the physician was a medication error and had the potential to cause Resident 1 to experience bleeding. During an interview on 4/22/2026 at 11:52 a.m. with the Director of Nursing (DON), the DON stated the physician had ordered to hold Eliquis after Resident 1's discoloration on right upper arm was noted until the cause of the discoloration was identified. The DON stated failure to follow the physician's order and hold Eliquis had the potential for Resident 1 to experience bleeding and adverse effects (harmful, unintended, and undesired reactions resulting from medications). During a review of facility provided policy and procedure (P&P) titled, Administering Medications, last reviewed on 3/26/2026, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders, including any required time frame. 5. Medication administration times are determined by resident need and benefit, not staff convenience.

Based on observation, interview, and record review, the facility failed to ensure: 1. A licensed Administrator (ADM) was appointed to serve in the capacity of a Nursing Home Administrator (NHA). 2. A licensed Administrator (ADM) was present at the facility for sufficient hours to provide adequate oversight and management of operations. These deficient practices resulted in the facility operating without consistent administrative oversight and had the potential to adversely affect the facility's overall operations, regulatory compliance, and quality of care provided to residents.Findings: During an observation and concurrent interview on 3/13/2026 at 10:15 a.m., the Director of Nursing (DON) license was observed posted in the facility lobby identifying the DON as the Abuse Coordinator. During the same time, the Receptionist stated the facility had a temporary Administrator (ADM) who was attending a corporate conference and had not been present in the facility for the past three days. During a record review of the Department Head Directory on 3/13/2026 at 10:15 a.m., the directory indicated there was no Administrator (ADM) listed. During an interview on 3/13/2026 at 9:49 a.m., Licensed Vocational Nurse (LVN) 1 stated the facility's Administrator left on January 10, 2026. LVN 1 further stated the facility had an interim ADM who came to the facility approximately three times per week for a few hours. During an interview on 3/13/2026 at 11:00 a.m., the DON stated she had worked at the facility for three years. The DON confirmed the previous ADM left on January 10, 2026, and stated the facility had been actively seeking a replacement. The DON further stated a new ADM had been hired and was scheduled to start on March 23, 2026. The DON stated a regional ADM was currently providing oversight and came to the facility for approximately three to four hours per visit, either in the morning or afternoon. The DON further stated the regional ADM did not have a formal appointment letter designating them as the Administrator and had been assigned by the corporate office.

Based on observation, interview, and record review, the facility failed to implement its infection control measures for one of three sampled residents (Resident 2) who was on enhanced barrier precaution (EBP- wearing a protective gown and gloves whenever you are doing close-contact care with a patient who might be carrying these germs) by failing to ensure Licensed Vocational Nurse 1 (LVN 1) wore protective gown while providing gastrostomy (G tube-a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) tube care.This deficient practice had the potential for cross contamination (unintentional transfer of bacteria or germs or other contaminants from one surface to another) of infection among staff and residents.Findings:During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 3/12/2025, with diagnoses that included unspecified (unconfirmed) organism sepsis (a life-threatening blood infection), unspecified organism lobar pneumonia (infection and inflammation that may affect one part [lobe] of the lung, and gastrostomy. During a review of Resident 2's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 5/6/2025, the H&P indicated Resident 2 did not have the capacity to understand and make decisions.During a review of Resident 2's Physician Order, dated 5/6/2025, the Physician Order indicated Enhanced Barrier Precaution due to presence of wound and tube feeding. [NAME] (to put on) personal protective equipment (PPE- clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) gown when providing direct patient care.During a review of Resident 2's Minimum Data Set (MDS-a resident assessment tool), dated 9/19/2025, the MDS indicated Resident 2's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 2 was dependent on staff for all activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily). The MDS indicated Resident 2 had a feeding tube.During a concurrent observation, and interview on 12/4/2025, at 9:46 a.m., with LVN 1, in Resident 2's room. Observed an EBP signage posted by Resident 2's door that indicated Resident 2 was on EBP. Observed LVN 1 went inside Resident 2's room wearing gloves but without a gown and stood by Resident 2's right side. Observed LVN 1 opened Resident 2's blanket and LVN 1 attempted to disconnect Resident 2's G tube from the feeding formula tubing. LVN1 stated she (LVN 1) wanted to loosen the G tube first before donning the gown. LVN 1 stated she (LVN 1) should have worn the gown before providing G ube care.During an interview on 12/4/2025, at 10:30 a.m., with the Director of Nursing (DON), the DON stated Resident 2 was on EBP because of the G tube. The DON stated LVN 1 should have worn a gown before touching the G tube to prevent the transmission of infection.During an interview on 12/4/2025, at 10:43 a.m., with the Infection Preventionist (IP), the IP stated Resident 2 was on EBP and LVN 1 should wear PPE like gloves and gown, when providing G tube care. The IP stated Resident 2 had an opening (G tube) in the abdomen therefore Resident 2 was at risk for infection as staff can introduce it because PPE was not worn.During a review of facility's policy and procedure (P&P), titled, Enhanced Barrier Precautions dated 2001, and last reviewed on 10/23/2025, the P&P indicated, Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDRO-is a germ that is resistant to many antibiotics) to residents. 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms (MDROs) to residents.2. EBPs employ targeted gown and glove use during high contact (activities that have been demonstrated result in the transfer of MDROs to hands or clothing of healthcare personnel, even if blood and body fluid exposure is not anticipated) resident care activities when contact precautions do not otherwise apply.a. Gloves and gowns are applied prior to performing the high contact resident care activity (as opposed to before entering the room).b. Personal protective equipment (PPE) is changed before caring for another resident.c. Face protection may be used if there is also a risk of splash or spray.3. Examples of high-contact resident care activities requiring the use of gowns and gloves for EBPs include:a. dressing;b. bathing/showering;c. transferring;d. providing hygiene;e. changing linens;f. changing briefs or assisting with toileting;g. device care or use (central line [provides access to a person's blood supply, which allows the patient to receive medications, fluids or additional blood, and allows practitioners to measure or draw blood], urinary catheter [a hollow tube inserted into the bladder to drain or collect urine], feeding tube, tracheostomy [a procedure to help air and oxygen reach the lungs by creating an opening into the windpipe from outside the neck]/ventilator [a medical device to help support or replace breathing]); andh. wound care (any skin opening requiring a dressing).

Based on interview and record review, the facility failed to maintain accurate and complete medical record for one of three sampled residents (Resident 2) by failing to document medications that were held (temporarily stopping certain medications as instructed by a healthcare provider) following a physician order.This deficient practice had the potential to result in medication errors, cause confusion in care and the medical records containing inaccurate documentation for Resident 2.Findings:During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 3/12/2025, with diagnoses that included unspecified (unconfirmed) organism sepsis (a life-threatening blood infection), unspecified organism lobar pneumonia (infection and inflammation that may affect one part [lobe] of the lung), and essential hypertension (high blood pressure that is not due to another medical condition).During a review of Resident 2's Physician Order, dated 5/5/2025, the Physician Order indicated the following:1. Amlodipine Besylate (medication used to treat elevated blood pressure) oral tablet five milligrams (mg-metric unit of measurement, used for medication dosage and/or amount), give one tablet via gastrostomy (G tube-a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) tube two times a day for hypertension (HTN-high blood pressure), hold for systolic blood pressure (sbp- the top number in a blood pressure reading, indicating the pressure in your arteries when your heart beats) less than 110 millimeter of mercury (mmHg-a standard unit of pressure).2. Sacubitril-valsartan (medication used to treat congestive heart failure [CHF-heart was too weak to pump enough blood]) oral tablet 24 mg - 26 mg, give one tablet via G tube two times a day for CHF, hold for sbp less than 110 mmHg.During a review of Resident 2's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 5/6/2025, 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 9/19/2025, the MDS indicated Resident 2's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 2 was dependent on staff for all activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 2's Medication Administration Record (MAR- flowsheet that indicates medications given to a resident), dated 11/2025, the MAR indicated Licensed Vocational Nurse 2 (LVN 2) administered amlodipine to Resident 2 on 11/25/2025, at 9 a.m. with a blood pressure of 109/65 mmHg.During a review of Resident 2's MAR, dated 11/2025, the MAR indicated (LVN 2) administered Sacubitril-valsartan to Resident 2 at 9 a.m. on the following dates:1. On 11/6/2025, with a blood pressure of 105/56 mmHg2. On 11/ 25/2025, with a blood pressure of 109/65 mmHgDuring a concurrent interview, and record review on 12/5/2025, at 8:30 a.m., with the Assistant Director of Nursing (ADON), Resident 2's Physician Order, dated 5/5/2025, and MAR, dated 11/2025, were reviewed. The ADON stated LVN 2 should have held the amlodipine on 11/25/2025, and the Sacubitril-valsartan on 11/6/2025, and 11/25/2025. The ADON stated nurses should obtain the blood pressure and follow the physician order to not administer the amlodipine and the Sacubitril-valsartan for blood pressure below 110 mmHg. The ADON stated Resident 2's blood pressure can drop by taking medication to lower the blood pressure when Resident 2's blood pressure was already low.During an interview on 12/5/2025, at 8:40 a.m., with LVN 2, LVN 2 stated she (LVN 2) did not administer the amlodipine on 11/25/2025, and she (LVN 2) did not administer the Sacubitril-valsartan on 11/6/2025, and 11/25/2025. LVN 2 stated she (LVN 2) must have documented administration in the electronic health record, but she (LVN 2) knows she (LVN 2) did not administer the medications because Resident 2's blood pressure was low.During an interview on 12/5/2025 at 8:59 a.m., with the Director of Nursing (DON), the DON stated LVN 2 should document accurately especially for medication administration. The DON stated LVN 2 documented the blood pressure but did not document if she (LVN 2) had held the medication. The DON stated LVN 2 should have documented the right code which is number five for holding medication in MAR to prevent confusion and inaccurate medical record.During a review of facility's policy and procedure (P&P) titled, Charting and Documentation, dated 7/2017 and last reviewed on 10/23/2025, the P&P indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.2. The following information is to be documented in the resident medical record:a. Objective observations.b. Medications administered.c. Treatments or services performed.d. Changes in the residents' condition.e. Events, incidents or accidents involving the residents; andf. Progress toward or changes in the care plan's goals and objectives.3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of three sampled residents (Resident 2) by failing to follow Resident 2's physician order to hold (temporarily stopping certain medications as instructed by a healthcare provider) amlodipine (medication used to treat high blood pressure) for systolic blood pressure (sbp- the top number in a blood pressure reading, indicating the pressure in your arteries when your heart beats) below 110 millimeters of mercury (mmHg-a standard unit of pressure).This deficient practice had the potential to result in medication error and could cause hypotension (low blood pressure) to Resident 2.Findings:During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 3/12/2025, with diagnoses that included unspecified (unconfirmed) organism sepsis (a life-threatening blood infection), unspecified organism lobar pneumonia (infection and inflammation that may affect one part [lobe] of the lung), and essential hypertension (high blood pressure that is not due to another medical condition).During a review of Resident 2's Physician Order, dated 5/5/2025, the Physician Order indicated amlodipine besylate oral tablet five milligrams (mg- metric unit of measurement, used for medication dosage and/or amount), give one tablet via gastrostomy (G-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) tube two times a day for hypertension (HTN- high blood pressure), hold for sbp less than 110 mmHg.During a review of Resident 2's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 5/6/2025, 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 9/19/2025, the MDS indicated Resident 2's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 2 was dependent on staff for all activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 2's Medication Administration Record (MAR- flowsheet that indicates medications given to a resident), dated 11/2025, the MAR indicated amlodipine was administered to Resident 2 at 9 a.m. on 11/1/2025, with a blood pressure of 105/76 mmHg.During a concurrent interview, and record review on 12/5/2025, at 8:30 a.m., with the Assistant Director of Nursing (ADON), Resident 2's Physician Order, dated 5/5/2025, and MAR, dated 11/2025, were reviewed. The ADON stated Registered Nurse 1 (RN 1) should have held the amlodipine on 11/1/2025. The ADON stated nurses should obtain the blood pressure and follow the physician order to not administer the amlodipine for blood pressure below 110 mmHg. The ADON stated Resident 2's blood pressure can drop by taking medication to lower the blood pressure when Resident 2's blood pressure was already low.During an interview on 12/5/2025, at 8:40 a.m., with the Director of Nursing (DON), the DON stated RN 1 should verify the physician order before amlodipine administration. The DON stated Resident 2's blood pressure can drop because amlodipine was administered.During a review of facility's policy and procedure (P&P) titled, Administering Medications, dated 4/2019, and last reviewed on 10/23/2025, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed.4. Medications are administered in accordance with prescriber orders, including any required time frame.11. The following information is checked/verified for each resident prior to administering medications: a. Allergies to medications; and b. Vital signs (measurements of the body's most basic functions), if necessary.

Based on interview and record review, the facility failed to implement a person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for one of three sampled residents (Resident 1) by failing to implement interventions to address Resident 1's preference of not attending group activities.This deficient practice had potential for a delay in the delivery of necessary care and services to Resident 1. Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 4/3/2024, with diagnoses that included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) with diabetic neuropathy (nerve damage that is caused by diabetes), acquired absence of right leg below the knee and left shoulder pain.During a review of Resident 1's Order Summary Report, dated 4/4/2024, the Order Summary Report indicated Resident 1 may participate in planned activities if not contraindicated with resident's plan of care.During a review of Resident 1's Care Plan, dated 5/28/2024 about not attending group activities, the Care Plan indicated the following interventions: a. to encourage self-directed (making your own decisions and organizing your own work) activities. b. conduct rounds (visits) to monitor activity needs and offer appropriate interventions.During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 10/12/2025, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 1 required set up assistance from staff for toileting, lower body dressing and transfers.During a review of Resident 1's Interdisciplinary Team (IDT-a coordinated group of experts from several different fields who work together), dated 10/12/2025, the IDT indicated Resident 1's preferred activity was to attend group activities, independent activities, and room visits.During an interview on 12/4/2025, at 9:30 a.m. with Resident 1, Resident 1 stated activity room visits were not done. Resident 1 stated activity had not asked him (Resident 1) what he (Resident 1) needed for in-room activity. Resident 1 stated he (Resident 1) likes to create a ball made from rubber elastic band.During an interview, and record review on 12/4/2025, at 10:17 a.m., with Activity Staff (AS), AS stated Resident 1 only attends group activities when his (Resident 1) room is being deep cleaned. AS stated, he (Resident 1) last attended a group activity on 12/2/2025. AS stated the activity staff does not visit him (Resident 1) unless he (Resident 1) asks for the activity staff. AS stated they (AS) do not do room visits unless he (Resident 1) asks. AS stated, Resident 1 had no group activity and in room visits from 11/1/2025 to 12/1/2025.During an interview on 12/4/2025, at 10:30 a.m., with the Director of Nursing (DON), the DON stated Resident 1's care plan on refusal of group activity was not followed. The DON stated Activity Staff should encourage self-directed activities and conduct rounds to monitor activity needs and offer appropriate interventions as indicated in Resident 1's care plan. The DON stated providing daily activity helps Resident 1 to get away from the routine of the facility and helps Resident 1 boost his (Resident 1) self-esteem. The DON stated if activity was not provided daily, it could lower the self-esteem (confidence in one's own worth or abilities; self-respect) of Resident 1.During an interview o0n 12/5/2025 at 8:59 a.m. with the DON, the DON stated Resident 1's care plan outlines the care and intervention individualized for him (Resident 1). The DON stated staff should follow the interventions in Resident 1's Care Plan to prevent Resident 1's emotional decline (a sudden decrease in mood, energy, or emotional state). During a review of facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Plan, dated 3/2022, and last reviewed on 10/23/2025, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial (the interrelation of social factors and individual thought and behavior) and functional needs is developed and implemented for each resident 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes. b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment, . c. includes the resident's stated goals upon admission and desired outcomes. d. builds on the residents' strengths; and e. reflects currently recognized standards of practice for problem areas and conditions. 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. 11. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. 13. The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. Such refusals are documented in the resident's clinical record in accordance with established policies.During a review of facility's policy and procedure (P&P) titled, Activity Program, undated and last reviewed on 10/23/2025, the P&P indicated, Activity Plan as Part of Resident Care Plansa. The activity plan shall be included in the total resident care plan. The plan shall be developed with participation of the resident and family or responsible person to include resident's realistic goals and expectations.b. The resident care plan is derived from the information provided in nursing history which is completed when the resident is first admitted , c. The activity coordinator consults with the nursing staff to develop a suitable activity plan for the resident. f. The plan is utilized by the nursing staff and nurse assistant to encourage and help the resident to participate in appropriate activities.

Based on interview and record review, the facility failed to provide an ongoing activity program that is resident-centered for one of three sampled residents (Resident 1).This deficient practice had the potential to affect Resident 1's sense of self-worth (the internal sense of being good enough and worthy of love and belonging from others) and psychosocial (the interaction between an individual's mental and emotional state [psychological] and their social environment) well-being.Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 4/3/2024, with diagnoses that included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) with diabetic neuropathy (nerve damage that is caused by diabetes), acquired absence of right leg below the knee and left shoulder pain.During a review of Resident 1's Order Summary Report, dated 4/4/2024, the Order Summary Report indicated may participate in planned activities if not contraindicated with resident's plan of care.During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 10/12/2025, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 1 required set up assistance from staff for toileting, lower body dressing and transfers.During a review of Resident 1's Interdisciplinary Team (IDT-a coordinated group of experts from several different fields who work together), dated 10/12/2025, the IDT indicated Resident 1's preferred activity was to attend group activities, independent activities and room visits.During an interview on 12/4/2025, at 9:30 a.m. with Resident 1, Resident 1 stated activity was not provided to him (Resident 1). Resident 1 stated activity room visits were not done. Resident 1 stated activity had not asked him (Resident 1) what he (Resident 1) needed for in-room activity. Resident 1 stated he (Resident 1) likes to create a ball made from rubber elastic band.During an interview, and record review on 12/4/2025, at 10:17 a.m., with Activity Staff (AS), AS stated Resident 1 only attends group activities when his (Resident 1) room is being deep cleaned. AS stated he (Resident 1) last attended a group activity on 12/2/2025. AS stated the activity staff does not visit him (Resident 1) unless he (Resident 1) asks for the activity staff. AS stated they (AS) do not do room visits unless he (Resident 1) asks. AS stated Resident 1 had no group activity and in room visits from 11/1/2025 to 12/1/2025.During an interview on 12/4/2025, at 10:30 a.m., with the Director of Nursing (DON), the DON stated activity should be provided daily to Resident 1. The DON stated there should be a documentation when Resident 1 refuses activity or Resident 1 only wants activity when he (Resident 1) requests it. The DON stated providing daily activity helps Resident 1 to get away from the routine of the facility and helps Resident 1 boost his (Resident 1) self-esteem. The DON stated if activity was not provided daily, it could lower the self-esteem (confidence in one's own worth or abilities; self-respect) of Resident 1.During a review of facility's policy and procedure (P&P) titled, Activity Program, undated and last reviewed on 10/23/2025, the P&P indicated, This chapter provides information on the facility's policies and procedures related to the activity program. All activity program has the following benefits: .- Encourages motivation for activities of daily living and the resumption of as normal functioning as is reasonably possible.- Provides alternatives to compensate for loss of mental and physical capacities.- Gives psychological support and understanding in helping the resident accept his/her illness and/ or limitations.- Creates in the resident the will to make his/her life more meaningful by using his/her physical and mental capacities to their fullest extent; and- Maintains the resident's sense of usefulness, self-respect, and self-satisfaction.B. Resident Activity Program1. Assessment for Activity Program.d. The activity coordinator uses the assessment form to write progress notes and maintain records of the resident's progress and response.e. The activity coordinator determines to the best of his/her ability the residents' interests, capacities, motivations, and realistic objectives and includes information regarding rehabilitative potential during this initial assessment. This information Is changed whenever new information is received and is used to modify the activity plan, with participation from the resident.2. Activity Plan as Part of Resident Care Plans.c. The activity coordinator consults with the nursing staff to develop a suitable activity plan for the resident.f. The plan is utilized by the nursing staff and nurse assistant to encourage and help the resident to participate in appropriate activities.

