Every finding on record at Shoreline Healthcare Center

Based on observation, interview, and record review, the facility failed to ensure residents were treated with dignity and respect for two of five sampled residents (Resident 82 and Resident 46) as evidenced by:A. Failing to ensure Resident 82 was dressed in the resident's own clothing appropriate to the time of day and consistent with the resident's preferences instead of hospital gowns.B. Failing to ensure staff spoke to Resident 46 in a respectful manner.These failures had the potential to negatively affect Resident 82 and 46's sense of dignity, autonomy (the ability to make your own choices and control your own actions), and psychosocial well being. Findings: A. During a review of Resident 82's admission Record (Face Sheet-page of the chart that contains a summary of basic information about the resident), the admission Record (Face Sheet) indicated Resident 82 was admitted to the facility on [DATE] with diagnoses including morbid obesity (an extreme level of excess body fat that poses severe, life-threatening risks to your overall health and significantly reduces life expectancy), gout (painful form of inflammatory arthritis), and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) on hips. During a review of Resident 82's History and Physical (H&P), dated 6/9/2026, the H&P indicated, Resident 82 had the capacity (ability) to make medical decisions. During a review of Resident 82's Minimum Data Set (MDS-a resident assessment tool), dated 6/11/2026, the MDS indicated Resident 82's cognitive skills for daily decision making was intact. TMDS indicated Resident 82 required maximal assistant (Helper does more than half the effort) from one staff for toilet hygiene, shower, dressing, bed mobility, transfer, and supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) from one staff for eating, oral hygiene, dressing. During a concurrent observation and interview on 6/22/2026 at 11:08 a.m., with Resident 82 in her room, Resident 82 was in bed and wearing a hospital gown. Resident 82 stated she did not want to wear a hospital gown but did not have her clothes with her. Resident 82 stated she was admitted to the facility 14 days ago, on 6/8/2026 and had been wearing the same hospital gown since admission. Resident 82 stated no one had informed her the facility offered clothes (donated) to residents that need them. Resident 82 stated she wanted to wear regular clothing. Resident 82 stated she felt ashamed to leave the room and socialize with other residents, because the other residents wore their own clothing. During a concurrent interview and record review on 6/24/2026 at 10:55 a.m., with Registered Nurse Supervisor (RNS) 1, Resident 82's Resident's Clothing and Possessions document, dated 6/8/2026 was reviewed. The Resident's Clothing and Possessions indicated Resident 82 had one phone, one phone charger, one purple color sweater, one scarf, and one blood pressure cuff on 6/6/2026. The Resident's Clothing and Possessions document indicated, Resident 82 did not have any clothing other than the purple sweater. RNS 1 stated, all residents were expected to wear their own clothes rather than hospital gowns unless they preferred to wear a gown. RNS 1 stated the facility promoted a home like environment and noted individuals did not typically wear hospital gowns at home. RNS 1 stated, this was why all residents were encouraged to wear their regular clothing to honor and respect their dignity. During an interview on 6/24/2026 at 11:12 a.m., with the Social Service Director (SSD), the SSD stated that staff should have offered Resident 82 donated clothing or contacted the resident's family members to bring clothing from home. The SSD stated that the facility had a responsibility to provide proper clothing if residents were unable to obtain their own. The SSD stated that staff should have respected and honored the resident by ensuring the resident was dressed according to their preference so they could present themselves to others properly and with dignity. During an interview on 6/25/2026 at 3:39 p.m., with the Director of Nursing (DON), the DON stated the DON stated that staff should have contacted Resident 82's family to bring clothing as soon as they realized the resident did not have proper clothing when completing the admission inventory. The DON stated that the facility encouraged residents to be dressed in their own clothing appropriate to the time of day and consistent with the resident's preferences, but instead placed the resident in hospital gowns, which did not align with promoting dignity and respect. During a review of the facility's Policy and Procedure (P&P) titled, Dignity and Privacy, dated 11/2021, the P&P indicated, Policy: It is the policy of this facility that all residents be treated with kindness, dignity and respect. PROCEDURES: 2. Residents will be appropriately dressed in clean clothes arranged comfortably on their persons and be well groomed. During a review of the facility's Policy and Procedure (P&P) titled, Resident Rights, dated 10/4/2016, the P&P indicated, Respect and Dignity. You have the right to be treated with respect and dignity, including the right to: Retain and use personal possessions, including furnishings, and clothing, as space permits, and reside and receive services in the facility with reasonable accommodation of your needs and preferences. B. During a review of Resident 46's admission Record, the admission Record indicated the facility admitted the resident on 5/20/2026, with diagnoses including wedge compression fracture of fourth lumbar vertebrae (collapse of the lower back bone), dysphagia (difficulty swallowing), cognitive communication deficit (a communication impairment caused by disrupted brain function), bundle branch block (a delay or blockage in the electrical pathways of the heart's lower chambers), benign neoplasm of cerebral meninges (tumor), and inflammatory spondylopathy (chronic inflammation in the spine and joints). During a review of resident 46's Minimum Data Set (MDS – a resident assessment tool) dated 5/26/2026, the MDS indicated Resident 46 was capable to make decisions. The MDS indicated Resident 46 needed supervision and/or touch assistance with eating, oral hygiene, and personal hygiene. The MDS indicated, Resident 46 needed substantial or maximal assistance with toileting, showering, upper body dressing, lower body dressing, putting on and taking off footwear, rolling from left to right side, sitting to lying, sit to stand, chair to bed transfer, toilet transfer and walking 10 feet. During an interview on 6/22/2026, at 9:15 a.m., with Resident 46, Resident 46 stated Certified Nurse Assistant (CNA) 6 stated you need to clean yourself and turn off the light. Resident 46 stated CNA 6 was rude to her. Resident 46 stated when she called CNA 6 to assist her to use the restroom, CNA 6 stated first you are using the bathroom on the toilet, then in the bedside and now in the bed, what's wrong with you! Resident 46 stated she informed Restorative Nurse Assistant (RNA) 1 about the situation four days ago and has not heard from RNA 1 since the incident occurred. During an interview on 6/22/2026, at 1:00 p.m., with RNA 1, RNA 1 stated Resident 46 informed her that CNA 6 was rude to her. RNA 1 stated she notified the Director of Staff Development (DSD) about Resident 46's concern with CNA 6. During an interview on 6/22/2026, at 2:20 p.m., with the Director of Staff Development (DSD), the DSD stated she was aware of the incident with Resident 46 and CNA 6. The DSD stated she was informed by Resident 46 that she did not like the way CNA 6 treated her. The DSD stated Resident 46 reported feeling rushed while getting assistance from CNA 6 in the restroom. During a review of the facility's policy and procedures (P&P) titled Resident Rights, Dignity and Privacy, undated, the P&P indicated, staff shall display respect for residents when speaking, caring for, or talking about them as constant affirmation of their individuality and human beings.