Based on interview, and record review, the facility failed to ensure the medical records of one of three sampled residents (Resident 1) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to ensure Resident 1's Change of Condition (COC -major decline or improvement in a resident's status that will not resolve without intervention) form contained documentation of Resident 1's oxygen administration and vital signs (measurements that indicate a resident's basic psychological functions such as temperature, heart rate, blood pressure, respiratory rate, and oxygen saturation) monitoring. This deficient practice had the potential to result in inaccurate medical interventions for Resident 1. Findings: During a review of Resident 1's admission Record, the admission Record indicated that the facility originally admitted Resident 1 on 7/11/2025, and readmitted on [DATE], with diagnoses including anemia (a condition where the body does not have enough healthy red blood cells), chronic kidney disease (a condition in which they kidneys gradually lose their ability to filter waste products from the blood, leading to damage and impaired function over time), and urinary tract infection (UTI- an infection in the bladder/urinary tract). During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 8/21/2025, the MDS indicated Resident 1's moderately impaired (poor decisions, supervision required) cognitive (relating to the mental process of knowing, learning, and understanding) skills for daily decision making. The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort) from facility staff with oral hygiene and upper body dressing. The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort) with toileting hygiene, showers, lower body dressing. During a review of Resident 1's Care Plan, initiated on 10/11/2025, the Care Plan indicated Resident 1 had a change of condition manifested by tachycardia (a condition where the hears beats abnormally fast, exceeding 100 beats per minute at rest) and hypertension (HTN-high blood pressure [force exerted by blood on the walls of the blood vessels]). During a review of Resident 1's COC form, dated 10/11/2025, the COC form indicated on 10/11/2025, at approximately 9:30 a.m., Resident 1's heart rate (the number of times the heart beats per minute) reached 130 beats per minute, oxygen saturation (O2 sat-measurement of how much oxygen blood is carrying as a percentage of the maximum it could carry) was 96 percent at room air and Resident 1 denied having difficulty breathing. The COC form indicated on 10/11/2025, at approximately 1 p.m., Resident 1 was experiencing oxygen desaturation (a decrease in the blood oxygen level), tachycardia, and Resident 1's blood pressure was varying. The COC form indicated on 10/11/2025, at approximately 1:20 p.m. paramedics arrived at the facility while Resident 1 was experiencing hypoxia (a condition where there is an inadequate supply of oxygen to the body's organs). The COC form indicated on 10/11/2025, at approximately 1:40 p.m., Resident 1 was transferred to general acute care hospital (GACH) per physician's order. During an interview on 10/11/2025 at 10:40 p.m. with Registered Nurse (RN) 1, RN 1 stated on 10/11/2025, at approximately 1 p.m., Resident 1's oxygen saturation went down to approximately 85 percent (%-unit of measurement) and Resident 1 was placed on oxygen via nonrebreather mask (a medical device that delivers high concentration of oxygen to a resident) and later via nasal cannula (a device that gives additional oxygen through the nose). RN 1 was unable to indicate the time and the amount of oxygen administered to Resident 1. RN 1 stated that after the oxygen administration (unable to indicate time), Resident 1's O2 level increased to approximately 91%. RN 1 stated he (RN 1) documented Resident 1's change in condition and treatment provided on the COC form dated 10/11/2025. During an interview on 10/16/2025 at 11:45 a.m. with the Director of Nursing (DON), the DON stated the Resident 1's COC form, dated 10/11/2025, did not have accurate, complete, and concise documentation of Resident 1' s vital signs. The DON stated the COC form did not have documentation of Resident 1's O2 changes and oxygen administration. The DON stated the facility staff failed to document accurate monitoring of Resident 1's vital signs and oxygen administration on Resident 1's COC form dated 10/11/2025. The DON stated the changes in residents' condition should be accurately documented during COCs, to reflect care and treatment that was provided to the residents. The DON stated the documentation of Resident 1's COC from was incomplete and had the potential to result in inaccurate description of Resident 1's condition. During a record review of the facility-provided policy and procedure titled, Charting and Documentation, last reviewed on 4/24/2024, the policy and procedure indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.2. The following information is to be documented in the resident medical record.c. Treatments or services performed; d. Changes in resident's condition.Documentation of procedures and treatments will include care-specific details. During a record review of the facility-provided policy and procedure titled, Acute Condition Changes-Clinical Protocol, last reviewed on 4/24/2024, the policy and procedure indicated, .The staff will monitor and document the resident/patient's progress and responses to treatment. During a record review of the facility-provided policy and procedure titled, Change in a Resident's Condition or Status, last reviewed on 4/24/2024, the policy and procedure indicated, .The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Based on interview and record review, the facility failed to: 1. Provide supervision (refers to the ongoing monitoring and guidance provided by staff to ensure the safety and well-being of a resident) to one of one sampled resident (Resident 97), who was cognitively impaired (refers to difficulties with thinking, learning, remembering, and using judgment, among other mental abilities), unable to verbalize needs due to aphasia (a disorder that makes it difficult to speak), had history of falls and elopement (the act of leaving a facility unsupervised and without prior authorization), and identified as at risk for elopement, by: A. Failing to monitor Resident 97's whereabouts on 7/25/2025 at 12:14 p.m. (date and time of Resident 97's elopement). The facility staff were not aware Resident 97 had left the facility until around 5 p.m. when CNA 2 was distributing the dinner trays and Resident 97 was not in his (Resident 97) room. Facility staff (Certified Nursing Assistant [CNA] 1, CNA 2, CNA 3, Licensed Vocational Nurse [LVN] 1, Registered Nurse [RN] 1, and RN 2) did not know Resident 97 was an elopement risk and did not know what interventions are in place to prevent Resident 97 from eloping. There were multiple missed opportunities for the facility staff to prevent Resident 97's elopement and to remain aware of Resident 97's whereabouts: a.1 On 7/25/2025 at 12:07 p.m., CNA 1 documented in Resident 97's Nutritional Amount Eaten Percentage (%) as 50% and set-up or clean-up assistance was provided to Resident 97 without directly observing Resident 97 eat his (Resident 97) lunch. Resident 97 had a physician's order to provide Resident 97 with supervision during meals which was not followed. a.2 On 7/25/2025 at 12:53 p.m., LVN 1 documented a blood pressure (BP - the pressure of circulating blood against the walls of blood vessels) reading of 110/62 millimeters of mercury (mmHg- unit of pressure, normal range is between 90/60 mmHg and 120/80 mmHg) for Resident 97, stating that he (LVN 1) used the BP reading previously obtained on 7/25/2025 at 8:00 a.m. Resident 97 had a physician's order to monitor Resident 97's BP every six hours (midnight - 6 a.m.-12 p.m.- 6 p.m. intervals). a.3 Resident 97 had physician's orders for monitoring every shift for falls and episodes of depression (a mental health condition that makes you feel persistently sad and lose interest in things you usually enjoy) manifested by crying which were not completed during the 7 a.m. to 3 p.m. shift on 7/25/2025. a.4. During the 3 p.m. hand off report (change of shift) on 7/25/2025, CNA 2 stated there was no mention of Resident 97. RN 2 stated that RN 1 did not provide any information regarding Resident 97. Both RN 1 and RN 2 were unaware that Resident 97 had an elopement incident on 1/29/2025 and had been identified as an elopement risk. B. Failing to implement the facility's Policy and Procedures (P&P) titled, Wandering and Elopements, last reviewed on 4/24/2025 indicating, . the resident's care plan will include strategies and interventions to maintain the resident's safety. Resident 97's care plan titled, Elopement Risk, initiated on 1/30/2025, was not person-centered (prioritizing the resident's needs, preferences, values and goals) and did not include interventions for monitoring and supervision to ensure Resident 97's safety. C. Failing to implement their P&P titled, Safety and Supervision of Residents, last reviewed on 4/24/2025 indicating, Resident safety and supervision and assistance to prevent accidents are facility-wide priorities The care team shall target interventions to reduce individual risks related to hazards in the environment including adequate supervision Resident supervision is a core component of the system's approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs This deficient practice resulted in Resident 97's elopement on 7/25/2025 at 12:14 p.m., placing Resident 97 at risk for vehicular accidents since the facility is located in a busy street with many cars passing by, negative outcome from not receiving Resident 97's medication, and exposure to environmental elements (hot weather), and possible physical attacks from strangers that could lead to serious injury, serious harm and death. On 7/25/2025, in the afternoon (exact time not indicated), Resident 97 was found on the ground in the street (not known) with a small contusion (known as bruise, an injury to the soft tissue often produced by a blunt force such as a kick, fall, or blow) to the right frontal scalp (area at the very front of your head where your hairline begins and the hair that frames your face, including the area around your temples). Resident 97 was admitted to General Acute Care Hospital (GACH) 1 on 7/25/2025 at 2:23 p.m. for trauma (a physical injury or wound caused by an external force, or a psychological or emotional upset resulting from severe mental or emotional stress or physical injury). On 7/29/2025, Resident 97's family visited Resident 97 at GACH 1 and upon seeing the family member, Resident 97 cried for 10 minutes. 2. Ensure Resident 7's bed was at the lowest position and the floor/fall mat (a cushioned floor pad designed to help prevent injury should a person fall) on the right side of the bed did not have a side table on top of them. 3. Ensure Residents 21 and 32 did not have any medications left at the bedside. 4. Ensure Resident 70's feeding pump pole was not placed on top of the left floor mat. 5. Ensure Resident 82's pathway to the restroom was unobstructed with the two roommate's bedside tables. These deficient practices increased the risk of accidents such as falls with injuries and accidental ingestion of chemicals/biologicals on residents. On 7/31/2025 at 2:30 p.m., while onsite at the facility, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility's non-compliance with one or more requirements of participations has caused, or is likely to cause, serious injury, harm, impairment, or death of a resident) in the presence of the Administrator (Adm) and the Director of Nursing (DON) due to the facility's failure to provide supervision to Resident 97 and to prevent the elopement of Resident 97 on 7/25/2025 at 12:14 p.m. On 8/1/2025 at 4:36 p.m., the DON provided an acceptable IJ removal plan (a detailed plan to address the IJ findings) for the facility's failure to provide supervision to Resident 97 and to prevent the elopement of Resident 97 on 7/25/2025 at 12:14 p.m. On 8/1/2025 at 5:19 p.m., while onsite at the facility, the SSA verified and confirmed the facility's full implementation of the IJ Removal Plan through observations, interviews, and record reviews, and determined the IJ situation regarding elopement due to lack of supervision was no longer present. The SSA removed the IJ on 8/1/2025 at 5:19 p.m., in the presence of the Adm and DON. The acceptable IJ Removal Plan included the following summarized actions: 1. On 7/29/2025, the facility marketer visited Resident 97 at GACH 1 and confirmed with the attending nurse that Resident 97 had been brought to GACH 1's emergency room by paramedics (emergency medical services [EMS], persons trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital) on 7/25/2025. 2. On 7/31/2025 and 8/1/2025 the Licensed Nurses and Social Services Director (SSD) completed a reassessment of all current residents for elopement risk evaluation utilizing the facility's Point Click Care (PCC - a software system used in healthcare facilities, especially those dealing with long-term care, to manage patient information and daily operations) Elopement Risk Assessment Tool and no current residents are at risk for elopement. The Elopement Risk Assessment Tool covers 12 questions, including but not limited to history of elopement, wandering behavior, verbal expressions of a desire to go home, etc. Effective 8/1/2025, the facility will utilize the previous Elopement Risk Assessment that addresses the residents' cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), Activities of Daily Living (ADLs - refers to the basic self-care tasks that a person performs regularly to maintain their health and well-being), ambulation, and elopement history. 3. As of 7/31/2025, the Quality Assurance (QA) Consultant provided one-on-one in-service (an individual employee receives instruction and guidance from a trainer or mentor) training regarding Wandering and Elopement policy and Safety and Supervision of Resident policy emphasizing importance of resident monitoring to CNA 1, CNA 2, CNA 3, LVN 1, RN 1, and RN 2. 4. On 7/31/2025, the QA Consultant conducted one-on-one in-service regarding accurate documentation to CNA 1 and LVN 1. 5. As of 8/1/2025, the DON/DSD completed the in-service training to staff members regarding Wandering and Elopement policy and Safety and Supervision of Resident policy emphasizing importance of resident monitoring and the following topics: a. Licensed nurses assigned to all facility nursing stations, including station 1, station 2, and subacute station (refers to designated area within a facility that provides subacute care to residents who require more intensive medical services than those typically offered in standard long term care) will conduct rounds every two hours and document and sign off resident's presence or non-presence in the Residents Whereabouts Monitoring Log and indicate any unusual behaviors noted during the shift and endorse to RN supervisor accordingly. b. RN supervisors will utilize the Midnight Census (a PCC generated census after midnight, stating resident status including occupied or empty, to check off and verify resident's presence during shift-change, endorsement, or rounds. This document is signed off by an outgoing and incoming RN supervisor after the shift-change, endorsement or rounds. c. Develop and implement a person-centered care plan for elopement risk, including but not limited to frequent supervision. 6. As of 8/1/2025, all current active employees have completed the in-service training, with the exception of one RN and two LVNs who were unable to complete the in-service training due to being on medical leave. The DON/Designee will complete their in-services upon their return. 7. On 8/1/2025, the DON provided a written warning to LVN 1 and CNA 1 for inaccurate documentation on Resident 97's clinical records. Findings: 1.During a review of Resident 97’s admission Record (AR), the AR indicated the facility originally admitted Resident 97 on 4/3/2024 and readmitted the resident on 5/10/2024 with diagnoses including aphasia, dysphagia (difficulty swallowing), history of falling, anxiety (a feeling of unease, worry, or fear), and depression. During a review of Resident 97’s Minimum Data Set (MDS – a resident assessment tool), dated 5/17/2025, the MDS indicated that Resident 97 was sometimes able to understand others and was sometimes understood by others. During a review of Resident 97’s History and Physical (H&P – comprehensive assessment conducted by a healthcare provider that includes gathering a thorough medical history from the resident and performing a physical examination to assess their overall health and identify any potential medical concern), dated 5/22/2025, the H&P indicated Resident 97 did not have the capacity to understand and make decisions. During a review of Resident 97’s Care Plan for aspiration (when something swallowed enters the airways or lungs), initiated on 5/16/2024 and revised on 3/12/2025, the care plan indicated Resident 97 is at risk for aspiration of food and liquids secondary to dysphagia. The care plan interventions included monitoring signs and symptoms of aspiration (such as choking [refers to the inability to breathe due to a blockage in the airway, typically caused by a foreign object lodged in the throat], shortness of breath [SOB], respiration changes), and resident’s tolerance of prescribed diet and fluid intake. During a review of Resident 97’s Care Plan for self-care deficits, initiated on 7/29/2024, the care plan indicated Resident 97 required total assistance from staff with eating. The care plan intervention indicated to provide Resident 97 with a safe environment. During a review of Resident 97’s Change of Condition (COC – when there is a sudden change in a resident’s condition) Interaction Assessment form, dated 1/29/2025, timed at 9 p.m., the COC form indicated Resident 97 eloped and fell in front of the facility. The nursing notes indicated that on 1/29/2025 at 9 p.m., Resident 97 was walking on the sidewalk in front of the facility and attempted to cross the street. The CNA and LVN were able to bring Resident 97 back to the facility and as Resident 97 was walking up the stairs, Resident 97 lost his footing and fell. During a review of Resident 97’s Care Plan for elopement, initiated on 1/29/2025, the care plan indicated Resident 97 leaves the facility at times without authorization and permission. The care plan interventions included administering medications as ordered, notifying the physician and responsible party of the COC, and assisting Resident 97 to resident’s activities of choice. During a review of Resident 97’s Elopement Evaluation, dated 5/18/2025, the Elopement Evaluation indicated Resident 97 had an elopement score of one (score value of one or higher indicates risk for elopement). During a review of Resident 97’s Fall Risk Evaluation, dated 5/18/2025, the Fall Risk Evaluation indicated Resident 97’s fall risk score was seven (total score of 10 or greater indicates the resident should be considered as high risk for potential falls). The Fall Risk Evaluation indicated Resident 97 had balance problems while walking. During a review of Resident 97’s Physician Orders, dated 5/19/2025, the Physician’s Orders indicated implementation of the falling star program, frequent visual monitoring due to the resident’s increased risk for falls and injury. The Physician’s Orders indicated to document per shift, every shift. During a review of Resident 97’s Care Plan for falling star program, initiated on 5/19/2025, the care plan indicated Resident 97 was at risk for falls related to antihypertensive medication (medications used to treat high blood pressure), auditory (hearing) deficits, balance deficits, cognitive impairment, decreased strength and endurance, history of falls, noncompliant with request for assistance on use of call lights, poor safety awareness and judgment, unsteady gait (manner of walking), difficulty in walking, and muscle weakness. The care plan interventions indicated to remind staff during huddles (a brief, structured meeting, often daily, among healthcare professionals to discuss the day's plan, identify potential problems, and ensure smooth workflow) of the resident’s high fall risk status, implementing frequent visual monitoring, and placing the resident near the nursing station for closer observation. During a review of Resident 97’s Physician’s Orders, dated 5/30/2025, the Physician’s Orders indicated monitoring resident’s blood pressure every six hours. During a review of Resident 97’s Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for 7/2025, the MAR for 7/25/2025 indicated the following: - the monitoring for episodes of depression manifested by crying spells and tally by hashmark, was left blank for the day shift (7 a.m. to 3 p.m.) - the Falling Star Program frequent visual monitoring (due to higher risk for falls and injuries) document per shift was left blank for the day shift. - the blood pressure monitoring every six hours indicated a blood pressure of 110/62 mmHg at 12:53 p.m. During a review of Resident 97’s Physician Orders, dated 7/9/2025, the Physician Orders indicated Controlled Carbohydrates (CCHO- meal plan where individuals aim to eat roughly the same amount of carbohydrates at each meal, helping to stabilize blood sugar levels) no added salt (NAS) diet, dysphagia mechanical soft (a diet that involves eating foods that have been modified to be easy to chew and swallow) texture, nectar mildly thick consistency (means the liquid is thicker than regular water but still pourable), three meals, aspiration precautions, and supervision during meals. During a review of Resident 97’s ADL eating task, dated 7/25/2025, at 12:07 p.m., the ADL eating task indicated Resident 97 was provided with setup or clean up assistance (helper sets up or cleans up resident completes activity helper assists only prior or following the activity). During a review of Resident 97’s nutritional task amount eaten %, dated 7/25/2025, at 12:07 p.m., the nutritional task amount eaten % indicated Resident 97 ate 50 % of his (Resident 97) meal. During a review of Resident 97’s COC form, dated 7/25/2025, timed at 5:20 p.m., the COC form indicated Resident 97 eloped. The nursing notes indicated that on 7/25/2025 at 5 p.m., while passing dinner trays, CNA 2 observed that Resident 97 was not in his (Resident 97’s) assigned room. CNA 2 informed RN 2, who immediately initiated a thorough search of the facility. A code green (missing resident) was activated to alert all facility staff and initiate a coordinated facility wide search. The COC indicated that at approximately 6:30 p.m., RN 2 contacted the DON to report the incident, provide a timeline, and updates of the search effort. The COC form indicated that RN 2 then notified the local police department and reported Resident 97 as missing and requested assistance with the search. RN 2 contacted Resident 97’s family members to inform them of the situation and to verify whether they had seen or heard from Resident 97, neither family members reported recent contact with Resident 97. During a review of Resident 97’s GACH 1 record, dated 7/25/2025, at 2:23 p.m., the GACH 1 record indicated Resident 97’s admission type was for trauma. GACH 1’s Medicine H&P notes indicated that Resident 97 was brought in by EMS from the community for possible ground level fall (refers to a fall where a person falls from a standing position onto a flat surface, such as the floor or ground). GACH 1’s records indicated Resident 97 had a cervical collar (a medical device that supports the neck and limits its movement) and was tearful, crying, and pointing at the ceiling. GACH 1’s records indicated Resident 97 had a small right frontal scalp contusion. GACH ‘s 1 records further indicated Resident 97 had a fall and aspiration precaution orders started on 7/25/2025. During a concurrent interview and observation on 7/29/2025, at 2:20 p.m., with the Adm, the facility provided Close Circuit Television (CCTV - video surveillance technology) video footage of the camera located in the facility lobby, dated 7/25/2025, at 12:14 p.m., was reviewed. The Adm stated that the video footage shows a visitor opening the door leading to the lobby, after which Resident 97 is seen entering the lobby and subsequently exiting through the facility’s front door. During a concurrent interview and record review on 7/30/2025 at 11:48 a.m., with CNA 1, Resident 97’s nutritional task amount eaten %, dated 7/25/2025, timed at 12:07 p.m., was reviewed. CNA 1 stated she was not aware that Resident 97 had a Physician’s Order for supervision during all meals. CNA 1 stated that she (CNA 1) does not supervise Resident 97 during mealtimes and leaves the meal tray on Resident 97’s bedside table. CNA 1 stated that she was assigned to Resident 97 on 7/25/2025 and that the last time she (CNA 1) saw Resident 97 that day (7/25/2025) was between approximately 11:15 a.m. and 11:20 a.m. CNA 1 stated that prior to lunch, Resident 97 was in his (Resident 97) room. CNA 1 stated that she delivered Resident 97’s lunch tray and placed it on his (Resident 97) bedside table. CNA 1 stated Resident 97 was independent in using the bathroom. CNA 1 stated that she (CNA 1) observed that the bathroom door was closed and assumed Resident 97 was inside. CNA 1 stated that when she (CNA 1) returned sometime after 1:00 p.m. to retrieve the meal tray, CNA 1 observed the food had not been touched and the bathroom door remained closed. CNA 1 stated that she (CNA 1) did not knock on or open the bathroom door to verify Resident 97’s presence. CNA 1 reviewed Resident 97’s nutritional amount eaten % document and stated that she (CNA 1) documented a nutritional intake of 50% on 7/25/2025, despite knowing that Resident 97 had not eaten. During a concurrent interview and record review on 7/30/2025, at 1:29 p.m., with LVN 1, Resident 97’s MAR dated 7/25/2025 was reviewed. LVN 1 stated that he was the nurse assigned to Resident 97 on 7/25/2025 during the 7 a.m. to 3 p.m. shift. LVN 1 stated he checked Resident 97’s blood sugar between 11 a.m. and 12 p.m., prior to lunch. LVN 1 stated that while he (LVN 1) checks on residents periodically, he did not check on Resident 97 again that day (7/25/2025) because Resident 97 is ambulatory (able to walk and move around) and typically seeks out staff when assistance is needed. LVN 1 also stated that Resident 97 becomes emotional when family visits, often crying and clinging to them, while expressing a desire to go home. LVN 1 stated that during shift-change, he (LVN 1) is informed about which residents are at risk for elopement. LVN 1 stated that Resident 97 is not considered an elopement risk and has never previously eloped. LVN 1 also stated that he (LVN 1) was not aware of Resident 97’s elopement incident on 1/29/2025. LVN 1 stated that the BP documented at 12:00 p.m. was taken at 8:00 a.m. LVN 1 stated that he did not check Resident 97’s BP every six hours as ordered. LVN 1 stated that failing to check Resident 97’s BP as ordered could result in unrecognized high or low BP readings potentially leading to delays in necessary interventions and treatment. During an interview on 7/30/2025 at 2:13 p.m., with RN 1, RN 1 stated she (RN 1) was not initially aware that Resident 97 was an elopement risk but was later informed that Resident 97 had previously attempted to elope. RN 1 stated that the last time she (RN 1) saw Resident 97 on 7/25/2025 was around 12:00 p.m., when Resident 97 was observed walking near the nurses’ station by the intravenous (IV – within a vein) cart. During an interview on 7/30/2025 at 3:00 p.m., with CNA 2, CNA 2 stated that upon starting her shift (3:00 p.m. to 11:00 p.m.), she (CNA 2) receives verbal hand off from the previous CNA 2 at the nurses’ station. CNA 2 stated that the hand off includes information about residents who are out on pass or have appointments. CNA 2 stated that she worked on 7/25/2025 at 3:00 p.m. CNA 2 further stated that during her (CNA 2) initial rounds, she (CNA 2) did not see Resident 97. CNA 2 stated that not seeing Resident 97 at that time did not raise concern, as Resident 97 frequently walks around and attends activities. CNA 2 stated that on 7/25/2025 at around 5:00 p.m., during dinner time, she (CNA 2) informed RN 2 that she (CNA 2) was unable to locate Resident 97. CNA 2 stated facility staff then conducted a search for Resident 97 inside the facility approximately 30 minutes but were unable to locate Resident 97. CNA 2 stated that facility staff searched for Resident 97 outside the facility, both on foot and by car, for approximately one hour. CNA 2 stated she (CNA 2) was not aware that Resident 97 was an elopement risk. During an interview on 7/30/2025 at 4:18 p.m., with RN 2, RN 2 stated Resident 97 is alert and oriented to self with confusion and walks around the facility without assistive devices (tools, products, or equipment that can help an individual perform tasks and activities). RN 2 stated that Resident 97 had been crying and pointing at the door since the previous week, because he (Resident 97) wanted to go home. RN 2 stated he (RN 2) worked the 3 p.m. to 11 p.m. shift on 7/25/2025. RN 2 stated that during the hand off process, RNs begin by doing rounds, which involve standing outside residents’ rooms rather than entering. RN 2 stated that the hand off report includes any COC. RN 2 stated that during the 7/25/2025 report, RN 1 did not report any concerns regarding Resident 97. RN 2 stated that between 5 p.m. to 5:20 p.m., while CNAs were distributing dinner trays, CNA 2 informed RN 2 that she (CNA 2) had not seen Resident 97. RN 2 stated the facility staff conducted a search, and at 5:30 p.m., a “Code Green” was called to indicate a missing resident. RN 2 stated that he (RN 2) helped search the facility for approximately 20 minutes, then went outside around 6:00 p.m. to continue the search for about an hour. RN 2 stated he (RN 2) called the DON at approximately 6:30 p.m. to inform the DON that Resident 97 was missing. RN 2 also stated that another staff member contacted the local law enforcement (LLE). RN 2 stated that Resident 97 was not identified as an elopement risk, had never previously attempted to exit the facility, and that he (RN 2) was unaware Resident 97 had eloped back in 1/29/2025. During an interview on 7/31/2025 at 8:34 a.m., with CNA 1, CNA 1 stated that Resident 97 had never previously attempted to leave the facility. CNA 1 stated that she (CNA 1) was not aware that Resident 97 had eloped on 1/29/2025. CNA 1 stated Resident 97 would often point toward the