Based on observation, interview, and record review, the facility failed to provide services to improve or maintain range of motion ([ROM] full movement potential of a joint) and mobility (ability to move) for two of four sampled residents (Resident 2 and 5) with limited ROM and mobility (ability to move) concerns. a. For Resident 5, the facility failed to:1. Objectively measure Resident 5's ROM in both arms during the Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) Evaluations, dated 5/6/2025 and 11/11/2025.2. Provide passive range of motion ([PROM] movement of a joint through the range of motion with no effort from person) exercises and apply splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) to both of Resident 5's hands, elbows, knees, and ankles from 8/20/2025 to 9/4/2025 after Resident 5's discharge from Physical Therapy ([PT] profession aimed in restoration, maintenance, and promotion of optimal physical function) and OT services on 8/19/2025. b. For Resident 2, the facility failed to objectively measure Resident 2's ROM in both arms during the OT Evaluation, dated 4/16/2026. These failures had the potential for Resident 2 and 5 to experience undetected decline in ROM. Findings:a. During a review of Resident 5's Face Sheet (admission record details), the Face Sheet indicated the facility originally admitted Resident 5 on 12/13/2022 and readmitted on [DATE] with diagnoses including traumatic subarachnoid hemorrhage (type of stroke where bleeding occurs in the fluid-filled space between the brain and the tissues covering the brain), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) affecting the left nondominant side, aphasia (disorder that makes it difficult to speak), dysphagia (difficulty swallowing), and contractures (a stiffening/shortening at any joint that reduces the joint's range of motion) of muscle.During a review of Resident 5's Minimum Data Set ([MDS] a federally mandated resident assessment tool), dated 5/7/2026, the MDS indicated Resident 5 had no speech and had severely impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 5 had ROM limitation in both arms and legs and was dependent (helper does all the effort, resident does none of the effort to complete the activity, or the assistance of two or more helpers is required to complete the activity) for hygiene, toileting, bathing, dressing, rolling from the back to both sides in bed, and chair/bed-to-chair transfers.1. During a review of Resident 5's OT Evaluation and Plan of Treatment, dated 5/6/2025, the OT Evaluation indicated Resident 5's ROM in both shoulders, elbows/forearms, wrists, and hand were impaired. The OT Evaluation did not indicate a measurement of Resident 5's impairments in both arms.During a review of Resident 5's OT Evaluation and Plan of Treatment, dated 11/11/2025, the OT Evaluation indicated Resident 5's ROM in both shoulders, elbows/forearms, wrists, and hand were impaired. The OT Evaluation did not indicate a measurement of Resident 5's impairments in both arms.During an observation on 6/22/2026 at 10:43 a.m. in Resident 5's room, Resident 5 was awake while lying in bed and unable to speak. Resident 5 was observed wearing both elbow splints and hand splints.During an observation on 6/23/2026 at 9:26 a.m. with Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) 1 (RNA 1) in Resident 5's room, Resident 5 was lying awake in bed. RNA 1 provided PROM to both of Resident 5's shoulders, elbows, wrist, and hands. RNA 1 provided PROM on both shoulders to 90 degrees (unit of measurement for joint movement) at shoulder height. RNA 1 was unable to completely straighten both of Resident 5's elbows, which continued to have a slight bend. The middle joint of Resident 5's left-hand ring and small fingers were observed fixed (immovable) in a bent position. The large knuckles of Resident 5's right-hand were also observed in a fixed, bent position. RNA 1 applied both elbow extension splints and resting hand splints after completing the PROM exercises to both arms. During a concurrent interview and record review on 6/23/2026 at 2:43 p.m. with the Director of Rehabilitation (DOR), Resident 5's OT Evaluation, dated 5/6/2025, was reviewed. The DOR stated Resident 5's OT Evaluation did not include ROM impairments to both shoulders, elbows, wrists, and hands. During a concurrent interview and record review on 6/23/2026 at 2:53 p.m. with the DOR, Resident 5's OT Evaluation, dated 11/11/2025, was reviewed. The DOR stated Resident 5's OT Evaluation did not include ROM impairments to both shoulders, elbow, wrist, and hands.During an interview on 6/23/2026 at 3:19 p.m. with the DOR, the DOR stated PT and OT's professional schooling included objectively measuring the joints using a goniometer (instrument used to measure angle of joint movement). The DOR stated the purpose of measuring joints included to determine any changes in measurements over time. The DOR stated the absence of ROM measurements in therapy evaluations prevented the therapist from monitoring changes in the resident's ROM. 2. During a review of Resident 5's OT Discharge summary, dated [DATE], the OT Discharge Summary indicated recommendations for Resident 5 to reside at the facility with 24 hours, seven days per week care.During a review of Resident 5's PT Discharge summary, dated [DATE], the PT Discharge Summary indicated recommendations for a (unspecified) restorative nursing program ([RNP] nursing aide program that helps residents to maintain their function and joint mobility).During a review of Resident 5's physician's orders, dated 9/3/2025, the physician's order indicated for the RNA to provide PROM to both arms and legs, five times per week as tolerated. Another physician's order, dated 9/3/2025, indicated for the RNA to apply both resting hand splints (splints secured with straps that extends from the fingers to the forearm to properly position the fingers and wrist), both elbow extension (straightening) splints, both knee extension splints, and both ankles splints, five times per week for four to six hours as tolerated. During an interview on 6/22/2026 at 9:25 a.m. with the DOR, the DOR stated residents (in general) transition to RNA services after reaching their maximum potential with therapy. The DOR stated the therapists (PT and OT) provide a physician's order to start RNA services upon discharge from therapy services. The DOR stated RNA services included providing ROM and applying splints which maintained a resident's ROM. During an observation on 6/22/2026 at 10:43 a.m. in Resident 5's room, Resident 5 was awake while lying in bed and unable to speak. Resident 5's arms had both elbow splints and hand splints applied. Resident 5's legs appeared to be rotated toward the right side with both hips and knees in a bent position. Resident 5's legs were not clearly visible due to the presence of a sheet. During a concurrent interview and record review on 6/23/2026 at 2:43 p.m. with the DOR, the DOR reviewed Resident 5's OT Discharge summary, dated [DATE], and stated the OT did not include recommendations for RNA services. During a concurrent interview and record review on 6/23/2026 at 2:49 p.m. with the DOR, the DOR reviewed Resident 5's PT Discharge summary, dated [DATE], and stated the PT Discharge Summary included RNP for splinting and ROM. During a concurrent interview and record review on 6/25/2026 at 11:46 a.m. with the DOR, Resident 5's OT and PT Discharge Summaries, dated 8/9/2025, and physician's orders, dated 9/3/2025, were reviewed. The DOR stated Resident 5 was dependent and unable to move both arms and legs. The DOR stated Resident 5 did not receive ROM exercises and application of splints from 8/10/2025 to 9/3/2025. The DOR stated Resident 5 could have developed a decline in ROM without the provision of RNA services. During a review of the facility's policy and procedure (P&P) titled, ROM and Contracture Prevention, the P&P indicated the facility ensured the residents receive services, care and equipment to assure that.Every resident with limited range of motion and mobility maintains or improves function.b. During a review of Resident 2's Face Sheet, the Face Sheet indicated the facility initially admitted Resident 2 on 4/9/2026 and readmitted on [DATE] with diagnoses including muscle weakness, atherosclerosis (thickening and hardening of the arteries) of coronary artery bypass grafts ([CABG] surgery to replace blocked heart circulation with healthy blood vessels), atrial fibrillation (irregular and very rapid heart rate), and healed traumatic fracture.During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had unclear speech, usually understood verbal content, had difficulty communicating some words or finishing thoughts, and had severely impaired cognition. The MDS indicated Resident 2 was dependent for toileting, showering, dressing, rolling from the back to both sides in bed, chair/bed-to-chair transfers, and sit-to-stand transfers.During a review of Resident 2's OT Evaluation and Plan of Treatment, dated 4/16/206, the OT Evaluation indicated Resident 2's medical history included a CABG, right humeral fracture (break in upper arm between the elbow and the shoulder), and right shoulder anterior dislocation (injury where the ball of the shoulder pops out of the shoulder joint) with closed reduction (non-surgical procedure to realign bones into the proper position) on 2/30/2026. The OT Evaluation indicated Resident 2's prior level of function (ability prior to admission to the facility) was independent for eating, toileting, showering, toilet transfers, and dressing. The OT Evaluation indicated Resident 2's right shoulder had (unspecified) ROM impairment. During an interview on 6/22/2026 at 12:22 p.m. with Resident 2 in the room, Resident 2 stated Resident 2 had recently (unknown date) fallen, shattered the right shoulder, underwent surgery for the right shoulder, and returned home after shoulder surgery. Resident 2 stated Resident 2 underwent heart surgery after experiencing pain in both legs, the inability to walk, and incontinence (lack of control over urination or defecation) at home.During an interview on 6/23/2026 at 3:19 p.m. with the DOR, the DOR stated PT and OT's professional schooling included objectively measuring the joints using a goniometer. The DOR stated the purpose of measuring joints included to determine any changes in measurements over time. The DOR stated the absence of ROM measurements in therapy evaluations prevented the therapist from monitoring changes the resident's ROM. During a concurrent interview and record review on 6/24/2026 at 9:24 a.m. with the DOR, Resident 2's OT Evaluation, dated 4/16/2026 completed by Occupational Therapist 1 (OT 1), was reviewed. The DOR stated the OT Evaluation did not include ROM measurements for the right shoulder. During an interview and record review on 6/25/2026 at 12:11 p.m. with OT 1, Resident 2's OT Evaluation, dated 4/16/2026, was reviewed. OT 1 stated the purpose of OT included working with residents toward independence with activities of daily living ([ADLs] basic tasks that individuals perform to maintain their daily lives and independence). OT 1 stated measuring ROM using a goniometer was apart of OT's professional schooling. OT 1 stated the purpose of measuring ROM was to obtain a resident's baseline to determine improvement or decline in ROM and to determine if interventions were effective. OT 1 stated Resident 2's right shoulder ROM was not but should have been measured during the OT Evaluation because shoulder ROM could impact Resident 2's ability to perform ADLs. During a review of the facility's P&P titled, ROM and Contracture Prevention, the P&P indicated the facility ensured the residents receive services, care and equipment to assure that.Every resident with limited range of motion and mobility maintains or improves function.