outside, and when CNA 1 asked if he (Resident 97) wanted to go with his (Resident 97) sister, Resident 97 would nod “yes”. CNA 1 stated that Resident 97 had attempted to open the lobby door, but was unable to open it, and that the activity personnel would catch him and redirect him at those times. CNA 1 stated that CNAs do not provide hand off reports to each other because the nurses on the oncoming shift inform the CNAs about any important updates regarding the residents. CNA 1 stated CNAs receive a generalized report at the nurses’ station rather than individualized information about each resident. CNA 1 stated that on 7/25/2025, she (CNA 1) did not remove the cover from Resident 97’s meal tray and assumed Resident 97 was in the bathroom at the time. CNA 1 stated that she did not supervise Resident 97 during lunch on that day (7/25/2025) and was unaware that Resident 97 had an order requiring supervision during meals. CNA 1 stated she usually documents breakfast intake around 11:00 a.m. and lunch intake at 2:00 p.m. CNA 1 stated that on 7/25/2025 she (CNA 1) documented Resident 97’s lunch intake at 12:07 p.m. because she had time and wanted to complete her documentation early. CNA 1 stated Resident 97 did not finish lunch, but she (CNA 1) had not visually checked Resident 97’s meal tray at 12:07 p.m. CNA 1 stated that because she (CNA 1) did not visually check the meal tray, she (CNA 1) did not catch that Resident 97 was missing. CNA 1 stated because she was not aware of the required supervision order during meals, she was unable to provide the necessary supervision for Resident 97. CNA 1 further stated that if she had been supervising Resident 97 during lunch, Resident 97 would not have been able to leave the facility. During an interview on 7/31/2025 at 10:10 a.m., with Family Member (FM) 1, FM 1 stated that she visited GACH 1 on 7/29/2025 to see Resident 97. FM 1 stated that Resident 97 was traumatized, became emotional and restless, and was hysterical and crying for approximately 10 minutes. FM 1 stated that Resident 97 had a “bump” on his forehead and believed Resident 97 must have fallen. FM 1 stated that someone found Resident 97 on the floor and called 911. During a concurrent interview and record review on 7/31/2025 at 12:19 p.m., with the DON, Resident 97’s care plan for elopement, initiated on 1/29/2025 and Physician’s Orders dated 5/19/2025 were reviewed. The DON stated that Resident 97 eloped on 7/25/2025. The DON stated staff became aware of Resident 97’s elopement on 7/25/2025 at around 5:00 p.m., she (DON) was informed around 6:00 p.m., and LLE was notified around 6:30 p.m. The DON stated Resident 97 was identified as an elopement risk and had a previous elopement incident on 1/29/2025, during which Resident 97 attempted to cross the street in front of the facility. The DON stated that the interventions for residents at risk for elopement included: visual checks, distraction techniques, contacting family members for support, psychiatric evaluations (a comprehensive assessment of an individual's mental health, conducted by a mental health professional to identify potential mental health disorders, determine the severity of symptoms, and develop appropriate treatment plans) if indicated and monitoring prescribed medications. The DON stated that the most critical intervention is direct visualization of the resident. The DON further stated that the elopement care plan initiated for Resident 97 on 1/29/2025 was not person-centered and did not include specific interventions tailored to Resident 97’s needs, such as visual checks and supervision. The DON stated that the care plan should be individualized, especially given the potential for re-elopement and the associated risk of harm. The DON further stated that Resident 97 was at risk for aspiration and required supervision while eating. The DON stated that if staff (CNA 1) had not simply left the meal tray on 7/25/2025 during lunchtime and had supervised Resident 97, CNA 1 would have noticed Resident 97 was missing at that time. The DON stated that Resident 97 had an order for Falling Star Program, which requires visualization of the resident at the end of each shift. The DON stated that if LVN 1 had completed the Falling Star visualization at 3:00 p.m., LVN 1 would have noticed the resident was missing. The DON stated that LVN 1 did not perform the required visual check on 7/25/2025 at 3:00 p.m., which contributed to a delay in identifying that Resident 97 was missing. The DON further stated that LVN 1 used the BP reading taken at 8:00 a.m. to document the 12:00 p.m. BP check rather than taking a new BP reading as ordered. The DON stated that if LVN 1 had taken Resident 97’s BP as scheduled at 12:00 p.m., LVN 1 would have discovered Resident 97 was missing at that time, allowing for an earlier response. The DON stated that the hand off report during shift change is conducted from RN to RN, and that the oncoming RN is expected to physically enter each resident’s room to visually check on the residents. The DON stated that RN 1 was assigned as Resident 97’s nurse during the 7:00 a.m. to 3:00 p.m. shift, while RN 2 was assigned to the medication cart for medication pass (the process of administering medications to residents in a facility, ensuring each dose is given correctly and safely). The DON stated no formal hand off report was given to RN 2 regarding Resident 97. The DON stated that CNAs do not conduct formal hand off reports. Instead, any special endorsements or important information are communicated to the licensed nurses, who are then responsible for endorsing the information to the oncoming CNAs. The DON further stated that if staff had conducted a proper

Based on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic medication (medications that affect the mind, emotions, and behavior) and the use of chemical restraints (any drug that is used for discipline or staff convenience and not required to treat medical symptoms) for one of seven sampled resident (Residents 13) reviewed during the Accidents care area by failing to: 1. Provide ongoing re-evaluation of the need for psychotropic medication by ensuring as needed (PRN) lorazepam (a medication used to relieve symptoms of anxiety [a mental health condition that may result in restlessness, irritability, feelings of nervousness, panic, and fear]) was ordered with an end date (time at which a medication will no longer be dispensed and will be required to be re-prescribed) for Resident 13. 2. Ensure PRN lorazepam was prescribed and monitored for specific, measurable behavioral manifestation for Resident 13. 3. Provide ongoing re-evaluation of the need for psychotropic medication by failing to monitor for adverse effects (unwanted or dangerous medication-related side effects) of lorazepam for Resident 13. 4. Obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) prior to the administration of psychotropic medication for Resident 13. 5. Ensure the antipsychotic medication risperidone (a medication used to treat mental illness) was not used without a clear indication or diagnosis documented in the resident's clinical record for one of five residents sampled for unnecessary medications (Resident 15.) These deficient practices had the potential to result in an increased risk that Residents 13 and 15 could experience adverse effects related to psychotropic medication therapy, such as drowsiness, dizziness, constipation, or increased risk of fall, possibly leading to impairment or decline in their mental or physical condition or functional or psychosocial status. Findings: 1. During a review of Resident 13’s admission Record (AR), the AR indicated the facility admitted the resident on 6/25/2025 with diagnoses that included traumatic subarachnoid hemorrhage (bleeding in the area between the brain and the thin tissues that cover and protect it) with loss of consciousness (a state in which an individual lacks normal awareness of self and the surrounding environment), lack of coordination, muscle weakness, gastrostomy (GT - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), depression (persistent feelings of sadness and loss of interest that can interfere with daily living), and anxiety disorder. During a review of Resident 13’s History and Physical (H&P), dated 6/27/2025, the H&P indicated the resident could not make their own decisions but was able to make needs known. During a review of Resident 13’s Minimum Data Set (MDS – resident assessment tool) dated 7/2/2025, the MDS indicated the resident was sometimes able to understand others and was sometimes able to make themself understood. The MDS further indicated that the resident was dependent on staff for toileting, bathing, and lower body dressing; and required substantial/maximal assistance for upper body dressing, personal hygiene, and transferring from the bed to chair. The MDS indicated that the resident was administered the following high-risk medications (drugs that can cause significant patient harm if used incorrectly): antianxiety. During a review of Resident 13’s Order Summary Report, the Order Summary Report indicated the following physician’s orders: -Administer Lorazepam oral tablet five mg, one tablet via GT every 12 hours PRN for anxiety, dated 6/25/2025 and discontinue on 7/29/2025. -Administer Lorazepam oral tablet five mg, one tablet by mouth every 12 hours PRN for anxiety, dated 7/29/2025. -Monitor episodes of anxiety manifested by inability to relax and tally by hashmarks for lorazepam use, every shift, dated 7/7/2025. - Monitor for potential side effects for anti-anxiety lorazepam: Sedation, drowsiness, morning hangover, ataxia, every shift, dated 7/7/2025. 1.a. During a concurrent interview and record review on 7/31/2025 at 8:32 a.m., with Minimum Data Set Nurse (MDSN) 1, MDSN 1 reviewed Resident 13’s physician orders and medication administration record (MAR- a record of all medications taken by a resident on a day-to-day basis) for 6/2025 and 7/2025. MDSN 1 stated psychotropic medications are high-risk medications that alter a resident’s mental status and can cause adverse effects resulting in resident falls. MDSN 1 stated medicating a resident for behavior issues should be a last resort and other methods should first be attempted. MDSN 1 stated that all PRN psychotropic medications should be ordered with a stop date when the physician then evaluates and determines if the resident still needs the medication. MDSN 1 stated Resident 13’s lorazepam order did not have a stop date and was ordered to continue indefinitely. MDSN 1 stated Resident 13 had been administered PRN lorazepam for over a month without a stop date. During a concurrent interview and record review on 7/31/2025 at 8:53 a.m., with Registered Nurse (RN) 3, RN 3 reviewed Resident 13’s physician orders and MAR for 6/2025 and 7/2025. RN 3 stated psychotropic medications have side effects like increased confusion and increased risk for falls leading to injury. RN 3 stated the goal is to try to wean a resident off psychotropic medication because of the risk for side effects. RN 3 stated the benefits of psychotropic medication should outweigh the risks of taking the medication. RN 3 stated psychotropic medication administered PRN is ordered with a 14 day stop date. RN 3 stated PRN psychotropic medication will only be reordered after the physician re-evaluates the resident to determine if the behaviors continue and the resident has a need for the medication. RN 3 stated if a resident’s behavior is resolved, then the medication should not be reordered to prevent the medication from being administered unnecessarily. RN 3 further stated Resident 13 was not appropriately administered PRN lorazepam because there was no stop date for the order. RN 3 stated when psychotropic medication was not appropriately administered to Resident 13 there was the potential that the resident may be unnecessarily chemically restrained to control the resident behavior, without attempts to try alternative methods. RN 3 stated the unnecessary administration of lorazepam may potentially result in physical side effects leading to falls or psychosocial issues leading to the resident not participating in in activities of daily living. During a concurrent interview and record review on 8/1/2025 at 2:05 p.m. with the Assistant Director of Nursing (ADON), the ADON reviewed the facility policy and procedures regarding psychotropic medication. The ADON stated psychotropic medications affect how the resident’s brain works and can cause major side effects. The ADON stated the facility process for psychotropic medication is for the physician to obtain informed consent from the resident or resident representative, obtain an order that indicates specific behaviors to administer and monitor for, ensure PRN psychotropics are ordered for a specified time, and monitor the resident for side effects of the medication. The ADON stated it was important to follow the facility process to minimize the duration of administration of psychotropic medications due to side effects potentially resulting in tremors, sedation, drowsiness, and possible falls in residents. The ADON stated the facility P&P was not followed when Resident 13 was administered PRN lorazepam without an end date. 1.b. During a concurrent interview and record review on 7/31/2025 at 8:53 a.m., with RN 3, RN 3 reviewed Resident 13’s physician orders and MAR for 6/2025 and 7/2025. RN 3 stated psychotropic medications have side effects like increased confusion and increased risk for falls leading to injury. RN 3 stated the goal is to try to wean a resident off psychotropic medication because of the risk for side effects. RN 3 stated the benefits of psychotropic medication should outweigh the risks of taking the medication. RN 3 stated PRN psychotropic medications should be ordered and monitored for specific measurable behaviors to determine when to administer the medication. RN 3 reviewed Resident 13’s PRN lorazepam orders and noted the following: -From 6/25/2025 to 7/6/2025, lorazepam was ordered to be administered for anxiety. RN 3 stated anxiety is not a specific measurable behavior because anxiety manifests differently in different residents. RN 3 stated Resident 13 has restlessness and is easily agitated. RN 3 stated Resident 13’s PRN Lorazepam should have been ordered, administered, and monitored for a specific measurable behavior, but it was not. -From 7/6/2025 to 7/31/2025, lorazepam was ordered to be administered for anxiety manifested by an inability to relax. RN 3 stated the inability to relax may look different in different residents and is not a specific measurable behavior. RN 3 stated Resident 13’s PRN Lorazepam should have been ordered, administered, and monitored for a specific measurable behavior, but it was not. RN 3 further stated Resident 13 was not appropriately administered PRN lorazepam because there was no clear behavioral manifestation to determine when to administer the medication. During a concurrent interview and record review on 8/1/2025 at 2:05 p.m. with the ADON, the ADON reviewed the facility policy and procedures regarding psychotropic medication. The ADON stated psychotropic medications affect how the resident’s brain works and can cause major side effects. The ADON stated the facility process for psychotropic medication is for the physician to obtain informed consent from the resident or resident representative, obtain an order that indicates specific behaviors to administer and monitor for, ensure PRN psychotropics are ordered for a specified time, and monitor the resident for side effects of the medication. The ADON stated it was important to follow the facility process to minimize the duration of administration of psychotropic medications due to side effects potentially resulting in tremors, sedation, drowsiness, and possible falls in residents. The ADON stated the facility P&P was not followed when Resident 13 was administered PRN lorazepam without specific measurable behavioral manifestations. 1.c. During a concurrent interview and record review on 7/31/2025 at 8:53 a.m., with RN 3, RN 3 reviewed Resident 13’s physician orders and MAR for 6/2025 and 7/2025. RN 3 stated psychotropic medications have side effects like increased confusion and increased risk for falls leading to injury. RN 3 stated the goal is to try to wean a resident off psychotropic medication because of the risk for side effects. RN 3 stated the benefits of psychotropic medication should outweigh the risks of taking the medication. RN 3 stated the facility process for monitoring is psychotropic medication side effects are monitored for and documented in the Medication Administration Record. RN 3 reviewed Resident 13’s MAR and noted the following: -On 6/27/2025 at 7:20 p.m. lorazepam was administered and there was no documented evidence of monitoring for side effects. On 6/28/2025 at 10:06 a.m. lorazepam was administered and there was no documented evidence of monitoring for side effects. - On 6/28/2025 at 7:30 p.m. lorazepam was administered and there was no documented evidence of monitoring for side effects. -On 6/29/2025 at 5:39 a.m. lorazepam was administered and there was no documented evidence of monitoring for side effects. - On 6/30/2025 at 7:21 p.m. lorazepam was administered and there was no documented evidence of monitoring for side effects. - On 7/1/2025 at 5:45 a.m. lorazepam was administered and there was no documented evidence of monitoring for side effects. - On 7/3/2025 at 4:36 a.m. lorazepam was administered and there was no documented evidence of monitoring for side effects. - On 7/5/2025 at 5:08 p.m. lorazepam was administered and there was no documented evidence of monitoring for side effects. - On 7/6/2025 at 10:07 p.m. lorazepam was administered and there was no documented evidence of monitoring for side effects. During a concurrent interview and record review on 8/1/2025 at 2:05 p.m. with the ADON, the ADON reviewed the facility policy and procedures regarding psychotropic medication. The ADON stated psychotropic medications affect how the resident’s brain works and can cause major side effects. The ADON stated the facility process for psychotropic medication is for the physician to obtain informed consent from the resident or resident representative, obtain an order that indicates specific behaviors to administer and monitor for, ensure PRN psychotropics are ordered for a specified time, and monitor the resident for side effects of the medication. The ADON stated it was important to follow the facility process to minimize the duration of administration of psychotropic medications due to side effects potentially resulting in tremors, sedation, drowsiness, and possible falls in residents. The ADON stated the facility P&P was not followed when Resident 13 was administered PRN lorazepam without monitoring for side effects. 1.d. During a concurrent interview and record review on 7/31/2025 at 8:53 a.m., with RN 3, RN 3 reviewed Resident 13’s physician orders and Informed Consent form dated 7/7/2025. RN 3 stated psychotropic medications have side effects like increased confusion and increased risk for falls leading to injury. RN 3 stated the benefits of psychotropic medication should outweigh the risks of taking the medication. RN 3 stated prior to administering psychotropic medication, the physician must obtain written informed consent from the resident or resident representative after explaining the risk and benefits and side effects of the medication. RN 3 stated Resident 13’s written informed consent form for PRN lorazepam did not indicate who was informed of the risks and benefits of the medication and provided informed consent, and when informed consent was obtained. RN 3 stated all the nurses that administered PRN lorazepam to Resident 13 were responsible for ensuring that informed consent was obtained prior to the administration of the medication, but that was not done. RN 3 further stated Resident 13 was not appropriately administered PRN lorazepam because there was no documented evidence of who provided consent for the psychotropic medication to be administered. RN 3 stated when psychotropic medication was not appropriately administered to Resident 13 there was the potential that the resident may be unnecessarily chemically restrained to control the resident behavior without family consent or attempts to try alternative methods. RN 3 stated the unnecessary administration of lorazepam may potentially result in physical side effects leading to falls or psychosocial issues leading to the residents not participating in activities of daily living. During a concurrent interview and record review on 8/1/2025 at 2:05 p.m. with the ADON, the ADON reviewed the facility policy and procedures regarding psychotropic medication. The ADON stated psychotropic medications affect how the resident’s brain works and can cause major side effects. The ADON stated the facility process for psychotropic medication is for the physician to obtain informed consent from the resident or resident representative, obtain an order that indicates specific behaviors to administer and monitor for, ensure PRN psychotropics are ordered for a specified time, and monitor the resident for side effects of the medication. The ADON stated the facility P&P was not followed when Resident 13 was administered PRN lorazepam without documented evidence of who gave informed consent. The ADON stated if the resident or family is not aware that psychotropic medication is administered to the resident then it could result be considered an unnecessary chemical restraint because the resident is potentially being sedated without their knowledge. The ADON stated chemically restraining a resident can affect the resident physically and emotionally causing a dignity issue. 2. A review of Resident 15’s AR, dated 7/31/25, indicated she was admitted to the facility on [DATE] with diagnoses including dementia (the loss of cognitive function, including memory, thinking, and reasoning, that interferes with daily life) and alcohol abuse. Further review of Resident 15’s admission Record indicated her brother was listed as her representative party (RP - a person delegated to make medical decisions for the resident in the event they are unable to do so.) A review of Resident 15’s History and Physical (H&P – a record of a comprehensive physician’s assessment), dated 11/9/24, indicated Resident 15 likely has Wernicke-Korsakoff Syndrome (WKS – a medical condition causing confusion, disorientation, seeing and hearing things that are not there, and memory loss caused by a vitamin deficiency and usually associated with a history of alcohol abuse) and had “fluctuating capacity” to understand and make medical decisions. Further review of Resident 15’s H&P indicated she had “psychosis” (a mental condition characterized by a disconnection from reality in which someone may believe things that are untrue or see or hear things that are not there) and to follow up with psychiatry, but did not indicate any significant history of schizophrenia (a mental illness characterized by seeing or hearing things that are not there.) A review of the psychiatry progress note (a record of a psychiatrist’s evaluation), dated 11/24/24, indicated Resident 15 had a “history of paranoid schizophrenia” and was “on risperidone.” Further review of the psychiatry note indicated there was no discussion of how it was determined that Resident 15 had a history of schizophrenia, how Resident 15 met the Diagnostic and Statistic Manual of Mental Disorders (DSM-5 – an objective tool used as a clinical guideline to diagnose mental illness) criteria for schizophrenia or how WKS or other medical conditions were ruled out as the cause of her psychotic symptoms. A review of the psychiatry progress note, dated 3/6/25, indicated the “diagnosis of schizophrenia is questionable” due to “denied hallucinations.” A review of Resident 15’s MDS, dated [DATE], Section I (active diagnoses) did not include schizophrenia as an active diagnosis. A review of Resident 15’s available care plans, last reviewed 5/27/25, indicated there were no care plans that referenced a diagnosis of schizophrenia for which risperidone was listed as a targeted intervention. A review of Resident 15’s Physician Order Summary (a monthly summary of all active physician orders), dated 7/31/25, indicated Resident 15 was prescribed risperidone 0.25 milligrams (mg – a unit of measure for mass) by mouth two times a day for “Schizophrenia manifested by extreme paranoid thoughts causing fear and stress.” During a telephone interview on 7/31/2025 at 10:09 a.m. with Resident 15’s brother (FM 3), FM 3 stated he is not aware of Resident 15 having a history of schizophrenia prior to her admission to this facility. FM 3 stated her primary diagnosis is WKS and to his knowledge, she only started having psychosis-related behaviors (such as paranoid beliefs) since her initial diagnosis with WKS in November 2024. During a concurrent observation and interview on 7/31/2025 at 10:23 a.m. of Resident 15, Resident 15 was observed lying in her bed using her cellular phone. Resident 15 was observed to be alert and oriented and able to respond to questions. Resident 15 adamantly stated she does not have schizophrenia and does not have a history of schizophrenia. Resident 15 stated no one from the facility has discussed a diagnosis of schizophrenia or medication related to treatment of schizophrenia with her. During an interview on 7/31/2025 at 11:15 a.m. with the Director of Nursing (DON), the DON stated antipsychotic medications must have a clear indication for use which is diagnosed and documented in the resident’s clinical record. The DON stated Resident 15’s clinical record including diagnosis list, care plans, and MDS assessments do not contain a record of a diagnosis of schizophrenia. The DON stated the psychiatric progress note from 11/24/24 referenced a history of schizophrenia, but Resident 15's record contains no other documentation of a diagnosis or history of schizophrenia. The DON stated the psychiatric progress note on 3/6/25 appears to cast doubt on the validity of the diagnosis of schizophrenia. The DON stated that without a clear, confirmed diagnosis of schizophrenia, the use of risperidone may be questionable and would need to be reevaluated. The DON stated using antipsychotic medications without a clear indication may increase the risk that Resident 15 may experience adverse effects of risperidone including movement disorders, drowsiness, dizziness, actual falls, or dry mouth which could lead to a decline in her quality of life. During a review of the facility P&P titled, “Psychotropic Medication Use,” last reviewed on 4/24/2025, the P&P indicated a psychotropic drug is any medication that affects brain activities associated with mental processes and behavior, which includes anxiolytics. The facility should not use psychotropic medications to address behaviors without first determining if there is a medical, physical, functional, psychological, social or environmental cause of the resident's behaviors. Facility staff should take a holistic approach to behavior management that involves a thorough assessment of underlying causes of behaviors and individualized person-centered non-drug and pharmaceutical interventions. Psychotropic medications may be used to address behaviors only if non-drug approaches and interventions were attempted prior to their use. Psychotropic medications to treat behaviors will be used appropriately to address specific underlying medical or psychiatric causes of behavioral symptoms. PRN orders for psychotropic drugs are limited to 14 days. For psychotropic PRN medications, if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. A review of the facility’s policy “Psychotropic Medication Use,” revised March 2023, indicated “Residents who have not used psychotropic medications are not prescribed or given these medications unless the medication is determined to be necessary to treat a specific condition that is diagnosed and documented in the medical record…” A review of the facility’s policy “Antipsychotic Medication Use, revised March 2023, indicated “Residents who are admitted from the community or transferred from a hospital and who are already receiving antipsychotic medications will be evaluated for the appropriateness and indications for use… Diagnosis of a specific condition for which antipsychotic medication are necessary to treat will be based on a comprehensive assessment of the resident… Resident diagnosis is based on a comprehensive assessment and evidence-based criteria and is consistent with professional standards, such as the Diagnostic and Statistical Manual of Mental Disorders (current edition.)…” During a review of the facility P&P titled, “Psychotropic Medication Use,” last reviewed 4/24/2025, the P&P indicated the facility should not use psychotropic medications to address behaviors without first determining if there is a medical, physical, functional, psychological, social or environmental cause of the resident's behaviors. Psychotropic medications to treat behaviors will be used appropriately to address specific underlying medical or psychiatric causes of behavioral symptoms. Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. All medications used to treat behaviors must have a clinical indication and be used in the lowest possible dose to achieve the desired therapeutic effect. All residents receiving medications used to treat behaviors should be monitored for: a. Efficacy b. Risks c. Benefits d. Harm or adverse consequences. Facility staff should monitor resident's behavior pursuant to Facility policy using a behavioral monitoring chart or behavioral assessment record for residents receiving psychotropic medication. Facility staff should monitor behavioral triggers, episodes, and symptoms. Facility staff should document the number and/or intensity of symptoms. During a review of the facility P&P titled, “Psychotropic Medication Use,” last reviewed 4/24/2025, the P&P indicated the facility should not use psychotropic medications to address behaviors without first determining if there is a medical, physical, functional, psychological, social or environmental cause of the resident's behaviors. It is the responsibility of the attending health care practitioner to inform the resident and/or resident representative of the initiation, reason for use, and the risks associated with the use of psychotropic medications, per facility policy or applicable state regulation. The informed consent will be obtained by the Prescriber prior to initiation of the psychotropic medication. The Facility shall verify informed consent prior to the administration of a psychotropic.

Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for one of seven sampled residents (Resident 10, 44, ) reviewed during the Physical Restraints care area by failing to: 1. Ensure side rails (SR, adjustable rigid bars attached to the bed that may be positioned in various locations; upper or lower, either or both sides) were not placed in the raised (up) position on bilateral upper (area including the arms and head) and lower sides (area including the legs) without assessing for the need, assessing for safety, and obtaining informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) prior to use for Resident 10. 2. Ensure two pillows and a folded blanket were not placed under the resident's fitted sheet while Resident 44 was lying in bed. 3. Ensure an entrapment risk assessment was completed on 2/2025 for the use of bilateral half upper SR for Resident 102. 4. Ensure an entrapment risk assessment was completed on 11/26/2024, 2/2025, 5/27/2025, and 7/26/2025 for the use of lower SR up for preference or family request for Resident 102. 5. Ensure a quarterly restraint assessment was completed on 5/2025 for the use of lower SR for Resident 102. 6. Ensure Residents 5 and Resident 103's tab alarm (a type of personal alarm used in healthcare settings, particularly in long-term care facilities and hospitals, to monitor patient movement and help prevent falls) was assessed initially and quarterly for safety of use. These deficient practices had the potential to result in the restriction of residents' freedom of movement, a decline in physical functioning, psychosocial harm, physical harm from entrapment (a state in which a person is trapped by the bed rail in a position that they cannot move from), and death of residents. Cross reference F700 Findings: a. During a review of Resident 10’s admission Record, the AR indicated the facility admitted the resident on 12/7/2024 and most recently admitted the resident on 12/23/2024 with diagnoses that included nontraumatic intracerebral hemorrhage (a type of stroke caused by bleeding in the brain), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (partial paralysis or weakness on one side of the body) affecting the left non-dominant side, and need for assistance with personal care. During a review of Resident 10’s Care Plan (CP) titled, “Resident is on: lower bed, floor mat, and bilateral half upper SRs up and locked,” initiated 12/17/2024, the CP indicated a goal to prevent or reduce incidents of injury / fall as well as for comfort of getting in and out of bed. The CP indicated interventions including attempts to use the least restrictive devices on an ongoing basis. During a review of Resident 10’s History and Physical (H&P), dated 12/24/2024, the H&P indicated the resident was able to understand and make decisions. The H&P further indicated the resident was able to move both the lower extremities and was able to move the right upper extremity. During a review of Resident 10’s Order Summary Report, the Order Summary Report indicated a physician’s order for the following: - [non-restraint] bilateral upper half side rails up and locked when in bed for safety, balance, activities of daily living, positioning, and as an enabler. Informed consent obtained from resident / responsible party after explanation of risk and benefits, and verified by medical doctor, dated 5/29/2025. During a review of Resident 10’s Minimum Data Set (MDS – resident assessment tool), dated 6/16/2025, the MDS indicated the resident was sometimes able to understand others and was sometimes able to be understood. The MDS further indicated the resident was totally dependent on staff for dressing, bathing, toileting, and personal hygiene. During a review of Resident 10’s SR Entrapment Assessment, dated 6/23/2025, the SR Entrapment Assessment indicated a recommendation for bilateral half upper SRs. During an observation on 7/29/2025 at 3:45 p.m. Resident 10 was observed lying in bed with the bilateral lower and bilateral upper SRs in the raised position. During a concurrent observation and interview on 7/30/2025 at 10:07 a.m., with Resident 10 and Restorative Nurse Aide (RNA) 1, Resident 10 was lying in bed with all four SRs in the raised position. RNA 1 walked to Resident 10’s bedside. RNA 1 stated Resident 10 had all four SRs in the raised position and RNA 1 did not know why all the SRs were up. During an interview on 7/30/2025 at 10:15 a.m. with Certified Nursing Assistant (CNA) 9, CNA 9 stated CNA 9 was assigned to care for Resident 10. CNA 9 stated CNA 9 did not put Resident 10’s bilateral lower SRs in the raise position because that would be considered a restraint. CNA 9 stated CNA 9 did not know who placed all four of Resident 10’s SRs up. During a concurrent interview and record review on 7/31/2025 at 10:27 a.m. with Registered Nurse (RN) 3, RN 3 reviewed Resident 10’s physician orders, SR Entrapment assessment dated [DATE], and Informed Consents. RN 3 stated the facility uses hospital beds that have bilateral lower and upper SRs attached to the bed. RN 3 stated sometimes the CNAs just put all four SRs up just because the SRs are there. RN 3 stated Resident 10 had an assessment and an order for only two upper SRs. RN 3 stated Resident 10 should not have all four SRs in the raised position because there was no need for all four SRs, there was no assessment for the safety of the bilateral lower SRs, no physician’s order for the use of bilateral lower SRs, and no informed consent for bilateral SRs. RN 3 stated the use of four SRs is considered a restraint because Resident 10 would not be able to lower the SRs and the SRs may prevent the resident from moving freely. RN 3 stated Resident 10 is able to move the legs and there was a potential for entrapment if the resident got caught between the bed and the lower SRs. RN 3 stated when a resident becomes caught it may result in an injury or even death of the resident if they are not found in time. RN 3 stated using the use of four SRs may also result in the resident feeling confined to the bed resulting in psychosocial issues. During a concurrent interview and record review on 8/1/2025 at 2:05 p.m. with the Assistant Director of Nursing (ADON), the ADON reviewed the facility P&P regarding SRs and Restraints. The ADON stated that when SRs are used, informed consent is obtained, and an initial safety assessment is completed to ensure entrapment and falls are prevented. The ADON stated in general residents may use bilateral upper sides rails for safety and repositioning. The ADON stated when all four SRs are up a resident is not able to remove the SRs and it confines the resident to one specific area and is considered a restraint. The ADON stated Resident 10 should not have had all four SRs raised and it was every staff member’s responsibility to ensure the lower SRs were not up. The ADON stated when Resident 10 had all four SRs in use, there was the potential to result in complications like injury to the resident if the resident tried to get over the SR to get out of the bed or psychosocial effects causing stress to the resident when they could not move out of the bed. b. During a review of Resident 44’s admission Record, the admission Record indicated the facility originally admitted the resident on 4/12/2019 and readmitted on [DATE] with diagnoses including encephalopathy (a broad term describing any disorder or disease that affects the brain's structure or function, leading to impaired brain function), epilepsy (a condition that affects the brain and causes frequent seizures [sudden, uncontrolled body movements and changes in behavior that occurs because of abnormal electrical activity in the brain]), contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of muscle on right upper arm, right lower leg, left lower leg, and left upper arm. During a review of Resident 44’s CP Report titled at risk for falls/injury, dated 2/21/2023 and revised on 3/13/2025, the CP Report indicated a goal to reduce risks of falls and injury, which included interventions such as low bed with one left sided mattress against the wall when in bed, right side mattress on the floor next to the bed as landing mat to minimize risks of injury of fall. During a review of Resident 44’s MDS, dated [DATE], the MDS indicated the resident had adequate hearing, no speech, was rarely/never makes self-understood and rarely/never had the ability to understand others. The MDS indicated the resident had impairment on both upper and lower extremities that interfered with daily functions or placed the resident at risk of injury. The MDS indicated the resident was dependent on staff for mobility which included rolling left and right, sitting to lying, lying to sitting on side of the bed, and chair/bed-to-chair transfer. During an observation on 7/29/2025 at 9:32 a.m., while at Resident 44’s bedside, Resident 44 was lying in bed and the following was observed: - Two pillows and a folded blanket tucked under the resident’s fitted sheet by the resident’s right hip and right leg. - Bed placed against the wall with mattress in between, mattress on the floor at the right side of bed, and a mattress at the head of bed, and right-side rail up with padding. - unknown number of pillows under the mattress the resident was lying on. During a concurrent observation and interview on 7/29/2025 at 9:42 a.m. with the Assistant Director of Staff Development (ADSD), while at Resident 44’s bedside, the ADSD stated a total of six pillows were under the mattress of the resident and one pillow was underneath the fitted sheath. There was one pillow and a folded blanket on the floor on the right side of the resident’s bed. The ADSD stated she does not know why the pillow and blanket were on the floor. The ADSD stated the resident has a behavior of kicking. During a concurrent interview and record review on 7/29/2025 at 9:45 a.m. with the ADSD, Resident 44’s Physician Orders were reviewed. The ADSD stated there was no order for the use of pillows under the fitted sheet. The ADSD stated there should be an order and care plan for the use of pillows under the fitted sheet. The ADSD stated if there is no order then they are not following the order. The ADSD stated that when the use of pillow underneath the fitted sheet has not been care planned the resident may get stuck between the bed and the mattress. During an interview on 8/1/2025 at 3:13 p.m. with the ADON, the ADON stated when pillows are placed under the fitted sheet this is considered as a restraint. The ADON stated the resident could climb over it and could cause an injury and the psychosocial effects could cause stress to the residents when they cannot move out of bed. The ADON stated placing pillows under the fitted sheet is not an intervention here at the facility. c. During a review of Resident 102’s AR, the AR indicated the facility admitted the resident on 5/14/2024 with diagnoses including tracheostomy (a surgical opening in the neck into the windpipe when a person is unable to breathe thru the nose or mouth), lack of coordination, and gastrostomy (GT - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 102’s restraint assessment dated [DATE] and 2/26/2025, the restraint assessment indicated the use of lower SR for preference or family request as a precautionary measure and poor trunk control to decrease potential injuries. During a review of Resident 102’s H&P, dated 5/14/2025, the H&P indicated Resident 102 was incapacitated (refers to a state in which an individual was unable to make sound decisions or manage their affairs). During a review of Resident 102’s entrapment (when a resident gets trapped in the spaces in between or around the bed rails, mattress, or bed frame) risk assessment dated [DATE] and 5/27/2025, the entrapment risk assessment indicated a recommendation for the use of bilateral half upper SR due to generalized muscle weakness, poor trunk control, involuntary movement, and poor trunk control. During a review of Resident 102’s MDS, dated [DATE], the MDS indicated Resident 102 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and was unable to understand and make his needs known. The MDS further indicated Resident 102 required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 102’s CP on use of lower SR up per family preference or request initiated on 7/29/2025 and the CP on use of bilateral half upper SR up and locked when in bed initiated on 6/6/2024, the CP indicated to attempt to use less restrictive devices on an ongoing basis as one of the interventions to prevent or reduce incidence of injury or fall. During a review of Resident 102’s Order Summary Report dated 8/1/2025, the Order Summary Report indicated the following physician’s orders: -10/8/2024 and last revised on 7/29/2025: may put lower SR up for preference or family request. Informed consent obtained from the responsible party (RP) by the physician (MD) after explanation of risks and benefits. -5/18/2024 and last revised on 7/30/2025: bilateral upper half SR up and locked when in bed secondary to involuntary movement by gravity due to elevated head of bed. During a concurrent observation and interview on 7/29/2025 at 11:53 a.m. while inside Resident 102’s room with Registered Nurse (RN) 7, RN 7 stated Resident 102’s both upper and lower SR were up. RN 7 stated that from her knowledge, Resident 102 is not supposed to have both upper and lower SR up. RN 7 stated that usually the CNAs put all 4 SR up while providing care for resident safety when turning but they must put down the lower SR after providing care. RN 7 stated Resident 102’s bilateral lower SR should have been lowered down as it was restricting the resident’s freedom of movement and can be considered a restraint. Resident 102 can get trapped in between the SR and get injured. During a concurrent interview and record review on 7/31/2025 at 2:30 p.m., Resident 102’s physician orders, entrapment risk assessments, and restraint assessments were reviewed with Registered Nurse (RN) 3. RN 3 stated Resident 102 had a physician’s order for bilateral half upper SR and locked while in bed dated 5/18/2024 and was revised 7/30/2025 and may put lower SR up for preference or family request dated 10/8/2024 and was revised 7/26/2025. RN 3 stated the entrapment risk assessments for the use of bilateral half upper SR dated 2/2025 and the entrapment risk assessment for the use of lower SR up for preference or family request for 11/26/2024, 2/27/2025, 5/27/2025, and 7/26/2025 were not completed. RN 3 stated the quarterly restraint assessment was not completed for 5/2025 for the use of bilateral upper and lower SR. RN 3 stated entrapment risk assessments and restraint assessments are completed during admission, quarterly or as needed. RN 3 stated entrapment risk assessment are completed to ensure resident safety with the use of SR when in bed. RN 3 stated Resident 102’s entrapment risk assessments should have been completed for the use of both bilateral half upper for 2/2025 and the use of lower SR up for 11/26/2024, 2/2025, 5/27/2025, and 7/26/2025 to ensure that the use of SR was appropriate and Resident 102 was not at risk of getting trapped in between the SR and the bed mattress/frame which could to injuries. RN 3 stated Resident 102’s quarterly restraint assessment for the use of bilateral half upper and lower SR up should have been completed for 5/2025 to ensure the use of both upper and lower SR were still needed and the resident still meets the criteria for the use of all SR up while in bed as the use of all SR up was restricting Resident 102’s freedom of movement and is considered a restraint. During a concurrent interview and record review on 7/31/2025 at 4:15 p.m., Resident 102’s physician orders, entrapment risk assessments, and restraint assessments were reviewed with the Director of Nursing (DON). The DON stated Resident 102 had a physician’s order for bilateral half upper SR and locked while in bed dated 5/18/2024 and was revised on 7/30/2025 and may put lower SR up for preference or family request dated 10/8/2024 and was revised on 7/26/2025. The DON stated the entrapment risk assessments for the use of bilateral half upper SR dated 2/2025 and the entrapment risk assessment for the use of lower SR up for preference or family request for 11/26/2024, 2/27/2025, 5/27/2025, and 7/26/2025 were not completed. The DON stated the quarterly restraint assessment was not completed on 5/2025 for the use of bilateral upper and lower SR. The DON stated entrapment risk assessments and restraint assessments are completed during admission by the admitting nurse if using bilateral half upper and/or lower SR up, then quarterly and as needed together with the MDS assessments. The DON stated entrapment risk assessments are completed quarterly to ensure the continued use of the side rails is still safe for the residents when in bed. The DON stated Resident 102’s entrapment risk assessments should have been completed for the use of both bilateral half upper for 2/2025 and the use of lower SR up for 11/26/2024, 2/2025, 5/27/2025, and 7/26/2025 to ensure that the use of SR was appropriate and Resident 102 was not at risk of getting trapped in between the SR and the bed mattress/frame which could to injuries and/or hospitalization. RN 3 stated Resident 102’s quarterly restraint assessment for the use of bilateral half upper and lower SR up should have been completed for 5/2025 to ensure the use of both upper and lower SR were still a necessity and the resident still meets the criteria for the use of all SR up while in bed as the use of all SR up was restricting Resident 102’s freedom of movement and can be considered a restraint. d. During a review of Resident 5’s AR, the AR indicated the facility admitted the resident on 12/31/2024, and readmitted the resident on 3/27/2025, with diagnoses including cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), difficulty in walking, and muscle weakness. During a review of Resident 5’s MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had severe cognitive impairment (a significant decline in a person's ability to think, learn, remember, and make decisions). The MDS indicated the resident was dependent on needing substantial assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). The MDS indicated that the resident had a bed alarm (a pad with sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff). During a review of Resident 5’s Fall Risk Evaluation, dated 7/10/2025, the Fall Risk Evaluation indicated the resident was moderate risk for falls. During a review of Resident 5’s Order Summary Report, dated 7/21/2025, the Order Summary Report indicated an order to apply a tab alarm when in bed and wheelchair to alert and remind the residents to ask for assistance when transferring or ambulating. Monitor for placement and functioning. (Informed consent obtained by MD from resident representative [RP] after explanation of risks and benefit and verified with MD). Every shift. During a concurrent observation and interview on 7/31/2025, at 9:41 a.m., with CNA 9, while inside Resident 5’s room, Resident 5 was in bed with a tab alarm on. CNA 9 stated the resident had a tab alarm to prevent the resident from falling. CNA 9 stated the resident was at a high risk for falls and does not ask for assistance from staff when getting out of bed. CNA 9 stated the tab alarms alert healthcare providers when the residents attempts to get out of bed. During a concurrent interview and record review on 7/31/2025, at 12:12 p.m., with Registered Nurse (RN) 3, Resident 5’s Order Summary Report, Informed Consent, Restraint Assessment, and Care Plan were reviewed. RN 3 stated the consent was not obtained prior to the use of tab alarm on the resident and the initial restraint assessment was not done. RN 3 stated it was important to obtain consent on the use of a restraint tab alarm to residents to ensure the risks and benefits were explained to the resident and/or representative. RN 3 also stated it was important to assess the restraint initially and quarterly for its safe use to prevent accidents such as the pull cord getting entangled on the resident. During an interview on 8/1/2025, at 2:05 p.m., with the ADON, the ADON stated the restraint tab alarm on Resident 5 should have been assessed for appropriateness of use by licensed staff. The ADON also stated the licensed staff should have obtained a new consent for the tab alarm as the previous consent was for a pad alarm (is placed underneath the patient, and when pressure is released from the pad, an alert is sent to caregivers via a monitor or alarm). The ADON stated restraints should have a physician’s order, an informed consent, restraint assessment, and should have a care plan on its use prior to applying the restraint tab alarm. During a review of the facility provided Tab Alarm 1 (TA) 1, copyright 2022, the information indicated TA 1 improves patient safety by alerting caregivers when a patient attempts to get out of a wheelchair or bed without assistance. WARNING: 1. Long pull cord can entangle the patient and be potentially dangerous. Use care and supervision. e. During a review of Resident 103’s AR, the AR indicated the facility admitted the resident on 10/30/2024, with diagnoses including difficulty in walking, age-related nuclear cataract (a type of cataract that develops in the center (nucleus) of the eye's lens, causing it to cloud over due to the natural aging process), and need for assistance with personal care. During a review of Resident 103’s MDS, dated [DATE], the MDS indicated the resident sometimes had the ability to make self-understood and understand others and had short-term and long-term memory loss. The MDS indicated the resident was dependent and needed supervision on mobility and ADLs. The MDS indicated the resident had a bed and chair alarm. During a review of Resident 103’s Fall Risk Evaluation, dated 5/24/2025, the Fall Risk Evaluation indicated the resident was high risk for falls. During a review of Resident 103’s Order Summary Report, dated 7/21/2025, the Order Summary Report indicated an order to apply a tab alarm when in bed and wheelchair to alert/remind resident to ask for assistance when transferring or ambulating. Monitor for placement and functioning. (Informed consent obtained by MD from RP after explanation of risks and benefits and verified with MD. Every shift. During a concurrent observation and interview on 7/31/2025, at 9:45 a.m., with CNA 9, while inside Resident 103’s room, Resident 103 was in bed with a tab alarm on. CNA 9 stated the resident had a tab alarm to prevent the resident from falls. CNA 9 stated the resident was a high risk for falls and does not ask for assistance from staff when getting out of bed. CNA 9 stated the tab alarms alert healthcare providers when the residents attempts to get out of the bed. During a concurrent interview and record review on 7/31/2025, at 12:21 p.m., with RN 3, Resident 103’s Order Summary Report, Informed Consent, Restraint Assessment, and Care Plan were reviewed. RN 3 stated the consent was not obtained prior to the use of tab alarm on the resident and the initial restraint assessment was not done. RN 3 stated it was important to obtain a consent on the use of restraint tab alarm to residents to ensure the risks and benefits were explained to the resident and/or representative. RN 3 also stated it was important to assess the restraint initially and quarterly for its safe use to prevent accidents such as the pull cord getting entangled to the resident. During an interview on 8/1/2025, at 2:05 p.m., with the ADON, the ADON stated the restraint tab alarm on Resident 103 should have been assessed for appropriateness of use by the licensed staff. The ADON also stated the licensed staff should have obtained a new consent for the tab alarm as the previous consent was for a pad alarm. The ADON stated restraints should have a physician’s order, an informed consent, restraint assessment, and should have a care plan on its use prior to applying the restraint tab alarm. During a review of the facility policy and procedures (P&P) titled, “Use of Restraints,” last reviewed 4/24/2025, the P&P indicated restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. Prior to placing a resident in restraints, there shall be an assessment and a review to determine the need for restraints. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative. During a review of the facility P&P titled, “Bed Safety and Bed Rails,” last reviewed 4/24/2025, the P&P indicated the use of bed rails is prohibited unless the criteria for use of bed rails have been met. The use of bed rails or side rails (including temporarily raising the side rails for episodic use during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. During a review of the facility P&P titled, “Resident Rights,” last reviewed 4/24/2025, the P&P indicated federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to be free from involuntary seclusion and physical or chemical restraints not required to treat the resident's symptoms. During a review of the facility's recent P&P titled Use of Restraints, last reviewed on 4/24/2025, the P&P indicated physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. Policy Interpretation and Implementation 5. Restraints may only be used if/when the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention AND a restraint is required for: a. Treat the medical symptom. b. Protect the resident's safety; and c. Help the resident attain the highest level of his/her physical or psychological well-being. 6. Prior to placing a resident in restraints, there shall be an assessment and a review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptoms and to determine if there are less restrictive interventions (programs, devices, referrals, etc.) that may improve the symptoms. 9. Restrains shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following: a. The specific reason for the restraint (as it relates to the resident's medical symptom). b. How restraint will be used to benefit the resident's medical symptom; and c. The type of restraint, and period of time for the use of the restraint. During a review of the facility provided Tab Alarm (TA) 1, copyright 2022, the information indicated TA 1 improves patient safety by alerting caregivers when a patient attempts to get out of a wheelchair or bed without assistance. WARNING: Long pull cord can entangle the patient and be potentially dangerous. Use care and supervision.

Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs and preferences by failing to ensure: 1.The call light (CL, an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach for two (2) of five (5) residents (Resident 1 and 10) reviewed under the Environment task. 2. The pad call light (a specialty alerting device that have ultra-sensitive touch surface for patients with limited mobility for nurses or other nursing personnel to assist a patient when in need) was within reach for two (2) of four (4) sampled residents (Residents 8 and 71) reviewed under the Environment task. These deficient practices had the potential to result in a delay of care and services and possible injury to residents when they are unable to summon health care workers. Findings:a.During a review of Resident 1’s admission Record (AR), the AR indicated the facility admitted the resident on 5/12/2022 and most recently admitted the resident on 2/15/2025 with diagnoses that included acute and chronic respiratory failure (a serious condition that occurs suddenly when the lungs cannot get enough oxygen), tracheostomy (opening surgically created through the front of the neck and into the trachea [windpipe]), dependence on respiratory ventilator (a medical device to help support or replace breathing), muscle weakness, and need for assistance with personal care. During a review of Resident 1’s Minimum Data Set (MDS – resident assessment tool), dated 5/18/2025, the MDS indicated the resident was totally dependent on staff for mobility, dressing, bathing, toileting, and personal hygiene. During a review of Resident 1’s History and Physical (H&P), dated 2/16/2025, the H&P indicated the resident was nonverbal, awake, alert, able to respond yes/no appropriately to questions, and was able to move all extremities. The H&P further indicated that the resident was able to understand and make decisions. During a review of Resident 1’s Care Plan (CP) regarding communication deficit, initiated 5/12/20218 and last reviewed 6/6/2025, the CP indicated a goal that the resident would have their needs met with an intervention to keep the CL within reach. During an observation on 7/29/2025 at 11:20 a.m., observed Resident 1 awake in bed. Observed the call light cord was wrapped around the resident`s right bedside rail (SR - rigid plastic bars attached to the bed) and dangling toward the floor. Observed the CL was not within reach of the resident. Resident 1 did not respond to the surveyor. During an interview on 7/29/2025 at 11:40 a.m. with Certified Nursing Assistant (CNA) 5, CNA 5 stated CNA 5 was covering while the assigned CNA, CNA 6, was on break. CNA 5 stated the CL should always be within reach for residents to use to get assistance when needed. CNA 5 stated Resident 1 is able to use his hands. CNA 5 entered Residents 1’s room and stated the CL was tied to the side rail and was not within reach of the resident. Observed CNA 5 untied the CL from the SR and placed the CL on Resident 1’s chest. During a concurrent interview and record review on 8/1/2025 at 2:05 p.m. with the Assistant Director of Nursing (ADON), the ADON reviewed the facility policy and procedure (P&P) regarding CLs. The ADON stated the CL should be within easy reach of all residents. The ADON stated when CLs are not within reach of residents, they may not be able to get assistance when needed. The ADON stated when the resident is not able to get assistance it may result in a delay of care and a potential resident fall if the resident attempts to get up. The ADON stated the facility P&P was not followed when Resident 1’s CL was not within reach. During a review of the facility P&P titled, “Fall and Fall Risk, Managing,” last reviewed 4/24/2025, the P&P indicated the staff will 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. During a review of the facility P&P titled, “Functioning Equipment: Call Lights,” last reviewed 4/24/2025, the P&P indicated the purpose of the P&P was to ensure residents will have a functioning Call light system. Staff shall ensure residents have a functioning call light for prompt assistance. Ascertain that a working call light is within residents reach when in his/her room. b. During a review of Resident 10’s AR, the AR indicated the facility admitted the resident on 12/7/2024 and most recently admitted the resident on 12/23/2024 with diagnoses that included nontraumatic intracerebral hemorrhage (a type of stroke caused by bleeding in the brain), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (partial paralysis or weakness on one side of the body) affecting left non-dominant side, and need for assistance with personal care. During a review of Resident 10’s MDS, dated [DATE], the MDS indicated the resident was sometimes able to understand others and was sometimes able to be understood. The MDS further indicated that the resident was totally dependent on staff for mobility, dressing, bathing, toileting, and personal hygiene. During a review of Resident 10’s H&P, dated 12/24/2024, the H&P indicated the resident was able to understand and make decisions. The H&P further indicated the resident was able to move both the lower extremities and was able to move the right upper extremity. During a review of Resident 10’s Order Summary Report, the Order Summary Report indicated a physician’s order for the following: -Falling Star Program (a fall prevention initiative designed to identify and protect patients at high risk of falling) frequent visual monitoring due to high risk for fall and injury, dated 5/23/2025. During a concurrent observation and interview on 7/30/2025 at 10:07 a.m., with Resident 10 and Restorative Nurse Aide (RNA) 1, observed Resident 10 lying in bed with the CL clipped to the sheet on the left side of the resident. Resident 10 stated Resident 10 had pain and would call the nurse. Observed Resident 10 moved the right arm in the direction of the CL at the left side of the resident’s body. Observed that Resident 10 was unable to move the left arm. Observed the CL was not within reach of Resident 10’s right hand. RNA 1 then exited from behind a closed curtain to Resident 10’s bedside. RNA 1 stated Resident 10’s CL was not within reach and the CL should not have been placed on the left side of the resident because the resident could not move the left arm. Observed RNA 1 unclip the CL from the sheet on the left side and re-clipped the CL to the sheet on the right side of the resident. During an interview on 7/30/2025 at 10:15 a.m. with CNA 9, CNA 9 stated Resident 10 cannot move the left arm and the CL light should not have been clipped to the left side of the resident’s sheet. CNA 9 stated Resident 10’s CL should always be placed on the right side of the resident so the resident can call for assistance with any needs. CNA 9 stated CNA 9 was sorry. During an interview on 7/31/2025 at 10:27 a.m. with Registered Nurse (RN) 3, RN 3 stated Resident 10 should have the CL on the resident’s right side, not the left. RN 3 stated the CL should be within reach to ensure the resident has access to call for assistance when help is needed. RN 3 stated when residents do not have access to the CL then a lot of things can happen like a delay in care and treatment of the resident, or the resident may fall when trying to do something on their own. During a concurrent interview and record review on 8/1/2025 at 2:05 p.m. with the ADON, the ADON reviewed the facility P&P regarding CLs. The ADON stated the CL should be within easy reach of all residents. The ADON stated when CLs are not within reach of residents, they may not be able to get assistance when needed. The ADON stated when the resident is not able to get assistance it may result in a delay of care and potentially a fall if the resident attempts to get up. The ADON stated the facility P&P was not followed when Resident 10’s CL was not within reach. During a review of the facility P&P titled, “Fall and Fall Risk, Managing,” last reviewed 4/24/2025, the P&P indicated the staff will 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. During a review of the facility P&P titled, “Functioning Equipment : Call Lights,” last reviewed 4/24/2025, the P&P indicated the purpose of the P&P was to ensure residents will have a functioning Call light system. Staff shall ensure residents have a functioning call light for prompt assistance. Ascertain that a working call light is within residents reach when in his/her room. c. During a review of Resident 8’s AR, the AR indicated the facility originally admitted the resident on 5/4/2011 and readmitted in the facility on 5/12/2025, with diagnoses including dependence on respirator (also known as ventilator – a machine used to help a person breath when they are unable to do so on their own) status , contracture of muscle multiple sites, and type two diabetes mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 8’s History and Physical (H&P) dated 5/13/2025, the H&P indicated Resident 8 did not have the capacity to understand and make decisions. During a review of Resident 8’s MDS, dated [DATE], the MDS indicated Resident 8 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and was unable to understand and make her needs known. The MDS further indicated Resident 8 had impairment of both upper extremities and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 8’s fall risk assessments dated 1/2/2025, 4/3/2025, 5/13/2025, and 7/4/2025, the fall risk assessments indicated Resident 8 was a low risk for falls. During a review of Resident 8’s care plan (CP) on risk for falls or injury initiated on 10/4/2016 and last revised on 4/16/2023, the CP indicated to keep call light within easy reach and encourage resident to use it to get assistance as one of the interventions to reduce the risk of falls and injury daily. During a concurrent observation and interview on 7/29/2025 at 10:57 a.m. inside Resident 8’s room with LVN 4, LVN 4 stated Resident 8’s both upper extremities were contracted and that the call light was placed next to the left upper siderail away from Resident 8’s reach. LVN 4 stated staff are supposed to ensure the call light is within a resident’s reach, especially the resident with specialty call lights prior to leaving the room. LVN 4 stated Resident 8’s call light should have been placed on top of the chest or on either side of the face so Resident 8 would be able to alert the staff for assistance. LVN 4 stated if Resident 8’s call light was not within reach, the staff would not be able to know she needed assistance, and it could lead to a delay in assisting and meeting the resident needs. During an interview on 7/29/2025 at 11:30 p.m. with Registered Nurse (RN) 4, RN 4 stated prior to leaving the room, all staff involved with the residents’ care should ensure that the call light is within reach to be able to alert staff for assistance even if they were unable to talk. RN 4 stated the pad call light is very sensitive with small movement and placed for residents who have limited mobility with their upper extremities. RN 4 stated Resident 8’s both upper extremities are severely contracted and that the call light should have been placed either on top of the chest or next to the face so the resident would be able to ask for assistance when needed by moving her face towards the pad call light. RN 4 stated if the call light was not placed within Resident 8’s reach, the resident would not be able to call for assistance, which could lead to a delay in assisting the resident and meeting her needs. During an interview on 7/31/2025 at 4:13 p.m. with the Director of Nursing (DON), the DON stated the staff should ensure that the call light is placed within the residents’ reach prior to leaving the rooms. The DON stated that for residents with contractures of the upper extremities and unable to use a call light with push button, they are provided with the pad call light. The DON stated the staff did not place the call light within Resident 8’s reach. The DON stated Resident 8’s pad call light should have been placed on top of the chest area or on either side of the face to ensure the resident would be able to call for assistance even if Resident 8 was unable to communicate verbally with the staff. The DON stated if Resident 8’s call light was not within reach, the resident would be able to call which could lead to a delay in meeting the resident’s needs. During a review of the facility’s recent P&P titled, “Functioning Equipment – Call Lights,” last reviewed on 4/24/2025, the P&P indicated the facility will ensure residents will have a functioning call light system and ascertain (make sure) that a working call light is within the resident’s easy reach when in his/her room or toilet. d. During a review of Resident 71’s AR, the AR indicated the facility originally admitted the resident on 5/4/2011 and readmitted in the facility on 5/12/2025, with diagnoses including tracheostomy (a surgical opening in the neck into the windpipe when a person is unable to breathe thru the nose or mouth), dependence on respirator status, contracture of muscle multiple sites, and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 71’s H&P dated 6/24/2025, the H&P indicated Resident 71 did not have the capacity to understand and make decisions. During a review of Resident 71’s MDS, dated [DATE], the MDS indicated Resident 71 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and was unable to understand and make her needs known. The MDS further indicated Resident 71 had impairment of both upper and lower extremities and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 71’s fall risk assessments dated 12/26/2024, 4/2/2025, and 7/3/2025, the fall risk assessments indicated Resident 71 was a low risk for falls. During a review of Resident 71’s CP on risk for falls or injury initiated on 2/16/2018 and last revised on 7/4/2025, the CP indicated to keep call light within easy reach as one of the interventions to reduce falls and injury daily. During a concurrent observation and interview on 7/29/2025 at 10:59 a.m. inside Resident 71’s room with LVN 4, LVN 4 stated Resident 71’s both upper extremities were contracted and that the pad call light was hanging over the left siderail and was already close to touching the floor and was not within Resident 71’s reach. LVN 4 stated staff are supposed to ensure the call light is within the resident’s reach, especially the residents with specialty call lights, prior to leaving the room. LVN 4 stated Resident 71’s call light should have been placed on top of the chest or on either side of the face so Resident 71 would be able to alert the staff for assistance. LVN 4 stated if Resident 71’s call light was not within reach, the staff would not be able to know she needed assistance, and it could lead to a delay in assisting and meeting the resident needs. During an interview on 7/29/2025 at 11:30 p.m. with RN 4, RN 4 stated prior to leaving the room, all staff involved with the residents’ care should ensure that the call light is within reach to be able to alert staff for assistance even if they were unable to talk. RN 4 stated the pad call light is very sensitive with small movement and placed for residents who have limited mobility with their upper extremities. RN 4 stated Resident 71’s both upper extremities are contracted and that the call light should have been placed either on top of the chest or next to the face so the resident would be able to ask for assistance when needed by moving her face towards the pad call light. RN 4 stated if the call light was not placed within Resident 71’s reach, the resident would not be able to call for assistance, which could lead to a delay in assisting the resident and meeting her needs. During an interview on 7/31/2025 at 4:13 p.m. with the DON, the DON stated the staff should ensure that the call light is placed within the residents’ reach prior to leaving the rooms. The DON stated that for residents with contractures of the upper extremities and unable to use a call light with push button, they are provided with the pad call light. The DON stated the staff did not place the call light within Resident 71’s reach. The DON stated Resident 71’s pad call light should have been placed on top of the chest area or on either side of the face to ensure the resident would be able to call for assistance even if Resident 71 was unable to communicate verbally with the staff. The DON stated if Resident 71’s call light was not within reach, the resident would be able to call which could lead to a delay in meeting the resident’s needs. During a review of the facility’s recent P&P titled, “Functioning Equipment – Call Lights,” last reviewed on 4/24/2025, the P&P indicated the facility will ensure residents will have a functioning call light system and ascertain (make sure) that a working call light is within the resident’s easy reach when in his/her room or toilet.