Based on observation, interview and record review, the facility failed to:1.Administer polyethylene glycol (laxative to relieve constipation) correctly to one of four sampled residents (Resident 30).2.Administer pregabalin (medication used to treat nerve pain) to one of one sampled residents (Resident 6) and did not notify the physician or clarify administration on 5/20/2026, 5/31/2026, 6/4/2026, and 6/20/2026. This deficient practice had the potential to result in increased risk of constipation for Resident 30 and unrelieved pain for Resident 6.Findings: a. During a review of Resident 30's admission Record, the admission Record indicated Resident 30 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including metabolic encephalopathy (any damage or disease that affects the brain), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and heart failure. During a review of Resident 30's History and Physical (H&P), dated 4/8/2026, the H&P indicated Resident 30 had the capacity to understand and make decisions. During a review of Resident 30's Minimum Data Set (MDS - a resident assessment tool), dated 4/7/2026, the MDS indicated Resident 30 had moderate cognitive (ability to learn, reason, remember, understand, and make decisions) impairment, required supervision when eating and for oral hygiene, and was dependent for toileting hygiene, bathing, personal hygiene, and dressing. During a review of Resident 30's Physician Order Summary, the Order Summary indicated an order for polyethylene glycol 3350 powder - Give 17 grams (g - a unit of measurement) by mouth two times a day for bowel management *mix with 8 ounces (oz - a unit of measurement) hold for loose stool - Start date 6/18/2025. During an observation on 6/23/2026 at 8:51 a.m., in the hallway outside Resident 30's room, Licensed Vocational Nurse (LVN) 2 prepared polyethylene glycol by mixing the polyethylene glycol in orange juice in a plastic cup for Resident 30. During an observation on 6/23/2026 at 8:56 a.m., in Resident 30's room, Licensed Vocational Nurse (LVN) 2 handed the polyethylene glycol to Resident 30. Resident 30 drank half of the polyethylene glycol in orange juice in the plastic cup and handed it back to LVN 2. LVN 2 disposed of the remaining polyethylene glycol in orange juice in the trash can. During an interview on 6/23/2026 at 8:57 a.m., with Resident 30, Resident 30 stated they (Resident 30) did not finish the orange juice. Resident 30 stated they (Resident 30) did not know that medication was mixed in the orange juice. During an interview on 6/23/2026 at 9:12 a.m. with LVN 2, LVN 2 stated Resident 30 drank half of the orange juice and did not receive the full dose of polyethylene glycol. LVN 2 stated not taking the full dose of polyethylene glycol could increase Resident 30's risk for constipation. b. During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or paralysis on one side of the body) following cerebral infarction (stroke - loss of blood flow to a part of the brain), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) with diabetic neuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet), and generalized muscle weakness. During a review of Resident 6's H&P dated 2/10/2026, the H&P indicated Resident 6 had the capacity to understand and make decisions. During a review of Resident 6's MDS dated [DATE], the MDS indicated Resident 6 had moderate cognitive (ability to learn, reason, remember, understand, and make decisions) impairment, required setup assistance when eating and for oral hygiene, required moderate assistance (helper does less than half the effort) for upper body dressing, required maximal assistance (helper does more than half the effort) for bathing and personal hygiene, and was dependent for toileting and lower body dressing. During a review of Resident 6's Physician Order Summary, the Order Summary indicated an order for pregabalin oral capsule 25 MG - Give 2 capsules orally three times a day for pain - start date 2/10/2026. During an interview on 6/22/2026 at 10:45 a.m., with Resident 6, Resident 6 stated there are a couple times a month when pregabalin is not in stock, and the facility does not give Resident 6 the medication. During a concurrent interview and record review on 6/25/2026 at 12:05 p.m., with LVN 4, Resident 6's May 2026 medication administrator record (MAR), June 2026 MAR, and nursing progress notes were reviewed. LVN 4 stated Resident 6's May 2026 MAR indicated Resident 6 did not receive pregabalin due to a pending pharmacy delivery. LVN 4 stated Resident 6's June 2026 MAR indicated Resident 6 did not receive pregabalin due to a pending pharmacy delivery. LVN 4 stated the physician should be notified if a resident did not receive the pregabalin. LVN 4 stated there was no documentation that indicated the physician was notified that Resident 6 did not receive pregabalin on 5/20/2026, 5/31/2026, 6/4/2026, or 6/20/2026. LVN 4 stated the facility should have clarified with the physician if it would be okay to give the pregabalin when it arrived or to wait until the next dose. During an interview on 6/25/2026 at 3:22 p.m., with the Director of Nursing (DON), the DON stated it was important for the Resident to take the entire medication dose as ordered by the physician to ensure the efficacy of the medication. The DON stated if a resident does not take the entire dose of polyethylene glycol, the resident may have bowel problems. During an interview on 6/25/2026 at 3:24 p.m., with the DON, the DON stated medications should be reordered within three days of remaining supply. The DON stated if a resident misses multiple doses of pregabalin, the resident's pain was not managed properly. The DON stated if a resident does not receive a dose of pregabalin, the physician should have been notified by facility staff to determine if an alternative can be administered or if the resident could be without the medication until the supply arrived. During a review of the facility's policy and procedure (P&P), titled Medication Administration, revised 11/2018, the P&P indicated medications must be administered in accordance with the written orders of the attending physician. The P&P indicated unless otherwise specified by the resident's attending physician, routine medications should be administered as scheduled.

Based on observation, interview and record review, the facility failed to ensure the standardized recipes for lunch menu were followed on 6/22/2026 by failing to:1.Ensure nine residents on pureed diet (foods that do not require chewing and are easily swallowed. All food should be smooth and pureed to the consistency of pudding) received corn texture in form that meet their needs and in accordance with international Dysphagia Diet Initiative (IDDSI-a framework made up of levels and describes food textures and drink thickness) Level Four (pureed foods and extremely thick drinks) when the texture of the pureed corn was dry, lumpy, not smooth and had pieces of corn present requiring chewing before swallowing.2.Follow the food production recipe for eight residents on the soft and bite size diet (food particle are soft and chopped into 1/2 inch pieces) who received minced (ground) texture meat and pureed potato instead of Salisbury steak and boiled potato chopped into bite size pieces 1/2 inch per diet order.These deficient practices had the potential to result in meal dissatisfaction, decreased nutritional intake and increased choking risk for the residents who received the pureed corn.Findings:1.During an observation of the tray line (tray line- a system of food preparation, in which trays move along an assembly line) service for lunch on 6/22/2026 at 12:00PM, the pureed corn looked lumpy, and dry while in a pan on the steam table.During a concurrent interview and taste test of the pureed corn with Dietary Supervisor, Cook1 and Registered Dietitian (RD1) on 6/22/2026 at 12:45PM, the pureed corn was dry, had a lumpy texture. There were small pieces of corn kernels that stayed in the mouth requiring chewing. During a spoon tilt test per the IDDSI guideline, the pureed corn was sticking to the spoon. DS stated it's the end of the tray line the corn became thicker and dry. Cook1 stated the pureed corn was prepared from the regular corn and pepper and blended with water. Cook1 stated we should add hot water when it's on the steam table and mix to make it soft. Cook1 stated DS stated the pureed corn was not smooth it should have been blended longer to make a smooth pureed texture. DS stated that when the pureed texture is lumpy it could be a risk for choking. During a review of the facility recipe titled Recipe: Corn with green peppers Week 4 Monday (dated 2026) the recipe indicated, IDDSI #4/Pureed: Make with creamed corn then puree.Utilize the critical tests and IDDSI audit to confirm texture meets level #4 specifications.During a review of the IDDSI guideline website titled IDDSI, dated 7/2019, the IDSSI guideline indicated that Level 4 Pureed is usually eaten with spoon, falls off spoon in a single spoonful when tilted and continues to hold shape on the plate, no lumps, not sticky, and liquid must not separate from solid. Food testing method: Spoon tilt test and Fork drip test. 2.During an observation in the kitchen on 6/22/2026 at 12:00PM, [NAME] 1 served minced/ground meat and pureed potato to residents who were on the soft and bite size diet (food particles are soft and chopped into 1/2 inch pieces)During a concurrent observation and interview with cook1, DS and Regional Dietitian (RD2) on 6/22/2026 at 12:30PM, RD2 stated the Salisbury steak prepared from scratch from ground beef and its soft. RD2 did not know why the soft and bite size was served ground beef. DS stated usually the spreadsheet (serving and portion guide) will indicate ground beef.During a concurrent interview and review of the cook's spreadsheet on 6/22/2026 at 12:30PM, DS stated it indicates to serve tender chopped Salisbury steak and not ground. DS stated we made a mistake and did not follow the correct texture.During an interview with RD1 on 6/23/2026 at 10:30AM, RD1 stated that soft and bite size diet texture is when food is cut into soft 1/2 inch pieces. RD1 stated we served ground textures to residents who were on soft and bite size diet. Changing the texture to ground can upset residents and decrease food intake.During a review of the facility's recipe titled Salisbury Steak with Onions Week 4 Monday (dated 2026) the recipe indicated, Soft and Bite size IDDSI level 6: tender meat, chop into pieces =1.5 cm by 1.5 cm in sizeDuring a review of the facility's recipe titled Diced potatoes (dated 2025), the recipe indicated, Soft and bit size: Serve fresh, boiled potatoes only. Soft no skin chop into pieces =1.5cm by 1.5cm in size.During a review of facility policy and procedures (p & p) titled, Menu Planning (dated 2023), the p & p indicated, The menus are planned to meet nutritional needs of residents in accordance with established national guidelines.Standardized recipes adjusted to appropriate yield shall be maintained and used in food preparation.During a review of the facility's cook's job description (dated 12/2021), the job description indicated, Essential Duties and Responsibilities: Prepare meals in accordance with planned menus, Inspect special diet trays to assure that the correct diet is served to the resident; prepare and serve meals that are palatable and appetizing in appearance; prepare food for therapeutic diets in accordance with planned menus; prepare food in accordance with standardized recipes and special diet orders.During a review of the IDDSI guideline website titled IDDSI, dated 1/2019, the IDSSI guideline indicated that Level 6 soft and Bite sized texture is for people who have ability to chew bite-sized pieces so that they are safe to swallow; Bite-Sized pieces no bigger than 1.5cm x 1.5cm in size and a knife is not required to cut this food.

Based on observation, interview and record review, the facility failed to ensure that food was prepared by methods that conserved flavor and served at appetizing temperatures for 64 out of 67 residents who received food from kitchen and for Resident 4 who complained that food was cold and Resident 6 who complained food texture was chewy not palatable.This deficient practice had the potential to result in meal dissatisfaction, decreased food intake and placed residents at risk for unplanned weight loss. Findings: During initial facility tour on 6/22/2026 at 8:30AM, complaints about the temperatures and texture of food were identified. Complaints about the flavor and temperature of food were also discussed during resident council meeting on 6/23/2026 at 2:36PM During an observation in the kitchen on 6/22/2026 at 10:15AM at the request of resident family member, the dietary supervisor (DS) was warming up a bowl of oatmeal for a resident. During a concurrent observation and interview with DS on 6/22/2026 at 10:15AM, DS stated the oatmeal was from the breakfast meal. DS said residents' families or nurses bring in resident food to be warmed up in the microwave. DS said the facility uses the kitchen microwave dedicated to residents to warm up food per request. DS said we often warm up food for residents. During an observation and interview in the kitchen with cook1, DS and RD on 6/22/2026 at 11:45AM, cook1 checked the temperature of lunch items using facility thermometer. The temperature of food checked was as follows: Salisbury Steak at 179 degrees Fahrenheit (F) Corn with bell peppers 174 degrees F Fried potato (potato quarters with skin on) 186 degrees F Pureed potato 161 degrees F Pureed corn 164 degrees F Pureed meat 174 degrees F Brown rice 174 degrees F Milk 32 degrees F Water 40 degrees F During the same observation and interview, DS stated facility starts serving lunch at 12:00PM and by 12:30PM we should be done and last cart is out of the kitchen. During the lunch observation and interview with DS and RD2 on 6/22/2026 at 12:45PM, several pans with food were not directly held on a heat source. Observed minced carrots, minced beef and brown rice sitting on top of other pans that are in the steam table (steam table (used to hold precooked food at safe temperatures >135 degrees F; it has multiple stainless-steel compartments (wells) that use heated water to produce steam and keep food warm). DS stated we don't have enough space to keep extra pans of food in the steam table. RD2 stated we should get half size pans (smaller pans) to fit the food in the wells of the steam table. During the test tray on 6/22/2026 at 1:18PM (A food tray test (or tray audit) is a quality control evaluation used in hospitals, nursing homes, and catering to ensure meal trays meet safety, accuracy, and quality standards. It involves tracking a mock or live meal from the kitchen to the bedside to assess temperature, portion, and presentation.) food temperatures of sampled food varied from warm to lukewarm. RD 1 took temperatures of the test tray items using facility thermometer which recorded