Based on interview and record review, the facility failed to have sufficient and competent nursing staff to provide one of five sampled residents (Resident 1) the necessary nursing care based on the resident's comprehensive plan of care. For Resident 1, who was dependent on staff for care, and was at risk for urinary tract infection (UTI - infection that happens when germs enter the urethra [the tube that conducts urine from the urinary bladder, a sac that holds urine for temporary storage, to the outside of the body) due to the use of an indwelling urinary catheter (a hollow flexible tube inserted in the bladder through the urethra to drain urine), bleeding, and hypoglycemia (condition that occurs when the sugar levels [glucose]in the blood are too low), the facility failed to ensure: 1. The Licensed Vocational Nurses' (LVNs) Job Description did not indicate the LVNs were to perform continuous assessment of residents' condition instead of data gathering (basic assessment). 2. LVNs did not perform comprehensive assessment of residents outside their scope of practice. 3. A Registered Nurse (RN) and not an LVN accurately and continuously assessed Resident 1 for signs (are objective findings that can be seen or measured) and symptoms (are subjective and can be perceived only by the person affected) of UTI (such as complaints of pain, burning sensation, increase in frequency and urgency during urination, increased temperature, or change in urine character [color, odor, amount, and clarity]) to prevent complications (such as repeated UTIs [two or more UTIs within six months or three or more within a year] and sepsis [a life-threatening reaction to infection that can lead to tissue damage, organ failure, and death]). 4. There was an RN available to supervise LVNs, to provide consultations and guidance to LVNs, and to perform residents' assessments. 5. There were policies policy and procedures (P&P) on documentation of residents' S/S of UTI, RN oversight (supervision), and LVNs' training on effective and accurate identification and documentation of S/S of UTI including the urine characteristics every shift (nursing shifts were 7 a.m. to 3 p.m., 3 p.m. to 11 p.m., and 11 p.m. to 7 a.m.). 6. LVN 1 informed an RN on [DATE] at 3:55 p.m. when Resident 1 was found with hematuria (presence of blood in the urine); at 8:50 p.m. when Resident 1's incontinent brief was full of blood as reported by Certified Nursing Assistant 1 (CNA 1); and at 9:20 p.m. before replacing Resident 1's indwelling urinary catheter and when the resident had loose stools and abnormal vital signs (measurements of the body's most basic functions; the four main vital signs routinely monitored are body temperature, heart rate, respiration rate, and blood pressure [the pressure of circulating blood against the blood vessel walls]). Resident 1's blood pressure was ,d+[DATE] millimeters of mercury (mmHg - measurement of pressure inside the blood vessels; ideal blood pressure range is between ,d+[DATE] mmHg and ,d+[DATE] mmHg), heart rate was 119 beats per minute (bpm; ideal normal range is between 60 bpm and 100 bpm), oxygen saturation (the amount of oxygen circulating in the blood) was 94% (ideal range is between 95% and 100%), and blood glucose (blood sugar) was 67 milligrams per deciliters (mg/dL - unit of measure; ideal range is between 70 mg/dL and 100 mg/dL). 7. RN oversight of LVN 1 to ensure LVN 1 took Resident 1's vital signs, oxygen saturation (O2 sat, the amount of oxygen circulating in the blood), and blood sugar level on [DATE] from 3:55 p.m. when Resident 1 was found with hematuria to 9:20 p.m. to promptly inform an RN to assess Resident 1's condition and to determine the need for immediate medical interventions. 8. RN management of Resident 1's change of condition to ensure LVN 1 monitored Resident 1's condition on [DATE] from 4:06 p.m. to 8:50 p.m. at total of four hours and 44 minutes. 9. RN management of Resident 1's status to ensure LVN 1 administered orange juice via gastrostomy tube (GT - a soft tubing inserted under surgery through the abdomen into the stomach to administer nutrition, fluids, and medications) to Resident 1 on [DATE] at 9:50 p.m., when Resident 1 had hypoglycemia and the reading was 67 mg/dL as ordered. 10. LVN 1 sought guidance from an RN about Physician 1's order dated [DATE] timed at 9:50 p.m. to transfer Resident 1 to GACH 1, whether the transfer was immediate (STAT) via paramedics (911 - emergency telephone number for Emergency Medical Services [EMS] healthcare professionals trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital) or via regular ambulance. 11. LVN 1 sought guidance from an RN on [DATE] before administering Resident 1's Eliquis (apixaban - anticoagulant medicine that helps prevent blood clots forming in the heart due to atrial fibrillation [irregular, often rapid heart rate that commonly causes poor blood flow] and reduce the risk of stroke) due at 5 p.m., as Resident 1 has been having hematuria since 3:55 p.m. of [DATE]. 12. Ensure implementation of the facility's policies and procedures (P&P) on Catheter Care, Urinary; Catheterizations; Change of Condition; Vital Signs, Weights, Height; and Documentation Principles. As a result, on [DATE] there was a delay of six hours and 49 minutes, from 3:55 p.m. to 10:44 p.m., to transfer Resident 1 to General Acute Care Hospital 1 (GACH 1) to receive the needed medical interventions. Resident 1 was transferred to GACH 1 via paramedics at 10:44 p.m. Resident 1's condition deteriorated, and the resident subsequently died at GACH 1 on [DATE]. On [DATE], at 5:58 p.m. during an abbreviated survey, the Survey State Agency (SSA) called 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) in the presence of the Administrator (ADM) and the Director of Nursing (DON) about the facility's failure to provide Sufficient and Competent Nursing Staff, 42 CFR S483.35(a). On [DATE], at 2:14 p.m. the ADM submitted an acceptable Removal Plan (a detailed plan to address the IJ findings) and while onsite, the surveyor verified the implementations of the Removal Plan through observations, interviews, and record reviews. The SSA confirmed the removal of the IJ situation on [DATE], at 2:52 p.m., in the presence of the ADM and the DON. The acceptable IJ Removal Plan included the following: a. The facility reviewed and revised the LVN Job Description on [DATE] based on scope of practice according to the LVN Practice Act California Business Professions Code Division 2 Chapter 6.5. b. The DON and the Quality Assurant (QA) nurse in-serviced (trained) and notified the LVNs and RNs of the changes and revisions of the LVN Job Description to follow the LVN's scope of practice according to the LVN Practice Act California Business Professions Code Division 2 Chapter 6.5. c. The ADM and the DON reviewed the Monthly Licensed Nurse Schedule and added an RN supervisor on each shift. d. The DON reviewed and revised the electronic Treatment Administration Record (TAR) UTI monitoring tool, to include documenting the presence or absence of signs and symptoms of UTI such as color, consistency, odor, hematuria, bladder distention (enlarged or inflamed bladder), or burning sensations. If any abnormal findings, a pop-up (a small window that appears while browsing a website) will appear on the TAR to instruct the licensed nurse to document in a progress note the specific findings, and to promptly notify the RN. e. The ADM and the QA nurse reviewed and revised the Change of Condition policy and procedures on [DATE]. f. The facility created a Quality Assurance Performance Improvement (QAPI, measures put into use to improve health care delivery and resident quality of life) for change of condition management to ensure the licensed nurses follow their scope of practice based on the LVN Practice Act California Business Professions Code Division 2 Chapter 6.5 to prevent delay in provision of care and services. Findings: A review of Resident 1's Admission Record (face sheet) indicated the facility admitted the resident on [DATE] and readmitted the resident on [DATE]. Resident 1's new diagnoses upon readmission included sepsis, UTI, and encephalopathy (brain disease that alters brain function or structure). Resident 1's other diagnoses included essential (primary) hypertension (the blood is pumping with more force than normal through the arteries [blood vessels that distribute oxygen-rich blood to your entire body]), aphasia (loss of ability to produce or understand language) following cerebral infarction (stroke, disrupted blood flow to the brain), type 2 diabetes mellitus (body does not make enough insulin [a hormone that lowers the level of sugar in the blood] or cannot use it as well as it should), sacral (triangular shaped bone at the base of the spine) pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin), foot ulcer (open sore or lesion that will not heal or that return over a long period of time), and dehydration (a harmful reduction in the amount of water in the body). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated [DATE], indicated the resident rarely/never made self understood and rarely/never understood others. The MDS indicated Resident 1 was totally dependent on bed mobility, transfer, dressing, eating (via enteral feeding - way of delivering nutrition directly to the stomach through tube feeding), toilet use, and personal hygiene. The MDS further indicated Resident 1 had an indwelling catheter and a gastrostomy tube. A review of Resident 1's Care Plan, developed on [DATE], for the resident's risk for bleeding and bruising due to the use of apixaban (anticoagulant - works by decreasing the clotting ability of the blood and helps prevent harmful clots from forming in the blood vessels), included the intervention to assess the resident for signs and symptoms of bleeding such as blood in urine or stool and notify the physician. A review of Resident 1's Care Plan, developed on [DATE], for Resident 1's risk of hypoglycemia due to diabetes, included the interventions to administer medications as ordered and to initiate nursing measures for hypoglycemia immediately. A review of Resident 1's Care Plan, developed on [DATE], for the resident's risk of unavoidable UTI due to history of UTI and catheter use, had a goal to reduce the risk of recurrence through interventions daily. The interventions included to notify the physician of any S/S of UTI (such as change in urine characteristic). A review of the Physician's Orders for Resident 1, dated [DATE], indicated to administer apixaban 5 milligrams (mg - unit of measure) one tablet through the GT twice a day. A review of the Physician's Orders for Resident 1, dated [DATE], indicated: - Change the Foley (type of an indwelling urinary catheter) catheter as needed when clogged, soiled, or pulled out. - Change the Foley catheter starting on the 15th and ending on the 15th every month. - Monitor the Foley catheter urinary drainage bag and document a plus (+) sign for presence of S/S of UTI and zero (0) for absence of S/S of UTI every shift. A review of the Physician's Orders for Resident 1, dated [DATE], indicated to give orange juice via GT if the resident's blood glucose is below 70 mg/dL. A review of the Physician's Orders for Resident 1, dated [DATE], indicated to monitor the resident for discolored urine, black-colored and tarry (sticky consistency) stools, sudden severe headache, nausea and vomiting, diarrhea, muscle/joint pain, lethargy (lack of energy), bruising, sudden change in in mental status and/or vital signs, shortness of breath, bleeding in any orifice (opening), and abnormal laboratory tests. Document every shift in the TAR: N if monitored and none of the above is observed. Document Y if monitored and any of the above is observed. Notify the physician and document in nurses' progress notes. A review of Resident 1's Change of Condition (COC)/Interact Assessment Form, dated [DATE], completed by LVN 1 indicated: - At 3:55 p.m., CNA 1 informed the Charge Nurse (LVN 1) that Resident 1's urinary catheter was leaking (of urine). LVN 1 went to check on the resident and when trying to replace the catheter (with a new one), LVN 1 noticed the presence of hematuria. There was no documentation at that time that the nurses took Resident 1's vital signs to identify any changes. - At 4:06 p.m., LVN 1 called and notified Resident 1's attending physician (Physician 1) who ordered urinalysis (UA - a laboratory test of the urine) and urine culture (urine test that can identify the germ causing a UTI). There was no documentation at that time that the nurses took Resident 1's vital signs to identify any changes. There was also no further documentation to indicate the status of Resident 1's bleeding from the urine until the next notes were entered at 8:50 p.m. - At 8:50 p.m., CNA 1 notified LVN 1 that Resident 1's incontinent brief was full of blood. LVN 1 also indicated the resident had quite an amount of blood and proceeded to notify Physician 1 to ask if he wanted to order a straight catheter (a hollow flexible tube inserted in the bladder through the urethra to quickly drain urine once) to obtain the urine sample for the laboratory tests, or if Physician 1 wanted to send Resident 1 out (to a GACH). Physician 1 ordered to reinsert an indwelling catheter to monitor the amount of blood. There was no documentation at that time that the nurses took Resident 1's vital signs to identify any changes. - At 9:20 p.m., LVN 1 and LVN 2 went to replace Resident 1's Foley catheter. LVN 1 checked Resident 1's vital signs after the urinary catheter insertion. Resident 1's blood pressure was ,d+[DATE] millimeters of mercury (mmHg - measurement of pressure inside the blood vessels; ideal blood pressure range is between ,d+[DATE] mmHg and ,d+[DATE] mmHg), heart rate was 119 beats per minute (bpm; ideal range is between 60 bpm and 100 bpm), oxygen saturation (the amount of oxygen circulating in the blood) was 94% (ideal range is between 95% and 100%), and the blood glucose was 67 milligrams per deciliters (mg/dL - unit of measure; ideal range is between 70 mg/dL and 100 mg/dL). LVN 1 notified Physician 1 who ordered to send Resident 1 out (to a GACH). LVN 1 documented trying to call several ambulances (companies) but none were available. There was no documentation at that time that LVN 1 called 911 to request for paramedics. - At 10:15 p.m., the Subacute Unit RN (RN 1, assigned to another unit of the facility that cares for residents needing more intensive care than those typically received in skilled nursing facilities [SNF - unit of the facility where residents need regular nursing care and other health-related services] but less intensive than acute care) informed LVN 1 that Resident 1's oxygen saturation dropped to 80%. The documentation further indicated that 911 was called (the notes did not indicate the name of the staff who called 911) and the respiratory therapist (Respiratory Therapist 1 [RT 1]) bagged (use of manual resuscitators to ventilate a patient in medical emergencies when the patient's breathing is insufficient or has ceased completely) Resident 1. The paramedics arrived at 10:30 p.m. and took Resident 1 to GACH 1 on [DATE] at 10:44 p.m. A review of Resident 1's Licensed Nursing Notes and TARs from [DATE] to [DATE] indicated no documentation that the resident manifested S/S of UTI. The TARs indicated zero (0) for absence of S/S of UTI in the urine and (N) for no presence of bleeding every shift. A review of Resident 1's GACH 1 Emergency Department (ED) Physician Note, dated [DATE], indicated Resident 1 arrived at GACH 1 on [DATE] and was seen by the ED physician at 10:59 p.m. Resident 1 had altered mental status and hypoxic respiratory failure (absence of enough oxygen in the tissues to sustain bodily functions). The notes also indicated the EMS intubated (inserting a tube through a person's mouth or nose, then down into the trachea [airway/windpipe] to keep the trachea open so that air can get through) Resident 1 on the way to the hospital. The notes further indicated Resident 1 was tachycardic with blood in her Foley catheter and her incontinent brief. The pulse rate taken on [DATE] at 11 p.m. indicated it was 130 bpm. Resident 1's urine laboratory test indicated significant pyuria (pus in the urine). Resident 1 required transfer to the Intensive Care Unit (ICU, a designated area of a hospital that is dedicated to the care of patients who are critically ill). A review of Resident 1's GACH 1 Discharge Summary, dated [DATE], indicated the resident's discharge diagnoses included severe sepsis and septic shock (a life-threatening condition that occurs when a widespread infection leads to dangerously low blood pressure) due to UTI which was present on admission (POA), acute (severe and sudden onset) hypoxic respiratory failure, on mechanical ventilator (a form of life support; a machine takes over the work of breathing when a person is not able to breathe enough on his/her own), severe anemia (the body does not get enough oxygen-rich blood) with acute blood loss component, hemorrhagic cystitis (condition in which the urinary bladder lining becomes inflamed resulting in bleeding and pain), acute renal failure (a sudden episode of kidney failure when the kidneys suddenly stop working properly which happens within a few hours or a few days), and metabolic acidosis (buildup of too much acid in the body due to kidney failure). Resident 1 developed cardiac arrest (when the heart suddenly and unexpectedly stops pumping) and expired (died ) on [DATE]. During an interview, on [DATE] at 3:35 p.m., LVN 1 stated that on [DATE] at around 3:55 p.m., CNA 1 notified her that Resident 1's urinary catheter was leaking and that the resident had blood in the urine. Upon assessment of Resident 1, LVN 1 stated she saw pink/reddish blood in the resident's incontinent brief. LVN 1 stated she then removed Resident 1's urinary catheter. LVN 1 stated she notified Physician 1 about the situation and obtained physician orders for UA and culture at 4:06 p.m. LVN 1 further stated that on [DATE] at around 8 p.m., CNA 1 informed her that Resident 1 had blood in the resident's incontinent brief. LVN 1 then assessed Resident 1 and observed bright red and thick blood in the resident's incontinent brief. LVN 1 stated she was sending text messages to the DON which was why she notified Physician 1 around 8:43 p.m., a delay of 43 minutes from the time CNA 1 had notified LVN 1 of Resident 1's condition. LVN 1 stated Physician 1 ordered to insert a new urinary catheter which she carried out (performed). LVN 1 also stated she did not check Resident 1's vital signs during the resident's change of condition. LVN 1 stated she should have checked Resident 1's vital signs as part of the Change of Condition policy and procedures. LVN 1 stated that on [DATE] at 9:20 p.m., she notified Physician 1 of Resident 1's BP of ,d+[DATE] mmHg, pulse rate of 119 bpm, and blood sugar of 67 mg/dl. Physician 1 ordered to transfer Resident 1 to GACH 1. LVN 1 stated she did not clarify if Physician 1 wanted Resident 1 to be sent to GACH 1 immediately by calling paramedics or just by calling regular transport ambulance. LVN 1 stated she called ambulance companies, but none were available. LVN 1 further stated RN 1 informed her (LVN 1) that on [DATE] at 10:15 p.m., Resident 1's oxygen saturation was low at 80%. 911 was called by staff (LVN 2). LVN 1 stated Resident 1 was not opening her eyes and had labored breathing (difficulty with breathing) at that time. LVN 1 stated RT 1 began to bag (used manual resuscitator to ventilate the patient) Resident 1. LVN 1 stated Resident 1's BP of ,d+[DATE] mmHg was low for the resident. LVN 1 stated if she had been monitoring Resident 1's vital signs, she may have caught the low blood pressure and may have informed Physician 1 to obtain an order. LVN 1 also stated Resident 1's blood sugar of 67 mg/dL was low, and they should notify the doctor if the resident's blood sugar is 70 mg/dL or less. LVN 1 stated calling 911 should have been faster and that Resident 1 could have been harmed because of the low oxygen saturation and the low BP. During an interview, on [DATE] at 4:50 p.m., CNA 1 stated that on [DATE] at around 4 p.m., she was providing perineal care (involves cleaning the genital and rectal areas) to Resident 1 when she saw blood in the resident's incontinent brief. CNA 1 stated she notified LVN 1 about it. CNA 1 further that stated on [DATE] at around 7 p.m., she observed Resident 1 with blood in the incontinent brief and the whole incontinent pad was soaked in bright red blood. CNA 1 stated she then informed LVN 1. During an interview, on [DATE] at 12:17 p.m., RN 1 stated that LVN 2 approached her on [DATE] around 10 p.m. asking what transportation to call for Resident 1's transfer to the GACH. RN 1 stated she went to Resident 1's room and observed the resident gasping for breath (struggling to breathe) and the resident's urinary catheter tubing had light red blood. RN 1 checked Resident 1's oxygen saturation which was at 80%. RN 1 stated she ran out to call the respiratory therapist (RT 1) who came right away and assisted. RN 1 stated not checking the resident's vital signs at that time because she was concerned about the resident's breathing. RN 1 stated not being sure if LVN 1 took Resident 1's vital signs then but RN 1 stated she (RN 1) did not. RN 1 stated for a resident who becomes unresponsive, staff should check the resident's vital signs and call 911. RN 1 stated the paramedics arrived within 10 minutes of the call. RN 1 stated she oversees the Subacute Unit and not the SNF side (where Resident 1 was located) of the facility. RN 1 stated she was the only RN during that shift. RN 1 stated LVN 1 reported to the physician. RN 1 stated she has never worked with Resident 1 in the past. RN 1 stated she got involved in the situation because she was asked help for Resident 1's transfer and paperwork. During an interview, on [DATE] at 1:07 p.m., LVN 2 stated that LVN 1 notified her on [DATE] during the 3 p.m. to 11 p.m. shift about Resident 1 having blood in the incontinent brief. LVN 2 told LVN 1 that she (LVN 2) can help as needed. LVN 2 stated going to Resident 1's room around 4 p.m. and assessed the resident's incontinent brief which had moderate amount of light red blood in the urine; the resident's indwelling urinary catheter was still inserted at that time. LVN 1 then notified LVN 2 about the physician's order to remove the resident's urinary catheter. LVN 2 stated she assisted LVN 1 in removing Resident 1's indwelling catheter. LVN 2 stated she tried helping LVN 1 with the resident's paperwork while LVN 1 calls for transportation to the GACH. LVN 2 stated that after ,d+[DATE] minutes with no available transportation contacted, RN 1 went to the resident's room and saw the resident with labored breathing. LVN 2 stated calling 911 while LVN 1 went to the resident. LVN 2 stated RT 1 was using an ambubag (hand-held self-inflating bag used to provide ventilation to patients who are not breathing or not breathing adequately) on the resident. During an interview and concurrent record review, on [DATE] at 3:45 p.m., LVN 1 stated she inaccurately documented in Resident 1's TAR for [DATE] during her shift (from 3 p.m. to 11 p.m.). LVN 1 stated she indicated zero (0) for no S/S of UTI present (when resident had hematuria) and (N) for no bleeding at that time. During an interview and concurrent record review, on [DATE] at 3:44 p.m., the DON stated LVN 1 documented accurately in Resident 1's TAR on [DATE] during the 3 p.m. to 11 p.m. shift as zero (0) because the bleeding was not observed in the catheter but in the resident's incontinent brief. The DON confirmed the skilled nursing side of the facility had no RN assigned in any of the shifts because there was an RN in the Subacute Unit. The DON acknowledged the Subacute Unit contract with the State did not allow sharing any staff (including the RN) outside the Subacute Unit. During an interview and concurrent record review, on [DATE] at 3:44 p.m., the DON stated LVN 1 documented accurately in Resident 1's TAR on [DATE] during the 3 p.m. to 11 p.m. shift as zero (0) because the bleeding was not observed in the catheter but in the resident's incontinent brief. The DON stated the facility was not required to have an RN on each shift and LVNs could assess residents. A review of the facility's P&P titled, Catheter Care, Urinary, last revised on [DATE] indicated the following information should be recorded in the resident medical records: 3. Character of urine such as color (straw-colored, dark, or red), clarity (cloudy, solid particles, or blood), and odor. 4. Any problems noted at the catheter-urethral junction during perineal care such as drainage, redness, bleeding, irritation, crusting, or pain. A review of the facility's P&P titled, Catheterizations, last revised on [DATE] indicated nursing staff is responsible of monitoring the resident for possible complications. A review of the facility's P&P titled, Change of Condition, last revised on [DATE], indicated to ensure proper assessment and follow-through for any resident with a change of condition. A change of condition is sudden or marked difference in resident's: 4. Output (e.g., low urine output, stool, hematuria, diarrhea, constipation, impaction [a mass of fecal material that is too large or too firm, or both, to pass through the anus], vomiting). A review of the facility's P&P titled, Vital Signs, Weights, Height, last revised on [DATE], indicated the resident's vital signs shall be recorded as the physician's order indicates, or as frequently as the resident's condition warrants. Vital signs shall be taken and recorded in accordance with the resident's condition, current treatment plan, and as prescribed by the attending physician. The physician shall be notified promptly when the vitals are out of range from the acceptable parameters provided. A review of the facility's P&P titled, Documentation Principles, last revised on [DATE], indicated resident's health record shall be current and kept in detail consistent with good medical and professional practices based on the service provided to each resident. Based on interview and record review, the facility failed to have sufficient and competent nursing staff to provide one of five sampled residents (Resident 1) the necessary nursing care based on the resident's comprehensive plan of care. For Resident 1, who was dependent on staff for care, and was at risk for urinary tract infection (UTI - infection that happens when germs enter the urethra [the tube that conducts urine from the urinary bladder, a sac that holds urine for temporary storage, to the outside of the body) due to the use of an indwelling urinary catheter (a hollow flexible tube inserted in the bladder through the urethra to drain urine), bleeding, and hypoglycemia (condition that occurs when the sugar levels [glucose]in the blood are too low), the facility failed to ensure: 1. The Licensed Vocational Nurses' (LVNs) Job Description did not indicate the LVNs were to perform continuous assessment of residents' condition instead of data gathering (basic assessment). 2. LVNs did not perform comprehensive assessment of residents outside their scope of practice. 3. A Registered Nurse (RN) and not an LVN accurately and continuously assessed Resident 1 for signs (are objective findings that can be seen or measured) and symptoms (are subjective and can be perceived only by the person affected) of UTI (such as complaints of pain, burning sensation, increase in frequency and urgency during urination, increased temperature, or change in urine character [color, odor, amount, and clarity]) to prevent complications (such as repeated UTIs [two or more UTIs within six months or three or more within a year] and sepsis [a life-threatening reaction to infection that can lead to tissue damage, organ failure, and death]). 4. There was an RN available to supervise LVNs, to provide consultations and guidance to LVNs, and to perform residents' assessments. 5. There were policies policy and procedures (P&P) on documentation of residents' S/S of UTI, RN oversight (supervision), and LVNs' training on effective and accurate identification and documentation of S/S of UTI including the urine characteristics every shift (nursing shifts were 7 a.m. to 3 p.m., 3 p.m. to 11 p.m., and 11 p.m. to 7 a.m.). 6. LVN 1 informed an RN on [DATE] at 3:55 p.m. when Resident 1 was found with hematuria (presence of blood in the urine); at 8:50 p.m. when Resident 1's incontinent brief was full of blood as reported by Certified Nursing Assistant 1 (CNA 1); and at 9:20 p.m. before replacing Resident 1's indwelling urinary catheter and when the resident had loose stools and abnormal vital signs (measurements of the body's most basic functions; the four main vital signs routinely monitored are body temperature, heart rate, respiration rate, and blood pressure [the pressure of circulating blood against the blood vessel walls]). Resident 1's blood pressure was ,d+[DATE] millimeters of mercury (mmHg - measurement of pressure inside the blood vessels; ideal blood pressure range is between ,d+[DATE] mmHg and ,d+[DATE] mmHg), heart rate was 119 beats per minute (bpm; ideal normal range is between 60 bpm and 100 bpm), oxygen saturation (the amount of oxygen circulating in the blood) was 94% (ideal range is between 95% and 100%), and blood glucose (blood sugar) was 67 milligrams per deciliters (mg/dL - unit of measure; ideal range is between 70 mg/dL and 100 mg/dL). 7. RN oversight of LVN 1 to ensure LVN 1 took Resident 1's vital signs, oxygen saturation (O2 sat, the amount of oxygen circulating in the blood), and blood sugar level on [DATE] from 3:55 p.m. when Resident 1 was found with hematuria to 9:20 p.m. to promptly inform an RN to assess Resident 1's condition and to determine the need for immediate medical interventions. 8. RN management of Resident 1's change of condition to ensure LVN 1 monitored Resident 1's condition on [DATE] from 4:06 p.m. to 8:50 p.m. at total of four hours and 44 minutes. 9. RN management of Resident 1's status to ensure LVN 1 administered orange juice via gastrostomy tube (GT - a soft tubing inserted under surgery through the abdomen into the stomach to administer nutrition, fluids, and medications) to Resident 1 on [DATE] at 9:50 p.m., when Resident 1 had hypoglycemia and the reading was 67 mg/dL as ordered. 10. LVN 1 sought guidance from an RN about Physician 1's order dated [DATE] timed at 9:50 p.m. to transfer Resident 1 to GACH 1, whether the transfer was immediate (STAT) via paramedics (911 - emergency telephone number for Emergency Medical Services [EMS] healthcare professionals trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital) or via regular ambulance. 11. LVN 1 sought guidance from an RN on [DATE] before administering Resident 1's Eliquis (apixaban - anticoagulant medicine that helps prevent blood clots forming in the heart due to atrial fibrillation [irregular, often rapid heart rate that commonly causes poor blood flow] and reduce the risk of stroke) due at 5 p.m., as Resident 1 has been having hematuria since 3:55 p.m. of [DATE]. 12. Ensure implementation of the facility's policies and procedures (P&P) on Catheter Care, Urinary; Catheterizations; Change of Condition; Vital Signs, Weights, Height; and Documentation Principles. As a result, on [DATE] there was a delay of six hours and 49 minutes, from 3:55 p.m. to 10:44 p.m., to transfer Resident 1 to General A [TRUNCATED]

Based on interview and record review, the facility failed to provide care and treatment for one of five sampled residents (Resident 1), who was dependent on staff for care, was at risk of bleeding and hypoglycemia (condition that occurs when the sugar levels [glucose]in the blood are too low), and was at risk for urinary tract infection (UTI - infection that happens when germs enter the urethra [the tube that allows urine from the urinary bladder, a sac that holds urine for temporary storage, exit the body during urination) due to the use of an indwelling urinary catheter (a hollow flexible tube inserted in the bladder through the urethra to drain urine), received treatment and care in accordance with the comprehensive plan of care and professional standards of practice to meet the resident's care needs by: 1. Not monitoring and accurately documenting Resident 1 ' s urine characteristics (such as color, odor, pain or discomfort, presence of blood [hematuria - blood in the urine]) as indicated in the plans of care, to promptly identify UTI in order to mitigate (to alleviate) the infection and prevent complications (such as repeated UTIs [two or more UTIs within six months or three or more within a year] and sepsis [a life-threatening reaction to infection that can lead to tissue damage, organ failure, and death]). 2. Not implementing Physician 1 ' s order to monitor Resident 1 ' s urinary drainage bag (collects urine) and document the presence of signs (objective findings that can be seen or measured) and symptoms (subjective and can be perceived only by the person affected) of UTI every shift (7 a.m. to 3 p.m. shift, 3 p.m. to 11 p.m. shift, and 11 p.m. to 7 a.m. shift). 3. Licensed Vocational Nurse 1 (LVN 1) not evaluating Resident 1 ' s vital signs (measurements of the body's most basic functions; the four main vital signs routinely monitored are body temperature, heart rate, respiration rate, and blood pressure [the pressure of circulating blood against the walls of blood vessels]), oxygen saturation (O2 sat, the amount of oxygen circulating in the blood); and blood sugar level to promptly identify Resident 1 ' s change of condition (COC) on [DATE], starting at 3:55 p.m. when Resident 1 was found with hematuria, in order to provide Physician 1 with the overall Resident 1 ' s condition. In addition, LVN 1 did not seek guidance from a registered nurse (RN). 4. Not monitoring Resident 1 ' s condition on [DATE] from 4:06 p.m. to 8:50 p.m. at a total of four hours and 44 minutes, despite knowing that Resident 1 had hematuria since 3:55 p.m. 5. LVN 1 not administering orange juice via gastrostomy tube (GT - a soft tubing inserted under surgery through the abdomen into the stomach to administer nutrition, fluids, and medications) to Resident 1 on [DATE] at 9:20 p.m., when Resident 1 ' s blood sugar was 67 milligrams per deciliters (mg/dL - unit of measure; ideal range is between 70 mg/dL and 100 mg/dL) as ordered and as indicated in the plan of care. 6. LVN 1 not clarifying with Physician 1 the order dated [DATE] at 9:20 p.m., to transfer Resident 1 to GACH 1 whether to transfer via paramedics (911 - emergency telephone number for Emergency Medical Services [EMS] health personnel trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital) or via regular ambulance. In addition, LVN 1 did not seek guidance from an RN. 7. Not implementing the facility ' s policies and procedures (P&P) on Catheter Care, Urinary; Catheterizations; Change of Condition; Vital Signs, Weights, Height; and Documentation Principles. As a result, on [DATE] there was a delay of six hours and 38 minutes in transferring Resident 1 to GACH 1 to receive the needed medical interventions. Resident 1 ' s condition deteriorated, and the resident subsequently died at GACH 1 on [DATE]. On [DATE], at 5:58 p.m. during an abbreviated survey, the Survey State Agency (SSA) called 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) in the presence of the Administrator (ADM) and the Director of Nursing (DON) about the facility ' s failure to ensure Resident 1 received care and treatment based on the person-centered plan of care and professional standards of practice (42 CFR S483.25). On [DATE], at 2:14 p.m. the ADM submitted an acceptable Removal Plan (a detailed plan to address the IJ findings) and while onsite, the surveyor verified the implementations of the Removal Plan through observations, interviews, and record reviews. The SSA confirmed the removal of the IJ situation onsite on [DATE], at 2:52 p.m., in the presence of the ADM and the DON. The acceptable IJ Removal Plan included the following: a. The DON reviewed and revised the electronic Treatment Administration Record (TAR) UTI monitoring tool, to include documenting the presence or absence of signs and symptoms of UTI such as observing for color, consistency, odor, hematuria, bladder distention (enlarged or inflamed bladder), or burning sensations. If an abnormal finding is identified, a pop-up (a small window that appears while browsing a website) will appear on the TAR to instruct the licensed nurse to document in a progress note the specific finding, and to promptly notify the RN and report to the physician. b. All LVNs and RNs completed and passed a competency (measurable pattern of knowledge, skills, abilities, behaviors in order to perform occupational functions successfully) test to ensure all licensed nurses can identify UTI signs and symptoms such as observing for color, consistency, odor, hematuria, bladder distention, or burning sensations, and can properly manage change of conditions specific to abnormal vital signs (like sudden or marked difference in resident ' s temperature, pulse rate, blood pressure, irregular pulse, or shortness of breath). c. The DON provided one-to-one (only to one individual) training about the importance of increased monitoring of residents ' status and notifying the physician of any abnormal findings; calling paramedics when residents have critical vital signs such as low blood pressure, high heart rate, and low blood sugar to prevent the delay in provision of care and services. d. The DON and the Clinical Care Coordinator (CCC) reviewed residents who had changes of conditions within the last 30 days to ensure there were no delays in the provision of care and services. No other residents were affected by the deficient practice and no delayed care was identified. e. The ADM and the Quality Assurance (QA) nurse reviewed and revised the Change of Condition policy and procedures on [DATE]. Findings: A review of Resident 1 ' s Admission Record (face sheet) indicated the facility admitted the resident on [DATE] and readmitted the resident on [DATE]. Resident 1 ' s new diagnoses upon readmission included sepsis, UTI, and encephalopathy (brain disease that alters brain function or structure). Resident 1 ' s other diagnoses included essential (primary) hypertension (the blood is pumping with more force than normal through the arteries [blood vessels that distribute oxygen-rich blood to your entire body]), aphasia (loss of ability to produce or understand language) following cerebral infarction (stroke, disrupted blood flow to the brain), type 2 diabetes mellitus (body does not make enough insulin [a hormone that lowers the level of sugar in the blood] or cannot use it as well as it should), sacral (triangular shaped bone at the base of the spine) pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin), foot ulcer (open sore or lesion that will not heal or that return over a long period of time), and dehydration (a harmful reduction in the amount of water in the body). A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated [DATE], indicated the resident rarely/never made self understood and rarely/never understood others. The MDS indicated Resident 1 was totally dependent on bed mobility, transfer, dressing, eating (via enteral feeding - way of delivering nutrition directly to the stomach through tube feeding), toilet use, and personal hygiene. The MDS further indicated Resident 1 had an indwelling catheter and a gastrostomy tube. A review of Resident 1 ' s Care Plan, developed on [DATE], for the resident ' s risk for bleeding and bruising due to the use of apixaban (anticoagulant - works by decreasing the clotting ability of the blood and helps prevent harmful clots from forming in the blood vessels), included the intervention to assess the resident for signs and symptoms of bleeding such as blood in urine or stool and notify the physician. A review of Resident 1 ' s Care Plan, developed on [DATE], for Resident 1 ' s risk of hypoglycemia due to diabetes, included the interventions to administer medications as ordered and to initiate nursing measures for hypoglycemia immediately. A review of Resident 1 ' s Care Plan, developed on [DATE], for the resident ' s risk of unavoidable UTI due to history of UTI and catheter use, had a goal to reduce the risk of recurrence through interventions daily. The interventions included to notify the physician of any signs and symptoms (S/S) of UTI (such as changes in urine characteristic). A review of the Physician ' s Orders for Resident 1, dated [DATE], indicated to administer apixaban 5 milligrams (mg - unit of measure) one tablet through the GT twice a day. A review of the Physician ' s Orders for Resident 1, dated [DATE], indicated: - Change the Foley (type of an indwelling urinary catheter) catheter as needed when clogged, soiled, or pulled out. - Change the Foley catheter starting on the 15th and ending on the 15th every month. - Monitor the Foley catheter urinary drainage bag and document a plus (+) sign for presence of S/S of UTI and zero (0) for absence of S/S of UTI every shift. A review of the Physician ' s Orders for Resident 1, dated [DATE], indicated to give orange juice via GT if the resident ' s blood glucose is below 70 mg/dL. A review of the Physician ' s Orders for Resident 1, dated [DATE], indicated to monitor the resident for discolored urine, black-colored and tarry (sticky consistency) stools, sudden severe headache, nausea and vomiting, diarrhea, muscle/joint pain, lethargy (lack of energy), bruising, sudden change in mental status and/or vital signs, shortness of breath, bleeding in any orifice (opening), and abnormal laboratory tests. Document every shift in the TAR: N if monitored and none of the above is observed. Document Y if monitored and any of the above is observed. Notify the physician and document in nurses ' progress notes. A review of Resident 1 ' s Change of Condition (COC)/Interact Assessment Form, dated [DATE], completed by LVN 1 indicated: - At 3:55 p.m., Certified Nursing Assistant 1 (CNA 1) informed the Charge Nurse (LVN 1) that Resident 1 ' s urinary catheter was leaking (of urine). LVN 1 went to check on the resident and when trying to replace the catheter (with a new one), LVN 1 noticed the presence of hematuria. There was no documentation at that time that the nurses took Resident 1 ' s vital signs to identify any changes. - At 4:06 p.m., LVN 1 called and notified Resident 1 ' s attending physician (Physician 1) who ordered urinalysis (UA - a laboratory test of the urine) and urine culture (urine test that can identify the germ causing a UTI). There was no documentation at that time that the nurses took Resident 1 ' s vital signs to identify any changes. There was also no further documentation to indicate the status of Resident 1 ' s bleeding from the urine until the next notes were entered at 8:50 p.m. - At 8:50 p.m., CNA 1 notified LVN 1 that Resident 1 ' s incontinent brief was full of blood. LVN 1 also indicated the resident had quite an amount of blood and proceeded to notify Physician 1 to ask if he wanted to order a straight catheter (a hollow flexible tube inserted in the bladder through the urethra to quickly drain urine once) to obtain the urine sample for the laboratory tests, or if Physician 1 wanted to send Resident 1 out (to a GACH). Physician 1 ordered to reinsert an indwelling catheter to monitor the amount of blood. There was no documentation at that time that the nurses took Resident 1 ' s vital signs to identify any changes. - At 9:20 p.m., LVN 1 and LVN 2 went to replace Resident 1 ' s Foley catheter. LVN 1 checked Resident 1 ' s vital signs after the urinary catheter insertion. Resident 1 ' s blood pressure was ,d+[DATE] millimeters of mercury (mmHg - measurement of pressure inside the blood vessels; ideal blood pressure range is between ,d+[DATE] mmHg and ,d+[DATE] mmHg), heart rate was 119 beats per minute (bpm; ideal range is between 60 bpm and 100 bpm), oxygen saturation (the amount of oxygen circulating in the blood) was 94% (ideal range is between 95% and 100%), and the blood glucose was 67 milligrams per deciliters (mg/dL - unit of measure; ideal range is between 70 mg/dL and 100 mg/dL). LVN 1 notified Physician 1 who ordered to send Resident 1 out (to a GACH). LVN 1 documented trying to call several ambulances (companies), but none were available. There was no documentation at that time that LVN 1 called 911 to request for paramedics. - At 10:15 p.m., the Subacute Unit RN (RN 1, assigned to another unit of the facility that cares for residents needing more intensive care than those typically received in skilled nursing facilities [SNF - unit of the facility where residents need regular nursing care and other health-related services] but less intensive than acute care) informed LVN 1 that Resident 1 ' s oxygen saturation dropped to 80%. The documentation further indicated that 911 was called (the notes did not indicate the name of the staff who called 911) and the respiratory therapist (Respiratory Therapist 1 [RT 1]) bagged (use of manual resuscitators to ventilate a patient in medical emergencies when the patient's breathing is insufficient or has ceased completely) Resident 1. The paramedics arrived at 10:30 p.m. and took Resident 1 to GACH 1 on [DATE] at 10:44 p.m. A review of Resident 1 ' s Licensed Nursing Notes and TARs from [DATE] to [DATE] indicated no documentation that the resident manifested S/S of UTI. The TARs indicated zero (0) for absence of S/S of UTI in the urine and (N) for no presence of bleeding every shift. A review of Resident 1 ' s GACH 1 Emergency Department (ED) Physician Note, dated [DATE], indicated Resident 1 arrived at GACH 1 on [DATE] and was seen by the ED physician at 10:59 p.m. Resident 1 had altered mental status and hypoxic respiratory failure (absence of enough oxygen in the tissues to sustain bodily functions). The notes also indicated the EMS intubated (inserting a tube through a person's mouth or nose, then down into the trachea [airway/windpipe] to keep the trachea open so that air can get through) Resident 1 on the way to the hospital. The notes further indicated Resident 1 was tachycardic (abnormally elevated heart rate), with blood in her Foley catheter and her incontinent brief. The pulse rate taken on [DATE] at 11 p.m. indicated it was 130 bpm. Resident 1 ' s urine laboratory test indicated significant pyuria (pus in the urine). Resident 1 required transfer to the Intensive Care Unit (ICU, a designated area of a hospital that is dedicated to the care of patients who are critically ill). A review of Resident 1 ' s GACH 1 Discharge Summary, dated [DATE], indicated the resident ' s discharge diagnoses included severe sepsis and septic shock (a life-threatening condition that occurs when a widespread infection leads to dangerously low blood pressure) due to UTI which was present on admission (POA), acute (severe and sudden onset) hypoxic respiratory failure, on mechanical ventilator (a form of life support; a machine takes over the work of breathing when a person is not able to breathe enough on his/her own), severe anemia (the body does not get enough oxygen-rich blood) with acute blood loss component, hemorrhagic cystitis (condition in which the urinary bladder lining becomes inflamed resulting in bleeding and pain), acute renal failure (a sudden episode of kidney failure when the kidneys suddenly stop working properly which happens within a few hours or a few days), and metabolic acidosis (buildup of too much acid in the body due to kidney failure). Resident 1 developed cardiac arrest (when the heart suddenly and unexpectedly stops pumping) and expired (died ) on [DATE]. During an interview, on [DATE] at 3:35 p.m., LVN 1 stated that on [DATE] at around 3:55 p.m., CNA 1 notified her that Resident 1 ' s urinary catheter was leaking and that the resident had blood in the urine. Upon assessment of Resident 1, LVN 1 stated she saw pink/reddish blood in the resident ' s incontinent brief. LVN 1 stated she then removed Resident 1 ' s urinary catheter. LVN 1 stated she notified Physician 1 about the situation and obtained physician orders for UA and culture at 4:06 p.m. LVN 1 further stated that on [DATE] at around 8 p.m., CNA 1 informed her that Resident 1 had blood in the resident ' s incontinent brief. LVN 1 then assessed Resident 1 and observed bright red and thick blood in the resident ' s incontinent brief. LVN 1 stated she was sending text messages to the DON which was why she notified Physician 1 around 8:43 p.m., a delay of 43 minutes from the time CNA 1 had notified LVN 1 of Resident 1 ' s condition. LVN 1 stated Physician 1 ordered to insert a new urinary catheter which she carried out (performed). LVN 1 also stated she did not check Resident 1 ' s vital signs during the resident ' s change of condition. LVN 1 stated she should have checked Resident 1 ' s vital signs as part of the Change of Condition policy and procedures. LVN 1 stated that on [DATE] at 9:20 p.m., she notified Physician 1 of Resident 1 ' s BP of ,d+[DATE] mmHg, pulse rate of 119 bpm, and blood sugar of 67 mg/dL. Physician 1 ordered to transfer Resident 1 to GACH 1. LVN 1 stated she did not clarify if Physician 1 wanted Resident 1 to be sent to GACH 1 immediately by calling paramedics or just by calling regular transport ambulance. LVN 1 stated she called ambulance companies, but none were available. LVN 1 further stated RN 1 informed her (LVN 1) that on [DATE] at 10:15 p.m., Resident 1 ' s oxygen saturation was low at 80%. 911 was called by staff (LVN 2). LVN 1 stated Resident 1 was not opening her eyes and had labored breathing (difficulty with breathing) at that time. LVN 1 stated RT 1 began to bag (used manual resuscitator to ventilate the patient) Resident 1. LVN 1 stated Resident 1 ' s BP of ,d+[DATE] mmHg was low for the resident. LVN 1 stated if she had been monitoring Resident 1 ' s vital signs, she may have caught the low blood pressure and may have informed Physician 1 to obtain an order. LVN 1 also stated Resident 1 ' s blood sugar of 67 mg/dL was low, and they should notify the doctor if the resident ' s blood sugar is 70 mg/dL or less. LVN 1 stated calling 911 should have been faster and that Resident 1 could have been harmed because of the low oxygen saturation and the low BP. During an interview, on [DATE] at 4:50 p.m., CNA 1 stated that on [DATE] at around 4 p.m., she was providing perineal care (involves cleaning the genital and rectal areas) to Resident 1 when she saw blood in the resident ' s incontinent brief. CNA 1 stated she notified LVN 1 about it. CNA 1 further that stated on [DATE] at around 7 p.m., she observed Resident 1 with blood in the incontinent brief and the whole incontinent pad was soaked in bright red blood. CNA 1 stated she then informed LVN 1. During an interview, on [DATE] at 12:17 p.m., RN 1 stated that LVN 2 approached her on [DATE] around 10 p.m. asking what transportation to call for Resident 1 ' s transfer to the GACH. RN 1 stated she went to Resident 1 ' s room and observed the resident gasping for breath (struggling to breathe) and the resident ' s urinary catheter tubing had light red blood. RN 1 checked Resident 1 ' s oxygen saturation which was at 80%. RN 1 stated she ran out to call the respiratory therapist (RT 1) who came right away and assisted. RN 1 stated not checking the resident ' s vital signs at that time because she was concerned about the resident ' s breathing. RN 1 stated not being sure if LVN 1 took Resident 1 ' s vital signs then but RN 1 stated she (RN 1) did not. RN 1 stated for a resident who becomes unresponsive, staff should check the resident ' s vital signs and call 911. RN 1 stated the paramedics arrived within 10 minutes of the call. RN 1 stated she oversees the Subacute Unit and not the SNF side (where Resident 1 was located) of the facility. RN 1 stated she was the only RN during that shift. RN 1 stated LVN 1 reported to the physician. RN 1 stated she has never worked with Resident 1 in the past. RN 1 stated she got involved in the situation because she was asked help for Resident 1 ' s transfer and paperwork. During an interview, on [DATE] at 1:07 p.m., LVN 2 stated that LVN 1 notified her on [DATE] during the 3 p.m. to 11 p.m. shift about Resident 1 having blood in the incontinent brief. LVN 2 told LVN 1 that she (LVN 2) can help as needed. LVN 2 stated going to Resident 1 ' s room around 4 p.m. and assessed the resident ' s incontinent brief which had moderate amount of light red blood in the urine; the resident ' s indwelling urinary catheter was still inserted at that time. LVN 1 then notified LVN 2 about the physician ' s order to remove the resident ' s urinary catheter. LVN 2 stated she assisted LVN 1 in removing Resident 1 ' s indwelling catheter. LVN 2 stated she tried helping LVN 1 with the resident ' s paperwork while LVN 1 calls for transportation to the GACH. LVN 2 stated that after ,d+[DATE] minutes with no available transportation contacted, RN 1 went to the resident ' s room and saw the resident with labored breathing. LVN 2 stated calling 911 while LVN 1 went to the resident. LVN 2 stated RT 1 was using an ambubag (hand-held self-inflating bag used to provide ventilation to patients who are not breathing or not breathing adequately) on the resident. During an interview and concurrent record review, on [DATE] at 3:45 p.m., LVN 1 stated she inaccurately documented in Resident 1 ' s TAR for [DATE] during her shift (from 3 p.m. to 11 p.m.). LVN 1 stated she indicated zero (0) for no S/S of UTI present (when resident had hematuria) and (N) for no bleeding at that time. During an interview and concurrent record review, on [DATE] at 3:44 p.m., the DON stated LVN 1 documented accurately in Resident 1 ' s TAR on [DATE] during the 3 p.m. to 11 p.m. shift as zero (0) because the bleeding was not observed in the catheter but in the resident ' s incontinent brief. On [DATE] at 3:15 p.m., during an interview, LVN 1 stated the documentation of Resident 1 ' s urine characteristics including color, odor, and appearance, could not be documented in the TAR as all S/S of UTI were grouped to indicate either a plus (+) sign or zero (0). LVN 1 stated she told Physician 1 about Resident 1 ' s blood in the urine but she did not document it. A review of the facility ' s P&P titled, Catheter Care, Urinary, last revised on [DATE] indicated the following information should be recorded in the resident medical records: 3. Character of urine such as color (straw-colored, dark, or red), clarity (cloudy, solid particles, or blood), and odor. 4. Any problems noted at the catheter-urethral junction during perineal care such as drainage, redness, bleeding, irritation, crusting, or pain. A review of the facility ' s P&P titled, Catheterizations, last revised on [DATE] indicated nursing staff is responsible of monitoring the resident for possible complications. A review of the facility ' s P&P titled, Change of Condition, last revised on [DATE], indicated to ensure proper assessment and follow-through for any resident with a change of condition. A change of condition is sudden or marked difference in resident ' s: 4. Output (e.g., low urine output, stool, hematuria, diarrhea, constipation, impaction [a mass of fecal material that is too large or too firm, or both, to pass through the anus], vomiting). A review of the facility ' s P&P titled, Vital Signs, Weights, Height, last revised on [DATE], indicated the resident ' s vital signs shall be recorded as the physician ' s order indicates, or as frequently as the resident ' s condition warrants. Vital signs shall be taken and recorded in accordance with the resident ' s condition, current treatment plan, and as prescribed by the attending physician. The physician shall be notified promptly when the vitals are out of range from the acceptable parameters provided. A review of the facility ' s P&P titled, Documentation Principles, last revised on [DATE], indicated resident ' s health record shall be current and kept in detail consistent with good medical and professional practices based on the service provided to each resident. Based on interview and record review, the facility failed to provide care and treatment for one of five sampled residents (Resident 1), who was dependent on staff for care, was at risk of bleeding and hypoglycemia (condition that occurs when the sugar levels [glucose]in the blood are too low), and was at risk for urinary tract infection (UTI - infection that happens when germs enter the urethra [the tube that allows urine from the urinary bladder, a sac that holds urine for temporary storage, exit the body during urination) due to the use of an indwelling urinary catheter (a hollow flexible tube inserted in the bladder through the urethra to drain urine), received treatment and care in accordance with the comprehensive plan of care and professional standards of practice to meet the resident's care needs by: 1. Not monitoring and accurately documenting Resident 1's urine characteristics (such as color, odor, pain or discomfort, presence of blood [hematuria - blood in the urine]) as indicated in the plans of care, to promptly identify UTI in order to mitigate (to alleviate) the infection and prevent complications (such as repeated UTIs [two or more UTIs within six months or three or more within a year] and sepsis [a life-threatening reaction to infection that can lead to tissue damage, organ failure, and death]). 