as follows: Salisbury steak at 120 degrees F Corn with peppers 112 degrees F Fried potatoes (potato quarters with skin) 115 F Milk 53 degrees F Ice cream at 30 degrees F melted During the same test tray, the Salisbury steak were lukewarm and had no flavor, the potato and corn were cold and bland and the ice cream was melted. During an observation and interview with RD on 6/22/2026 at 1:18PM, RD stated the tray line took a long time today and the food is not warm. During an interview with DS and RD1 on 6/23/2026 at 10:30AM DS stated we start tray line (tray line- a system of food preparation, in which trays move along an assembly line) service for lunch at 12:00PM and end by 12:30PM. DS stated yesterday the tray line went over the usuall time and the food got cold. During a review of facility's policy and procedure (P & P) titled Meal Service (dated 2023), the p&p indicated, Meals that [NAME] the nutritional needs of the resident will be served in an accurate and efficient manner and served at the appropriate temperatures. Temperature of the food when the resident receives it is based on palatability. The goal is to serve cold food cold and hot food hot. See table below for suggested temperatures. Recommended Temp at Delivery to residents: Cold Entrée < 50 degrees F Fruit or Cold Dessert < 50 degrees F Salads < 45 degrees F Milk/Cold Beverages < 45 degrees F Frozen Dessert < 20 degrees F Hot Entrees > 120 degrees F Starch > 120 degrees F Vegetables > 120 degrees F Hot beverage > 140 degrees F Soup or Hot cereal > 140 degrees F During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or paralysis on one side of the body) following cerebral infarction (stroke - loss of blood flow to a part of the brain), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) with diabetic neuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet), and generalized muscle weakness. During a review of Resident 6's History and Physical (H&P), dated 2/10/2026, the H&P indicated Resident 6 had the capacity to understand and make decisions. During a review of Resident 6's Minimum Data Set (MDS – a resident assessment tool), dated 6/8/2026, the MDS indicated Resident 6 had moderate cognitive (ability to learn, reason, remember, understand, and make decisions) impairment, required setup assistance when eating and for oral hygiene, required moderate assistance (helper does less than half the effort) for upper body dressing, required maximal assistance (helper does more than half the effort) for bathing and personal hygiene, and was dependent for toileting and lower body dressing. During a review of Resident 6's Physician Order Summary, the Order Summary indicated an order for a Regular diet – start date 2/9/2026. During an interview on 6/22/2026 at 10:45 a.m., with Resident 6, Resident 6 stated the chicken here tasted like rubber and the fish was raw. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including wedge compression fracture (when the front part of the bones of the spine body creating a wedge shape) of the lumbar vertebra (lower bones of the spinal column), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and end stage renal disease (ESRD - chronic kidney disease that causes gradual loss of kidney function). During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4 had moderate cognitive (ability to learn, reason, remember, understand, and make decisions) impairment, required maximal assistance (helper does more than half the effort) for eating, oral hygiene, and upper body dressing, and was dependent for toileting hygiene, bathing, and lower body dressing. During a review of Resident 4's Physician Order Summary, the Order Summary indicated an order for a Regular Diet – start date 4/17/2026. During an interview on 6/22/2026 at 10:41 a.m., with Resident 4, Resident 4 stated the food was cold most of the time. Resident 4 stated they (Resident 4) asked the staff to reheat the food almost every day. During a review of facility policy and procedure (p&p) title Food Preparation (dated 2023) the p&p indicated, Hold foods prior to service for as short time as practical. A maximum 1 hour holding time is recommended.

Based on observation, interview and record review, the facility failed to ensure 2 of 24 sampled residents were served the food preference listed on the lunch tray cards (a printed sheet that includes resident diet order, preferences and dislikes) when:1.Resident 43 food preferences were not honored when corn was served during lunch, despite corn being listed as a dislike on resident's lunch tray card.2.Resident 8 whose diet order indicated vegan (a person whose diet does not include animal products) received whole milk and dairy ice cream for lunch on 6/22/2026)These deficient practices had the potential to result in decreased meal satisfaction, decreased caloric intake, and negatively affect nutritional status of residents whose food preferences were not honored for lunch.Findings: 1.A review of Resident 43's Face sheet (admission record) indicated the resident was admitted to the facility on [DATE], with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD) (is a progressive, inflammatory lung disease that restricts airflow and makes breathing difficult. A review of Resident 43's Order Summary Report dated 6/8/2026, indicated No added salt fortified diet with 1200ml/day fluid restriction. (Fortified diet-A fortified diet incorporates foods and drinks with added concentrated calories to maximize nutritional intake without increasing portion size. It is highly effective for combating unintentional weight loss, especially for individuals with small appetites.) A review of resident 43's tray card for lunch dated 6/22/2026 indicated resident food dislikes included corn. During an observation in the kitchen on 6/22/2026 at 12:30PM, Dietary Supervisor (DS) was checking the tray cards and reading out loud the diet orders for the cook to serve. During the same observation DS did not read the dislikes on resident 43 tray card and the [NAME] (cook1) served corn with peppers to resident 43. During a dining observation in resident room on 6/22/2026 at 1:06PM, resident 43 tray on the bedside table had corn. During an interview with resident 43 on 6/22/2026 at 1:06PM, resident 43 stated I can't eat that food. Resident 43 stated I don't like beef and I cannot eat corn. Resident 43 pointing to the tray card, said its written in my paper and they still put corn in my food and refused to eat lunch. During an interview with the dietary supervisor (DS) on 6/23/2026 at 10:30AM, DS stated that there was a mistake for Resident 43 to receive corn. DS stated did not know resident dislikes beef. DS stated that when residents receive food that they don't like they become upset and will not eat food which can cause weight loss. During a review of the Facility's Nutrition Evaluation and RDN Review dated 6/8/2026 for sections Food likes and food dislikes it was documented as None given at this time and no food preference were indicated. During a review of the Facility's policy and procedures (p&p) titled Food Preferences (not dated) the p&p indicated, Food preference will be obtained as soon as possible though the initial resident screen. This screening must be completed within 7 days of admission by the food and nutrition director. Food preferences can be obtained from the residents, family or staff members. Updating of food preferences will be done as the resident's needs change and or during the quarterly review. 2. During a review of Resident 8's admission Record (Face Sheet-page of the chart that contains a summary of basic information about the resident), the admission Record (Face Sheet) indicated Resident 8 was initially admitted to the facility on [DATE] and last readmission was on 5/20/2026 with diagnoses including dysphagia (difficulty swallowing), dementia (a progressive state of decline in mental abilities), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and scoliosis (an abnormal, sideways curvature of the spine that often forms a C or S shape) During a review of Resident 8's History and Physical (H&P), dated 5/21/2026, the H&P indicated, Resident 8 had no capacity (ability) to make medical decisions. During a review of Resident 8's Minimum Data Set (MDS-a resident assessment tool), dated 5/25/2026, the MDS indicated Resident 8's cognitive skills for daily decision making were severely impaired (never or rarely made decisions). The MDS indicated Resident 8 required dependent assistance (Helper does all of the effort) from two or more staff for bed mobility, transfer, dressing, toilet hygiene, and moderate assistance (Helper does less than half the effort) from one staff for oral hygiene, eating. During a concurrent observation and record review on 6/22/2026 at 12:29 p.m., with Resident 8 in the dining room, Resident 8 was seated in a wheelchair in the dining room next to a dining table. Restorative Nurse Assistant (RNA) 2 was assisting the resident with eating her meal. Resident 8's lunch tray contained pureed (smooth, lump free foods with a pudding-like consistency) food items, a four ounce carton of whole milk, and ice cream. RNA 2 mixed the pureed food items together and fed them to Resident 8. RNA 2 also served Resident 8 ice cream and whole milk. Resident 8 stated she did not know what foods she was being served or whether she liked them. Resident 8 was unable to express her food preferences, likes, or dislikes. During a concurrent interview and record review on 6/22/2026, at 12:39 p.m., with RNA 2 in the dining room, Resident 8's Meal Ticket (a detailed, customized slip generated for each resident's meal that directs dietary staff exactly what to serve, ensuring the food matches the resident's medical diet order, swallowing requirements, allergies, and personal preferences), undated was reviewed. The Meal Ticket indicated Resident 8 had an allergy to pepper. The Meal Ticket indicated Resident 8's order and was pureed, fortified (foods enhanced with added vitamins, minerals, or calories), Vegan diet. The Meal Ticket indicated to provide a four ounce carton of milk and listed no disliked items. RNA 2 stated it was her responsibility to ensure Resident 8 received the correct food items and diet according to the Meal Ticket. RNA 2 stated she confirmed the Meal Ticket reviewed was for Resident 8's lunch on 6/22/2026. RNA 2 stated Resident 8 should have received Vegan food items. RNA 2 stated the tray contained dairy products such as ice cream, whole milk, and melted butter mixed into the pureed items, which included pureed chicken or beef. RNA 2 stated a Vegan diet consisted of vegetables and fruits and excluded meat and dairy products. She stated she had doubts about the tray but Resident 8 did not complain to her. During a phone interview on 6/24/2026 at 8:30 a.m., with the Resident 8's Responsible Party (RP- the person designated to handle a resident's affairs), the RP stated that Resident 8 and the RP had been Vegan for a long time. The RP stated that serving ice cream occasionally was acceptable, but the RP did not want Resident 8 to receive meat or dairy products if it could be avoided. The RP stated that Vegan substitutes are available, such as almond milk or vegetable patties, and did not understand why the facility was not honoring this preference. The RP stated no one had contacted the RP regarding food preferences. During a concurrent interview and record review on 6/24/2026, at 10:10 a.m., with the Dietary Supervisor (DS), Resident 8's Nutrition Evaluation and Registered Dietitian Nutritionist (RDN) Review, dated 5/27/2026 was reviewed. The Nutrition Evaluation and RDN Review indicated Resident 8's food likes included tofu and vegetable patties, and her dislikes included meat per RP. The DS stated she believed she had spoken with Resident 8's RP regarding food preferences at some point, but she could not recall the date and was not sure if she documented the communication. The DS stated the cook used melted butter to fortify food to prevent weight loss for Resident 8. The DS stated a Vegan diet should contain vegetables and fruits and should exclude meat, cheese, and dairy products. The DS stated she thought she could provide dairy products because Resident 8's RP seemed to be okay with ice cream. The DS stated she should have reconfirmed this with the RP. During an interview on 6/24/2026 at 3:15 p.m., with the Registered Dietitian (RD), the RD stated there were substitutes available for a Vegan diet such as tofu, almond milk, vegetable patties, and Vegan meat. The RD stated she did not recall the exact date, but she had spoken with Resident 8's RP regarding food preferences and believed the RP seemed to be fine with providing dairy items but not meat. The RD stated the nursing staff should have clarified the diet order because it still indicated a Vegan diet only. The RD stated margarine should have been used for fortification instead of butter, which is a dairy product. The RD stated that even though the RP and Resident 8 did not oppose dairy products, staff should have followed the Vegan diet order until it was clarified with the physician. During an interview on 6/25/2026 at 3:39 p.m., with the Director of Nursing (DON), the DON stated staff must assess, document, and honor residents' food preferences to prevent unintended weight loss, which can negatively affect their quality of life. The DON stated all communication with the residents and the family should have been documented. The DON stated Resident 8's food preferences and diet order should have been clarified to prevent conflict. The DON stated that if the diet order indicated Vegan, ice cream, whole milk, melted butter, and meat should not have been provided. During a review of Resident 8's Order Summary Report (OSR), dated 6/24/2026, the OSR indicated, Vegan diet with fortified, pureed texture, thin liquids was ordered on 5/27/2026. During a review of Resident 8's Care Plan Report (CPR) titled, Resident 8 had potential nutritional problems, revised 5/27/2026, the CPR [NAME] indicated, Resident 8 would maintain weight and nutritional balance by target date of 8/19/2026. The CPR interventions indicated to provide the diet as ordered by the physician and to honor the resident's right to make dietary choices. During a review of the facility's Policy and Procedure (P&P) titled, Food Preferences, undated, the P&P indicated, POLICY: Resident's food preferences will be adhered to within reason. Substitutes for all foods disliked will be given by the appropriate food group. Condiments such as salt, pepper, and sugar are available at each meal unless contraindicated by the diet order. PROCEDURE: Food preferences will be obtained as soon as possible through the initial resident screen. This screening must be completed within 7 days of admission by the FNS Director. Food preferences can be obtained from the residents, family, or staff members. Updating of food preferences will be done as the residents' needs change and/or during the quarterly review.