2. Not implementing Physician 1's order to monitor Resident 1's urinary drainage bag (collects urine) and document the presence of signs (objective findings that can be seen or measured) and symptoms (subjective and can be perceived only by the person affected) of UTI every shift (7 a.m. to 3 p.m. shift, 3 p.m. to 11 p.m. shift, and 11 p.m. to 7 a.m. shift). 3. Licensed Vocational Nurse 1 (LVN 1) not evaluating Resident 1's vital signs (measurements of the body's most basic functions; the four main vital signs routinely monitored are body temperature, heart rate, respiration rate, and blood pressure [the pressure of circulating blood against the walls of blood vessels]), oxygen saturation (O2 sat, the amount of oxygen circulating in the blood); and blood sugar level to promptly identify Resident 1's change of condition (COC) on [DATE], starting at 3:55 p.m. when Resident 1 was found with hematuria, in order to provide Physician 1 with the overall Resident 1's condition. In addition, LVN 1 did not seek guidance from a registered nurse (RN). 4. Not monitoring Resident 1's condition on [DATE] from 4:06 p.m. to 8:50 p.m. at a total of four hours and 44 minutes, despite knowing that Resident 1 had hematuria since 3:55 p.m. 5. LVN 1 not administering orange juice via gastrostomy tube (GT - a soft tubing inserted under surgery through the abdomen into the stomach to administer nutrition, fluids, and medications) to Resident 1 on [DATE] at 9:20 p.m., when Resident 1's blood sugar was 67 milligrams per deciliters (mg/dL - unit of measure; ideal range is between 70 mg/dL and 100 mg/dL) as ordered and as indicated in the plan of care. 6. LVN 1 not clarifying with Physician 1 the order dated [DATE] at 9:20 p.m., to transfer Resident 1 to GACH 1 whether to transfer via paramedics (911 - emergency telephone number for Emergency Medical Services [EMS] health personnel trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital) or via regular ambulance. In addition, LVN 1 did not seek guidance from an RN. 7. Not implementing the facility's policies and procedures (P&P) on Catheter Care, Urinary; Catheterizations; Change of Condition; Vital Signs, Weights, Height; and Documentation Principles. As a result, on [DATE] there was a delay of six hours and 38 minutes in transferring Resident 1 to GACH 1 to receive the needed medical interventions. Resident 1's condition deteriorated, and the resident subsequently died at GACH 1 on [DATE]. On [DATE], at 5:58 p.m. during an abbreviated survey, the Survey State Agency (SSA) called 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) in the presence of the Administrator (ADM) and the Director of Nursing (DON) about the facility's failure to ensure Resident 1 received care and treatment based on the person-centered plan of care and professional standards of practice (42 CFR S483.25). On [DATE], at 2:14 p.m. the ADM submitted an acceptable Removal Plan (a detailed plan to address the IJ findings) and while onsite, the surveyor verified the implementations of the Removal Plan through observations, interviews, and record reviews. The SSA confirmed the removal of the IJ situation onsite on [DATE], at 2:52 p.m., in the presence of the ADM and the DON. The acceptable IJ Removal Plan included the following: a. The DON reviewed and revised the electronic Treatment Administration Record (TAR) UTI monitoring tool, to include documenting the presence or absence of signs and symptoms of UTI such as observing for color, consistency, odor, hematuria, bladder distention (enlarged or inflamed bladder), or burning sensations. If an abnormal finding is identified, a pop-up (a small window that appears while browsing a website) will appear on the TAR to instruct the licensed nurse to document in a progress note the specific finding, and to promptly notify the RN and report to the physician. b. All LVNs and RNs completed and passed a competency (measurable pattern of knowledge, skills, abilities, behaviors in order to perform occupational functions successfully) test to ensure all licensed nurses can identify UTI signs and symptoms such as observing for color, consistency, odor, hematuria, bladder distention, or burning sensations, and can properly manage change of conditions specific to abnormal vital signs (like sudden or marked difference in resident's temperature, pulse rate, blood pressure, irregular pulse, or shortness of breath). c. The DON provided one-to-one (only to one individual) training about the importance of increased monitoring of residents' status and notifying the physician of any abnormal findings; calling paramedics when residents have critical vital signs such as low blood pressure, high heart rate, and low blood sugar to prevent the delay in provision of care and services. d. The DON and the Clinical Care Coordinator (CCC) reviewed residents who had changes of conditions within the last 30 days to ensure there were no delays in the provision of care and services. No other residents were affected by the deficient practice and no delayed care was identified. e. The ADM and the Quality Assurance (QA) nurse reviewed and revised the Change of Condition policy and procedures on [DATE]. Findings: A review of Resident 1's Admission Record (face sheet) indicated the facility admitted the resident on [DATE] and readmitted the resident on [DATE]. Re[TRUNCATED]

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1), who was at risk for urinary tract infection (UTI - infection that happens when germs enter the urethra [the tube that allows urine from the urinary bladder, a sac that holds urine for temporary storage, exit the body during urination), was accurately and continuously monitored for signs (objective findings that can be seen or measured) and symptoms (subjective data that can be perceived only by the person affected) of UTI (such as complaints of pain, burning sensation, increase in frequency and urgency during urination, increased temperature, or change in urine character [color, odor, amount, and clarity]) to prevent complications (such as repeated UTIs [two or more UTIs within six months or three or more within a year] and sepsis [a life-threatening reaction to infection that can lead to tissue damage, organ failure, and death]). The failures included: 1. Having a documentation in the Treatment Administration Record (TAR) of the signs and symptoms (S/S) of UTI, grouped to indicate a plus (+) if the S/S were present, or zero (0) if S/S of UTI were not present, during each of the nursing shift (7 a.m. to 3 p.m. shift, 3 p.m. to 11 p.m. shift, and 11 p.m. to 7 a.m. shift). 2. Having no policies and procedures (P&P) on how to document if there were any S/S of UTI present. 3. Documenting Resident 1 had zero (0) S/S of UTI throughout the resident's stays from [DATE] to [DATE] and from [DATE] to [DATE] when both times Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) where she was diagnosed with UTI and sepsis. 4. Licensed Vocational Nurse 1 (LVN 1) and Licensed Vocational Nurse 2 (LVN 2) not identifying and not documenting Resident 1's S/S of UTI. 5. LVN 1 not taking Resident 1's vital signs (measurements of the body's most basic functions; the four main vital signs routinely monitored are body temperature, heart rate, respiration rate, and blood pressure [the pressure of circulating blood against the blood vessel walls]) on [DATE] from 3:55 p.m. when Resident 1 was found with hematuria (presence of blood in the urine) to 9:20 p.m. to promptly identify Resident 1's need of prompt medical interventions. 6. LVN 1 and LVN 2 not promptly informing a registered nurse (RN) when Resident 1 had blood pressure of ,d+[DATE] millimeters of mercury (mmHg - measurement of pressure inside the blood vessels; ideal blood pressure range is between ,d+[DATE] mmHg and ,d+[DATE] mmHg), heart rate of 119 beats per minute (bpm; ideal range is between 60 bpm and 100 bpm), oxygen saturation (the amount of oxygen circulating in the blood) of 94% (ideal range is between 95% and 100%), and blood glucose (a type of sugar in the blood) of 67 milligrams per deciliters (mg/dL - unit of measure; ideal range is between 70 mg/dL and 100 mg/dL). 7. Not implementing the facility's policies and procedures (P&P) on Catheter (a tube inserted into the bladder to drain urine) Care, Urinary; Catheterizations (procedures used to drain the bladder and collect urine through a flexible tube); Change of Condition; Vital Signs, Weights, Height; and Documentation Principles. As a result, Resident 1 suffered recurrent (occurring often or repeatedly) unidentified UTI and sepsis on [DATE] and [DATE]. Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) via paramedics (911 - emergency telephone number for Emergency Medical Services [EMS] health personnel trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital) on [DATE]. Resident 1's condition deteriorated, and the resident subsequently died at GACH 1 on [DATE]. On [DATE] at 5:58 p.m., during an abbreviated survey, the Survey State Agency (SSA) called 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) in the presence of the Administrator (ADM) and the Director of Nursing (DON) about the facility's failure to ensure Resident 1 received appropriate treatment and services to prevent UTIs (42 CFR S483.25[e][1]), per physician's orders, plan of care, and facility's policies and procedures (P&P). On [DATE] at 2:14 p.m., the ADM submitted an acceptable Removal Plan (a detailed plan to address the IJ findings) and while onsite, the surveyor verified the implementations of the Removal Plan through observations, interviews, and record reviews. The SSA confirmed the removal of the IJ situation on [DATE] at 2:52 p.m., in the presence of the ADM and the DON. The acceptable IJ Removal Plan included the following: a. The DON reviewed and revised the electronic Treatment Administration Record (TAR) UTI monitoring tool, to include documenting the presence or absence of signs and symptoms of UTI such as observing for color, consistency, odor, hematuria, bladder distention (enlarged or inflamed bladder), or burning sensations. If an abnormal finding is identified, a pop-up (a small window that appears while browsing a website) will appear on the TAR to instruct the licensed nurse to document in a progress note the specific finding, and to promptly notify the RN and report to the physician. b. All LVNs and RNs completed and passed a competency (measurable pattern of knowledge, skills, abilities, behaviors in order to perform occupational functions successfully) test to ensure all licensed nurses can identify UTI signs and symptoms such as observing for color, consistency, odor, hematuria, bladder distention, or burning sensations, and can properly manage change of conditions specific to abnormal vital signs (like sudden or marked difference in resident's temperature, pulse rate, blood pressure, irregular pulse, or shortness of breath). c. The DON provided one-to-one (only to one individual) training about the importance of increased monitoring of residents' status and notifying the physician of any abnormal findings; calling paramedics when residents have critical vital signs such as low blood pressure, high heart rate, and low blood sugar to prevent the delay in provision of care and services; and properly documenting the presence or absence of UTI signs and symptoms. d. The DON and the Clinical Care Coordinator (CCC) reviewed residents who had changes of conditions within the last 30 days to ensure there were no delays in the provision of care and services. No other residents were affected by the deficient practice and no delayed care was identified. e. The DON and the CCC reviewed the residents with indwelling urinary catheters (a hollow flexible tube inserted in the bladder through the urethra to drain urine) and high risk for UTIs to ensure there were no delay of provision of care and services. No other residents were identified of the deficient practices. f. The ADM and the Quality Assurance (QA) nurse reviewed and revised the Change of Condition policy and procedures on [DATE]. Findings: A review of Resident 1's Admission Record (face sheet) indicated the facility admitted the resident on [DATE] with diagnoses including essential (primary) hypertension (the blood is pumping with more force than normal through the arteries [blood vessels that distribute oxygen-rich blood to your entire body]), and aphasia (loss of ability to produce or understand language) and dysphagia (difficulty swallowing) following cerebral infarction (stroke, disrupted blood flow to the brain). Other diagnoses included type 2 diabetes mellitus (body does not make enough insulin [a hormone that lowers the level of glucose, a type of sugar in the blood] or cannot use it as well as it should), sacral (triangular shaped bone at the base of the spine) pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin), foot ulcer (open sore or lesion that will not heal or that return over a long period of time), and dehydration (a harmful reduction in the amount of water in the body). A review of the Physician's Orders for Resident 1, dated [DATE], indicated: - Admit to hospice care (special kind of care that focuses on the quality of life for people who are experiencing an advanced, life-limiting illness). - Change the Foley (type of an indwelling urinary catheter) catheter as needed when clogged, soiled, or pulled out. - Change the Foley catheter starting on the 15th and ending on the 15th every month. - Monitor the Foley catheter urinary drainage bag (collects urine) and document a plus (+) sign for presence of S/S of UTI and zero (0) for absence of S/S of UTI every shift. A review of Resident 1's Care Plan, developed on [DATE], for the resident's impaired elimination (movement of urine or feces from the body) indicated the use of indwelling catheter due to wound management. The Care Plan indicated a goal for Resident 1 to have reduced risk of UTI daily. The interventions included to monitor signs and symptoms of UTI, to provide frequent incontinent care (care addressing loss of bowel and/or bladder control), and to change the Foley catheter and drainage bag according to policy. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated [DATE], indicated the resident rarely/never made self understood and rarely/never understood others. The MDS indicated Resident 1 was totally dependent on bed mobility, transfer, dressing, eating (via enteral feeding - way of delivering nutrition directly to the stomach through tube feeding), toilet use, and personal hygiene. The MDS further indicated Resident 1 had an indwelling catheter and a gastrostomy tube (GT - a soft tubing inserted under surgery through the abdomen into the stomach to administer nutrition, fluids, and medications). A review of Resident 1's Care Plan, developed on [DATE], for the resident's risk of unavoidable recurrent UTI due to history of UTI and catheter use, had a goal to reduce the risk of recurrence through daily interventions. The interventions included to notify the physician if the resident has any S/S of UTI. A review of Resident 1's Licensed Nursing Note, dated [DATE], indicated Family Member 1 (FM 1) asked about the care Resident 1 received and then proceeded to call the paramedics to get my mom out of here. The note also indicated the facility notified the hospice agency that FM 1 withdrew the resident from hospice care. Resident 1 left the facility accompanied by the paramedics, on [DATE] at 1:03 p.m. to GACH 1. A review of Resident 1's GACH 1 History and Physical (H & P), dated [DATE], indicated the resident presented to the emergency department after the family requested the transfer, and requested to break (cancel) hospice if admission to the hospital was needed. The H & P indicated the resident was reportedly very uncomfortable and moaning at the facility and the facility was not actively managing Resident 1's symptoms. The H & P also indicated Resident 1 was febrile (elevated body temperature [fever] 101 degrees Fahrenheit [ F - scale for measuring temperature], normal range is between 97 F to 99 F), tachycardic (abnormally elevated heart rate), and appeared dry and pale. The H & P indicated Resident 1 was positive (diagnosed ) for UTI. The reason for GACH 1 admission of Resident 1 was sepsis. A review of Resident 1's GACH 1 Discharge Summary, dated [DATE], indicated Resident 1 was treated for sepsis due to UTI from Proteus (a type of bacterium [one-cell microorganism] that is a frequent cause of catheter-associated UTIs [CAUTIs]). A review of Resident 1's GACH 1 Patient Discharge Instructions indicated the resident was discharged to the facility on [DATE]. A review of Resident 1's Licensed Nursing Note and TARs from [DATE] to [DATE] indicated no documentation that the resident manifested S/S of UTI. The TAR indicated zero (0) for absence of S/S of UTI in the urine every shift. On [DATE], there was no documentation of Resident 1 having a change of condition or being uncomfortable and moaning as identified by FM 1 and as reported to the staff of GACH 1. A review of Resident 1's Admission Record indicated the facility readmitted the resident on [DATE] with new diagnoses of UTI and sepsis. A review of the Physician's Orders after Resident 1's readmission, dated [DATE], indicated: - Change the Foley catheter as needed when clogged, soiled, or pulled out. - Change the Foley catheter starting on the 15th and ending on the 15th every month. - Monitor the Foley catheter urinary drainage bag and document a plus (+) sign for presence of S/S of UTI and zero (0) for absence of S/S of UTI every shift. A review of Resident 1's Change of Condition (COC)/Interact Assessment Form, dated [DATE], completed by LVN 1 indicated: - At 3:55 p.m., Certified Nursing Assistant 1 (CNA 1) informed the Charge Nurse (LVN 1) that Resident 1's urinary catheter was leaking (of urine). LVN 1 went to check on the resident and when trying to replace the catheter (with a new one), LVN 1 noticed the presence of hematuria. There was no documentation at that time that the nurses took Resident 1's vital signs to identify any changes. - At 4:06 p.m., LVN 1 called and notified Resident 1's attending physician (Physician 1) who ordered urinalysis (a laboratory test of the urine) and urine culture (urine test that can identify the germ causing a UTI). There was no documentation at that time that the nurses took Resident 1's vital signs to identify any changes. There was also no further documentation to indicate the status of Resident 1's bleeding from the urine until the next notes were entered at 8:50 p.m. - At 8:50 p.m., CNA 1 notified LVN 1 that Resident 1's incontinent brief was full of blood. LVN 1 also indicated the resident had quite an amount of blood and proceeded to notify Physician 1 to ask if he wanted to order a straight catheter (a hollow flexible tube inserted in the bladder through the urethra to quickly drain urine once) to obtain the urine sample for the laboratory tests, or if Physician 1 wanted to send Resident 1 out (to a GACH). Physician 1 ordered to reinsert an indwelling catheter to monitor the amount of blood. There was no documentation at that time that the nurses took Resident 1's vital signs to identify any changes. - At 9:20 p.m., LVN 1 and LVN 2 went to replace Resident 1's Foley catheter. LVN 1 checked Resident 1's vital signs after the urinary catheter insertion. Resident 1's blood pressure was ,d+[DATE] mmHg, the heart rate was 119 bpm, the oxygen saturation was 94%, and the blood glucose was 67 mg/dL. LVN 1 notified Physician 1 who ordered to send Resident 1 out (to a GACH). LVN 1 documented trying to call several ambulances (companies) but none were available. There was no documentation at that time that LVN 1 called 911 to request for paramedics. - At 10:15 p.m., the Subacute Unit RN (RN 1, assigned to another unit of the facility that cares for residents needing more intensive care than those typically received in skilled nursing facilities [SNF - unit of the facility where residents need regular nursing care and other health-related services] but less intensive than acute care) informed LVN 1 that Resident 1's oxygen saturation dropped to 80%. The documentation further indicated that 911 was called (the notes did not indicate the name of the staff who called 911) and the respiratory therapist (RT 1) bagged (use of manual resuscitators to ventilate a patient in medical emergencies when the patient's breathing is insufficient or has ceased completely) Resident 1. The paramedics arrived at 10:30 p.m. and took Resident 1 to GACH 1 on [DATE] at 10:44 p.m. A review of Resident 1's Licensed Nursing Notes and TARs from [DATE] to [DATE] indicated no documentation that the resident manifested S/S of UTI. The TARs indicated zero (0) for absence of S/S of UTI in the urine every shift. A review of Resident 1's GACH 1 Emergency Department (ED) Physician Note, dated [DATE], indicated Resident 1 arrived at GACH 1 on [DATE] and was seen by the ED physician at 10:59 p.m. Resident 1 had altered mental status and hypoxic respiratory failure (absence of enough oxygen in the tissues to sustain bodily functions). The notes also indicated the EMS intubated (inserting a tube through a person's mouth or nose, then down into the trachea [airway/windpipe] to keep the trachea open so that air can get through) Resident 1 on the way to the hospital. The notes further indicated Resident 1 was tachycardic with blood in her Foley catheter and her incontinent brief. The pulse rate taken on [DATE] at 11 p.m. indicated it was 130 bpm. Resident 1's urine laboratory test indicated significant pyuria (pus in the urine). Resident 1 required transfer to the Intensive Care Unit (ICU, a designated area of a hospital that is dedicated to the care of patients who are critically ill). A review of Resident 1's GACH 1 Discharge Summary, dated [DATE], indicated the resident's discharge diagnoses included severe sepsis and septic shock (a life-threatening condition that occurs when a widespread infection leads to dangerously low blood pressure) due to UTI which was present on admission (POA), acute (severe and sudden onset) hypoxic respiratory failure, and on mechanical ventilator (a form of life support; a machine takes over the work of breathing when a person is not able to breathe enough on his/her own). Other diagnoses included severe anemia (the body does not get enough oxygen-rich blood) with acute blood loss component, hemorrhagic cystitis (condition in which the urinary bladder lining becomes inflamed resulting in bleeding and pain), acute renal failure (a sudden episode of kidney failure when the kidneys suddenly stop working properly which happens within a few hours or a few days), and metabolic acidosis (buildup of too much acid in the body due to kidney failure). Resident 1 developed cardiac arrest (when the heart suddenly and unexpectedly stops pumping) and expired (died ) on [DATE]. During an interview, on [DATE] at 3:35 p.m., LVN 1 stated that on [DATE] at around 3:55 p.m., CNA 1 notified her that Resident 1's urinary catheter was leaking and that the resident had blood in the urine. Upon assessment of Resident 1, LVN 1 stated she saw pink/reddish blood in the resident's incontinent brief. LVN 1 stated she then removed Resident 1's urinary catheter. LVN 1 stated she notified Physician 1 about the situation and obtained physician orders for UA and culture at 4:06 p.m. LVN 1 further stated that on [DATE] at around 8 p.m., CNA 1 informed her that Resident 1 had blood in the resident's incontinent brief. LVN 1 then assessed Resident 1 and observed bright red and thick blood in the resident's incontinent brief. LVN 1 stated she was sending text messages to the DON which was why she notified Physician 1 around 8:43 p.m., a delay of 43 minutes from the time CNA 1 had notified LVN 1 of Resident 1's condition. LVN 1 stated Physician 1 ordered to insert a new urinary catheter which she carried out (performed). LVN 1 also stated she did not check Resident 1's vital signs during the resident's change of condition. LVN 1 stated she should have checked Resident 1's vital signs as part of the Change of Condition policy and procedures. LVN 1 stated that on [DATE] at 9:20 p.m., she notified Physician 1 of Resident 1's BP of ,d+[DATE] mmHg, pulse rate of 119 bpm, and blood sugar of 67 mg/dl. Physician 1 ordered to transfer Resident 1 to GACH 1. LVN 1 stated she did not clarify if Physician 1 wanted Resident 1 to be sent to GACH 1 immediately by calling paramedics or just by calling regular transport ambulance. LVN 1 stated she called ambulance companies, but none were available. LVN 1 further stated RN 1 informed her (LVN 1) that on [DATE] at 10:15 p.m., Resident 1's oxygen saturation was low at 80%. 911 was called by staff (LVN 2). LVN 1 stated Resident 1 was not opening her eyes and had labored breathing (difficulty with breathing) at that time. LVN 1 stated RT 1 began to bag (used manual resuscitator to ventilate the patient) Resident 1. LVN 1 stated Resident 1's BP of ,d+[DATE] mmHg was low for the resident. LVN 1 stated if she had been monitoring Resident 1's vital signs, she may have caught the low blood pressure and may have informed Physician 1 to obtain an order. LVN 1 also stated Resident 1's blood sugar of 67 mg/dL was low, and they should notify the doctor if the resident's blood sugar is 70 mg/dL or less. LVN 1 stated calling 911 should have been faster and that Resident 1 could have been harmed because of the low oxygen saturation and the low BP. During an interview, on [DATE] at 4:50 p.m., CNA 1 stated that on [DATE] at around 4 p.m., she was providing perineal care (involves cleaning the genital and rectal areas) to Resident 1 when she saw blood in the resident's incontinent brief. CNA 1 stated she notified LVN 1 about it. CNA 1 further that stated on [DATE] at around 7 p.m., she observed Resident 1 with blood in the incontinent brief and the whole incontinent pad was soaked in bright red blood. CNA 1 stated she then informed LVN 1. During an interview, on [DATE] at 12:17 p.m., RN 1 stated that LVN 2 approached her on [DATE] around 10 p.m. asking what transportation to call for Resident 1's transfer to the GACH. RN 1 stated she went to Resident 1's room and observed the resident gasping for breath (struggling to breathe) and the resident's urinary catheter tubing had light red blood. RN 1 checked Resident 1's oxygen saturation which was at 80%. RN 1 stated she ran out to call the respiratory therapist (RT 1) who came right away and assisted. RN 1 stated not checking the resident's vital signs at that time because she was concerned about the resident's breathing. RN 1 stated not being sure if LVN 1 took Resident 1's vital signs then but RN 1 stated she (RN 1) did not. RN 1 stated for a resident who becomes unresponsive, staff should check the resident's vital signs and call 911. RN 1 stated the paramedics arrived within 10 minutes of the call. RN 1 stated she oversees the Subacute Unit and not the SNF side (where Resident 1 was located) of the facility. RN 1 stated she was the only RN during that shift. RN 1 stated LVN 1 reported to the physician. RN 1 stated she has never worked with Resident 1 in the past. RN 1 stated she got involved in the situation because she was asked help for Resident 1's transfer and paperwork. During an interview, on [DATE] at 1:07 p.m., LVN 2 stated that LVN 1 notified her on [DATE] during the 3 p.m. to 11 p.m. shift about Resident 1 having blood in the incontinent brief. LVN 2 told LVN 1 that she (LVN 2) can help as needed. LVN 2 stated going to Resident 1's room around 4 p.m. and assessed the resident's incontinent brief which had moderate amount of light red blood in the urine; the resident's indwelling urinary catheter was still inserted at that time. LVN 1 then notified LVN 2 about the physician's order to remove the resident's urinary catheter. LVN 2 stated she assisted LVN 1 in removing Resident 1's indwelling catheter. LVN 2 stated she tried helping LVN 1 with the resident's paperwork while LVN 1 calls for transportation to the GACH. LVN 2 stated that after ,d+[DATE] minutes with no available transportation contacted, RN 1 went to the resident's room and saw the resident with labored breathing. LVN 2 stated calling 911 while LVN 1 went to the resident. LVN 2 stated RT 1 was using an ambubag (hand-held self-inflating bag used to provide ventilation to patients who are not breathing or not breathing adequately) on the resident. During an interview and concurrent record review, on [DATE] at 3:45 p.m., LVN 1 stated she inaccurately documented in Resident 1's TAR for [DATE] during her shift (from 3 p.m. to 11 p.m.). LVN 1 stated she indicated zero (0) for no S/S of UTI present (when resident had hematuria) and (N) for no bleeding at that time. On [DATE] at 4:19 p.m., during an interview and concurrent record review, Resident 1's Licensed Nursing Notes and TARs from [DATE] to [DATE] did not have documentation that Resident 1 manifested signs and symptoms of UTI. LVN 1 stated the TARs indicated zero (0) for absence of S/S of UTI in the urine every shift. LVN 1 also stated that on [DATE], there was no documentation of Resident 1 having a change of condition or being uncomfortable and moaning, as identified by FM 1 and as reported to the staff at GACH 1. LVN 1 stated the licensed nurses were not accurately documenting S/S of UTI. During an interview and concurrent record review, on [DATE] at 3:44 p.m., the DON stated LVN 1 documented accurately in Resident 1's TAR (where they are monitoring the urinary drainage bag for presence or absence of S/S of UTI) on [DATE] during the 3 p.m. to 11 p.m. shift as zero (0) because the bleeding was not observed in the catheter but in the resident's incontinent brief. On [DATE] at 3:15 p.m., during an interview, LVN 1 stated the documentation of Resident 1's urine characteristics including color, odor, and appearance, could not be documented in the TAR as all S/S of UTI were grouped to indicate either a plus (+) sign or zero (0). LVN 1 stated she told Physician 1 about Resident 1's blood in the urine but she did not document it. A review of the facility's P&P titled, Catheter Care, Urinary, last revised on [DATE] indicated the following information should be recorded in the resident medical records: 3. Character of urine such as color (straw-colored, dark, or red), clarity (cloudy, solid particles, or blood), and odor. 4. Any problems noted at the catheter-urethral junction (area where the catheter meets the urethral opening) during perineal care such as drainage, redness, bleeding, irritation, crusting, or pain. A review of the facility's P&P titled, Catheterizations, last revised on [DATE] indicated nursing staff is responsible of monitoring the resident for possible complications. A review of the facility's P&P titled, Change of Condition, last revised on [DATE], indicated to ensure proper assessment and follow-through for any resident with a change of condition. A change of condition is sudden or marked difference in resident's: 4. Output (e.g., low urine output, stool, hematuria, diarrhea, constipation, impaction [a mass of fecal material that is too large or too firm, or both, to pass through the anus], vomiting). A review of the facility's P&P titled, Vital Signs, Weights, Height, last revised on [DATE], indicated the resident's vital signs shall be recorded as the physician's order indicates, or as frequently as the resident's condition warrants. Vital signs shall be taken and recorded in accordance with the resident's condition, current treatment plan, and as prescribed by the attending physician. The physician shall be notified promptly when the vitals are out of range from the acceptable parameters provided. A review of the facility's P&P titled, Documentation Principles, last revised on [DATE], indicated resident's health record shall be current and kept in detail consistent with good medical and professional practices based on the service provided to each resident. Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1), who was at risk for urinary tract infection (UTI - infection that happens when germs enter the urethra [the tube that allows urine from the urinary bladder, a sac that holds urine for temporary storage, exit the body during urination), was accurately and continuously monitored for signs (objective findings that can be seen or measured) and symptoms (subjective data that can be perceived only by the person affected) of UTI (such as complaints of pain, burning sensation, increase in frequency and urgency during urination, increased temperature, or change in urine character [color, odor, amount, and clarity]) to prevent complications (such as repeated UTIs [two or more UTIs within six months or three or more within a year] and sepsis [a life-threatening reaction to infection that can lead to tissue damage, organ failure, and death]). The failures included: 1. Having a documentation in the Treatment Administration Record (TAR) of the signs and symptoms (S/S) of UTI, grouped to indicate a plus (+) if the S/S were present, or zero (0) if S/S of UTI were not present, during each of the nursing shift (7 a.m. to 3 p.m. shift, 3 p.m. to 11 p.m. shift, and 11 p.m. to 7 a.m. shift). 2. Having no policies and procedures (P&P) on how to document if there were any S/S of UTI present. 3. Documenting Resident 1 had zero (0) S/S of UTI throughout the resident's stays from [DATE] to [DATE] and from [DATE] to [DATE] when both times Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) where she was diagnosed with UTI and sepsis. 4. Licensed Vocational Nurse 1 (LVN 1) and Licensed Vocational Nurse 2 (LVN 2) not identifying and not documenting Resident 1's S/S of UTI. 5. LVN 1 not taking Resident 1's vital signs (measurements of the body's most basic functions; the four main vital signs routinely monitored are body temperature, heart rate, respiration rate, and blood pressure [the pressure of circulating blood against the blood vessel walls]) on [DATE] from 3:55 p.m. when Resident 1 was found with hematuria (presence of blood in the urine) to 9:20 p.m. to promptly identify Resident 1's need of prompt medical interventions. 6. LVN 1 and LVN 2 not promptly informing a registered nurse (RN) when Resident 1 had blood pressure of ,d+[DATE] millimeters of mercury (mmHg - measurement of pressure inside the blood vessels; ideal blood pressure range is between ,d+[DATE] mmHg and ,d+[DATE] mmHg), heart rate of 119 beats per minute (bpm; ideal range is between 60 bpm and 100 bpm), oxygen saturation (the amount of oxygen circulating in the blood) of 94% (ideal range is between 95% and 100%), and blood glucose (a type of sugar in the blood) of 67 milligrams per deciliters (mg/dL - unit of measure; ideal range is between 70 mg/dL and 100 mg/dL). 7. Not implementing the facility's policies and procedures (P&P) on Catheter (a tube inserted into the bladder to drain urine) Care, Urinary; Catheterizations (procedures used to drain the bladder and collect urine through a flexible tube); Change of Condition; Vital Signs, Weights, Height; and Documentation Principles. As a result, Resident 1 suffered recurrent (occurring often or repeatedly) unidentified UTI and sepsis on [DATE] and [DATE]. Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) via paramedics (911 - emergency telephone number for Emergency Medical Services [EMS] health personnel trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital) on [DATE]. Resident 1's condition deteriorated, and the resident subsequently died at GACH 1 on [DATE]. On [DATE] at 5:58 p.m., during an abbreviated survey, the Survey State Agency (SSA) called 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) in the presence of the Administrator (ADM) and the Director of Nursing (DON) about the facility's failure to ensure Resident 1 received appropriate treatment and services to prevent UTIs (42 CFR S483.25[e][1]), per physician's orders, plan of care, and facility's policies and procedures (P&P). On [DATE] at 2:14 p.m., the ADM submitted an acceptable Removal Plan (a detailed plan to address the IJ findings) and while onsite, the surveyor verified the implementations of the Removal Plan through observations, interviews, and record reviews. The SSA confirmed the removal of the IJ situation on [DATE] at 2:52 p.m., in the presence of the ADM and the DON. The acceptable IJ Removal Plan included the following: a. The DON reviewed and revised the electronic Treatment Administration Record (TAR) UTI monitor [TRUNCATED]

Based on observation, interview, and record review, the facility failed to provide supervision and assistive devices to prevent accident and injury for one of four sampled residents (Resident 1), who was assessed as high fall risk and had history of falls. The facility failed to ensure the tab alarm (a safety device consisting of a pull-string that attaches magnetically to the alarm [placed on the bed or the wheelchair] and to the resident with a garment clip; it alerts the staff when movement [attempting to get up without assistance] is detected while the resident is in bed and chair; staff in the area could respond immediately and may prevent falls) was in use as ordered by the physician. As a result, on 10/10/2022, at 1:40 a.m., Resident 1 got out of bed unnoticed by staff, fell and sustained a fracture (broken bone) on the left hip. Resident 1 required transfer to General Acute Care Hospital 1 (GACH 1) where he had a surgery on 10/11/2022 to repair the fracture. Findings: A review of Resident 1 ' s Admission Record indicated the facility admitted the resident, a [AGE] year-old male, on 12/27/2021, with diagnoses including pedestrian injured in a traffic accident involving unspecified motor vehicle, traumatic brain injury, dysphonia (impairment of the voice), and anxiety disorder (uncontrollable feelings of nervousness and fear such that it affects a person's daily life). A review of Resident 1 ' s Care Plan developed on 3/23/2022 for the resident ' s high fall risk secondary to poor balance, restlessness with constant movements, poor safety awareness, and history of falls had a goal for Resident 1 not to have falls with injuries by the target date of 10/30/2022. The care plan indicated Resident 1 fell on [DATE] and 3/22/2022. The interventions included to observe the resident frequently (frequency not specified) and provide a safe environment. A review of the Physician ' s Order for Resident 1, dated 3/25/2022, indicated to apply every shift a tab alarm when in bed and wheelchair to alert/remind resident to ask for assistance when transferring. A review of Resident 1 ' s Fall Risk Assessment, dated 5/1/2022, indicated the resident ' s score was 24. A score of 18 or above indicated high risk for falls. A review of Resident 1 ' s Care Plan developed on admission and revised on 5/22/2022 for the resident ' s high fall risk, had a goal for to reduce the resident ' s fall and injury by the target date of 10/30/2022. The interventions included to observe the resident frequently (frequency not specified) and a safe environment. The interventions did not include the use of the tab alarm. A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care- screening tool), dated 8/1/2022, indicated the resident sometimes could make self-understood and understood others and required one-person extensive assistance with bed mobility, transferring to or from bed, walking, dressing, toilet use, and personal hygiene. Resident 1 ' s balance during surface-to-surface transitions, walking with staff assistance, moving on and off toilet, and moving from seating to standing, was not steady and could only stabilize with staff assistance. Resident 1 was a high fall risk, had history of falls, and had tab alarm used in the bed and chair daily. The MDS also indicated Resident 1 used a walker and wheelchair as mobility devices. A review of Resident 1 ' s interdisciplinary team (IDT, group of healthcare staff from different disciplines involved in the care of the resident), dated 8/1/2022, indicated the resident had two falls in the facility, the bed was kept in the lowest position, had floor mat (or landing mat, hard floor covering placed by the bed to help prevent injury from potential falls) at bedside, and tab alarm in bed and wheelchair. A review of Resident 1 ' s Changes of Condition (COC) documentation dated 10/10/2022 and timed at 1:40 a.m., indicated Certified Nursing Assistant 2 (CNA 2) reported to Licensed Vocational Nurse 1 (LVN 1) finding Resident 1 lying on the floor mat (by the bedside). LVN 1 went to Resident 1 ' s room and the resident was lying on the floor mat leaning onto another resident ' s bed with head up high. Resident 1 nodded his head when asked if he had pain on his hip area. The physician when notified ordered X-rays (painless test that produces images of the bones inside the body) of both hips immediately. The COC documentation did not include information about the tab alarm if it went off and if it was in use. A review of the Physician ' s Orders for Resident 1, dated 10/10/2022 and timed at 1:16 p.m., indicated to transfer the resident GACH 1 due a left hip fracture (identified in the X-rays). A review of Resident 1 ' s GACH 1 Operative Report dated 10/11/2022, indicated the resident underwent an open reduction and internal fixation (ORIF, type of surgery to fix broken bones) of the left hip fracture. A review of Resident 1 ' s Admission Record indicated the resident returned to the facility on [DATE]. A review of Resident 1 ' s re-admission orders included the use of the tab alarm in bed and wheelchair for safety. On 10/24/2022, at 11:40 a.m., Resident 1 was observed in his room lying in bed, leaning on his right, with half side rail of the bed up. Resident 1 was moving repeatedly (restless), trying to sit up. There was no tab alarm or other safety device attached to Resident 1. Resident 1 could not participate in an interview due to his mental condition. CNA 1, present in the room, when asked about any safety device for Resident 1, CNA 1 responded she had been assigned to care for Resident 1 three days in a row during the day shift (7 a.m. to 3 p.m.) from 10/22/2022 to 10/24/2022, and she was not aware the resident needed a tab alarm or other safety device. On 10/24/2022, at 11:52 a.m., during an interview with Registered Nurse 1 (RN 1) in Resident 1 ' s room, RN 1 stated she was busy that morning and did not check if Resident 1 needed safety devices. On 10/24/2022, at 12:30 p.m., during an interview with the Director of Nursing (DON) and concurrent reviewed Resident 1 ' s COC dated 10/10/2022, the DON confirmed there was no documentation of the tab alarm going off or not when the resident fell . The DON stated the tab alarm was used with Resident 1 as a safety device. On 10/24/2022, at 1:10 p.m., during an interview with LVN 3 and concurrent review of Resident 1 ' s care plans prior to the fall and fracture incident dated 10/10/2022, LVN 3 stated the care plans related to fall risk did not address the use of a tab alarm. On 10/24/2022, at 2:30 p.m., during an interview, CNA 1 stated she did not hear any alarm sound when she found Resident 1 on the floor on 10/10/2022. During an interview, on 10/24/2022, at 5:15 p.m., the DON stated Resident 1 had an order for the tab alarm when in bed and wheelchair to alert staff of the resident ' s movements to reduce the fall risks. Resident 1 still had the tab alarm order as an active order, and it had not been changed. The DON could not provide documentation about the tab alarm on the day of Resident 1 ' s fall, whether it had gone off or was not in use. A review of the undated facility ' s policy and procedure titled, Personal Alarm indicated This facility will use, as indicated, a sensor pad that conveniently sounds an audible alarm when the sensor detects a patient rising out of the bed/wheelchair reminding the resident to return to a safe position while alerting the staff to a possible fall. Licensed nurses and therapists will assess the resident for potential safety issues. Residents at risk will demonstrate neuro muscular impairment/weakness, decrease mobility, poor safety and judgement, and frequent falls Check alarm system every day for proper functioning. Attend resident promptly when alarm sounds and provide appropriate assistance Nursing will monitor proper functioning and positioning of personal alarm Care plan will be developed.

Based on interview and record review, the facility failed to ensure two of three sampled residents (Resident 1 and Resident 2) were provided a safe environment and assistance to prevent accidents and injury by: 1. Not having two staff assisting Resident 1, who had functional [CONDITION(S)] (partial or complete paralysis [inability to move] from the neck down including both arms and legs), with transfers to and from bed; and 2. Not having two staff operating a Hoyer lift machine (assistive medical device to transfer residents by applying specially designed slings and pads under the resident to safely lift the resident from a bed to a chair or wheelchair and back) when transferring Resident 2 from bed to a wheelchair. As a result, Resident 1 sustained a dislocated shoulder (injury in which the upper arm bone comes out of the shoulder blade socket), and Resident 2 was placed at risk of falling from the lift machine. Findings: 1. A review of Resident 1's Admission Record indicated the facility admitted the resident, a [AGE] year-old female, on 1/29/2022 with diagnoses including [CONDITION(S)] (ALS, commonly known as Lou Gehrig's disease, a progressive neuromuscular degeneration of motor nerve cells in the brain and spinal cord), chronic [CONDITION(S)], muscle wasting and atrophy (a condition caused by disuse of the muscles or [CONDITION(S)] condition), and functional [CONDITION(S)]. A review of Resident 1's Minimum Data Set (MDS, standardized assessment and care-screening tool), dated 2/5/2022, indicated the resident had the ability to communicate needs and understand others. Resident 1 was totally dependent on staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident 1 did not walk and did not use a wheelchair or other mobility device (bedbound). Resident needed two or more staff assistance with transfers. Resident 1 was continent (able to control) of bowel and bladder functions. A review of Resident 1's Care Plan developed on admission and revised on 2/8/2022 for the resident's Self-Care Deficit with activities of daily living (ADLs, such as bed mobility, personal hygiene, transfers, toilet use, and bathing) indicated in the interventions to provide Resident 1 with the assistance needed. The care plan did not indicate how staff were to transfer the resident (manually or with the use of a transferring device/equipment) and how many staff were required for transferring. A review of Resident 1's Care Plan developed on admission and revised on 2/8/2022 for the resident's Risk for Falls and injuries, had a goal to reduce the resident's risks for falls and injuries. The interventions included providing safety measures and frequent supervision and monitoring. A review of Resident 1's ADLs documentation by CNAs from 3/1/2022 to 3/18/2022, completed by CNAs indicated the resident required either the support of one or two staff. For the 7 a.m. to 3 p.m. shift, the CNAs documented Resident 1 was assisted with transfers by two persons on five days and by one person on 12 shift, Resident 1 was assisted with transfers by two persons on nine days and by one person on seven days. For the 11 p.m. to 7 a.m., the activity did not occur. A review of Resident 1's SBAR (Situation, Background, Assessment, Recommendation, a communication technique to facilitate prompt communication between the health care team member), dated 3/18/2022 at 2:15 p.m. indicated CNA 1 called for the licensed nurse's attention to Resident 1's room and the resident's right shoulder had a bony protrusion (bone bulges out or sticks out) and Resident 1 complained right shoulder pain rated 7 of 10 (7/10, rating pain scale from zero to 10, zero indicating no pain and 10 the most excruciating pain). The licensed nurse notified the attending physician was notified and ordered X-rays ([CONDITION(S)] called electromagnetic waves which create pictures of the inside of the body) of the right shoulder. A review of Resident 1's Radiology (X-rays) Results Report dated 3/18/2022 indicated in the humerus (the long bone of the upper arm) was anteriorly (front) and inferiorly (lower) dislocated with respect to the glenoid (the end of the scapula [shoulder blade]). There was no fracture but anterior shoulder dislocation (the ball and socket bones of the shoulder are separated on the front). On 3/29/2022 at 12:15 p.m., an interview with Resident 1 was conducted with the resident using a communication device (for individuals who are unable to communicate reliably with their own voices due to language and physical impairments). Resident 1 stated that on 3/18/2022 at 2:20 p.m. CNA 1 transferred her (manually) to a shower chair (a seat made for bathtubs, showers and over the toilet designed for use by people who are unable to stand to take a shower and must sit instead) when she asked to go to the restroom. When CNA 1 lifted her from bed, I heard a popping sound from my shoulder but as you see me, I can't speak. I wanted to tell him, but he didn't see me. I was in tears, and he noticed I was crying. My shoulder was hurting. Resident 1 stated two staff were supposed to transfer her, but CNA 1 did it alone. Resident 1 stated she did not want to be transferred using a lift machine but manually. On 3/29/2022 at 12:48 p.m., during an interview, CNA 1 stated on 3/18/2022, around 2:30 p.m., Resident 1 called for assistance to go to the restroom, and he transferred Resident 1 to a shower chair by himself. CNA 1 stated he placed his arms underneath the resident's armpits and transferred her to the shower chair. CNA 1 noticed Resident 1 crying and asked if she was in pain and Resident 1 nodded. CNA 1 stated he transferred Resident 1 back to the bed and called the charge nurse. CNA 1 stated he was aware two staff were needed to transfer the resident. On 3/29/2022 at 1:15 p.m., during an interview with the Assistant Director of Nursing (ADON) and concurrent record review, ADON stated Resident 1 declined to get transferred to a hospital for further evaluation on 3/18/2022 and agreed to see an orthopedist (is a medical specialty focusing on injuries and diseases affecting the bones, muscles, joints, and soft tissues). Resident 1 visited an orthopedic doctor on 3/23/2022 who said Resident 1 was not a good candidate for surgery. The ADON confirmed the MDS indicated Resident 1 needed two-person assist for transfers but the care plan for ADLs deficit did not include the need of two-person assist and the technique staff was to use when manually transferring the resident. On 04/05/2022 at 12:54 p.m., during a telephone interview, Physical Therapist 1 (PT 1) stated Resident 1 was required two-person assistance was needed for transfer. A review of the undated facility's policy and procedure titled, Avoidance of Environmental Hazards indicated the facility will strive to provide a hazard-free environment to ensure that resident's safety is maintained. A review of the undated facility's policy and procedure titled, Accident/Incident Prevention indicated that the facility strives to prevent accidents by providing an environment that is free from accident hazards over which the facility has control, as well as identification of each resident at risk for accidents/incidents and the provision of adequate care plans with procedures to prevent accidents. A review of the facility's policy and procedure titled The Resident Care Plan, undated, indicated that the facility will provide an individualized nursing care plan and to promote continuity of resident care. The policy and procedure further indicated that the care necessitated by the resident's individual needs should be recorded. 2. A review of Resident 2's Admission Record indicated the facility admitted the resident on 11/09/2012 with diagnoses at included chronic [CONDITION(S)] (a condition that results in the inability to load the blood with oxygen), contracture of muscle (the stiffening of muscles due to disease or lack of use), [CONDITION(S)] (an opening surgically created through the neck into the windpipe to allow direct access to the breathing tube), gastrostomy (an opening into the stomach from the abdominal wall), and unspecified [CONDITION(S)] disease (a group of conditions that includes stroke and blocked arteries). A review of Resident 2's MDS, dated [DATE], indicated the resident had the ability to make self-understood and understand others. Resident 2 was totally dependent on one staff with bed mobility, walking, locomotion, dressing, toilet use, and personal hygiene. Resident 2 was totally dependent on two staff with transfers. A review of Resident 2's Care Plan Self-Care Deficit with Activities of Daily Living (ADLs, such as bed mobility, personal hygiene, transfers, toilet use, and bathing), revised on 9/15/2021, indicated to provide Resident 2 with the assistance needed. The care plan did not indicate how staff were to transfer the resident (manually or with the use of a transferring device/equipment) and how many staff were required for transferring. On 3/30/2022 at 1:58 p.m., during an observation in Resident 2's room, CNA 2 used a lift device alone. CNA 2 lifted Resident 2 on the lift device, to change the bed sheets. Resident 2 remained in the lift machine during the time CNA 2 changed the bedsheets. On 03/30/2022 at 2:44 p.m., during an interview, CNA 2 stated he did not feel like bothering other co-workers and just wanted to do it alone. On 03/30/2022 at 2: 51 p.m., during an interview, the Director of Staff Development (DSD) stated the Hoyer Lift should be operated with two persons while the resident is being transferred to prevent falls from the device. A review of the facility's policy and procedure titled Hoyer Lift/Mechanical Lift undated indicated two persons were required when using a lift. A review of the facility's policy and procedure titled The Resident Care Plan, undated, indicated that the facility will provide an individualized nursing care plan and to promote continuity of resident care. The policy and procedure further indicated that the care necessitated by the resident's individual needs should be recorded.