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when:1.One juice machine dispenser nozzle was dirty with dried red color residue.2.One reach in freezer (a commercial upright standing refrigeration unit with standard front door allows staff to quickly grab, store or organize items on shelving.) bottom shelf was dirty with food debris.3.The (Robot Coupe) Food processor bowl was wet, not air dried and not clean after they were washed, there was water inside the bowl and food stains stuck on the lid. One blender jar was not maintained clean. The base of the blender jar was covered with a gel seal. The seal was torn and not smooth to clean and sanitize.These deficient practices had the potential to result in harmful bacteria growth, compromised food quality and cross contamination (transfer of harmful bacteria from one place to another) that could lead to food borne illness (infectious organisms or their toxins are the most common cause of food poising symptoms may include cramping, nausea, vomiting, or diarrhea) for 64 out of 67 residents who received food from the kitchen.Findings: 1. During an observation in the kitchen on 6/22/2026 at 8:50AM, observed juice machine dispenser nozzle was not clean, there was dry red stains and residue inside the nozzle. A clean paper towel swipe inside the nozzle produced dark red stains on the paper towel.During a concurrent observation with Dietary supervisor (DS), and dietary aide (DA1), DS verified there were dark red stains and stated looks like dried up grape juice. DS stated the nozzle is removable and should be soaked in warm water every day and then washed to remove the residues before washing.During the same observation and interview with DS and DA1 on 6/22/2026 at 8:50AM DA1 was washing dishes. DA1 stated that they used a brush to clean the nozzle. DA1 said they did not soak the nozzle just cleaned the outside. DA1 stated facility does not have the correct brush to clean the inside of the juice machine dispenser nozzle. DS stated it is important to clean all parts of the juice machine to prevent bacteria growth that can contaminate juices and have bad effects on residents' health. DS stated will add cleaning the juice machine dispenser holder and nozzle on the schedule.During a review of facility's Daily Cleaning Schedule for the week of 6/15/2026-6/21/2026, the schedule did not include cleaning the juice machine dispenser holder and nozzle.During a review of the 2022 U.S. Food and Drug Administration Food Code 4-602.11 tilted Equipment Food-Contact Surfaces and Utensils, the code indicated, (E) Except when dry cleaning methods are used as specified under S 4-603.11, surfaces of UTENSILS and EQUIPMENT contacting FOOD that is not TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cleaned:(1) At any time when contamination may have occurred;(2) At least every 24 hours for iced tea dispensers and CONSUMER self-service UTENSILS such as tongs, scoops, or ladles;(3) Before restocking CONSUMER self-service EQUIPMENT and UTENSILS such as condiment dispensers and display containers; and(4) In EQUIPMENT such as ice bins and BEVERAGE dispensing nozzles and enclosed components of EQUIPMENT such as ice makers, cooking oil storage tanks and distribution lines, BEVERAGE and syrup dispensing lines or tubes, coffee bean grinders, and water vending EQUIPMENT:(a) At a frequency specified by the manufacturer, or(b) Absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold.2. During an observation in the kitchen on 6/22/2026 at 9:00AM one reach in freezer was not maintained clean. There was dried food debris on the bottom shelf of the freezer.During a concurrent observation and interview with DS, DS stated we have a cleaning schedule where we have deep cleaning of the refrigeration units. DS stated I will remind staff to clean better. DS said there is no cleaning log for the refrigerators and freezers. DS said it's important to keep refrigerators and freezers clean so it does not cross contaminate the food.During a review of facility's Daily Cleaning Schedule for the week of 6/15/2026-6/21/2026, the schedule did not include cleaning the refrigerators and freezers.During a review of the facility's schedule titled, Thursday Cleaning Schedule (not dated), the schedule is divided into 4 weeks, and it indicates, Week 1: Deep cleaning all carts; Deep clean refrigerator; and Racks, shelves, floors. Week 2: Clean the hood, shelves.Week3: Coffee machine, stream table. and Week4: Ice cream freezer, juice machine.During a review of facility's policy titled, Refrigerator and Freezer (not dated), the policy indicated, Maintaining a clean refrigerator and freezer can improve the safety and quality of your foods. Refrigerator and freezer should be on a weekly cleaning schedule. Wipe up spills immediately. Remove all the items and clean shelves. Wipe with sanitizer.3. During an observation in the kitchen on 6/22/2026 at 9:30AM, the food processor machine (Robot Coupe brand) bowl was stored wet, and the lid was dirty with dried food stains. The blender jar had a gap at the base and was covered with a gel like seal. The seal was torn and not smooth.During a concurrent observation and interview with DS, DA1 and [NAME] (Cook1) on 6/22/2026 at 9:30AM, Cook1 stated the DA1 just washed the food processor, and we should let it drain and air dry before storing. DA1 stated it was just washed and sanitized. DS stated the lid is not clean has food residue and returned to DA1 to wash again. During the same observation and interview DS stated the blender jar was loose and requested to be repaired by the facility maintenance department. DS stated it was only a temporary fix until purchasing a new blender jar/pitcher. DS agreed that surface of the blender jar is not smooth because of the glue and cannot be washed and sanitized which can lead to growth of microorganisms and contaminate food.During a review of facility's' policy and procedures (p&p) titled Sanitation (not dated) the p&p indicated, All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas.

Based on observation, interview, and record review, the facility failed to maintain accurate and complete medical records for two of four sampled residents (Resident 3 and 5) with limited range of motion ([ROM] full movement potential of a joint) and mobility (ability to move) concerns and failed to develop and implement a policy and procedure for medical record accuracy. a. For Resident 3, the facility failed to:1. Accurately document Resident 3's inability to perform sit-to-stand transfers and ambulation for 10 feet (unit of measure) during multiple dates from 4/2026 to 6/2026.2. Document Resident 3's sitting tolerance in the wheelchair during Physical Therapy ([PT] profession aimed in restoration, maintenance, and promotion of optimal physical function) Treatment sessions prior to discharge from PT services on 6/25/2026. b. For Resident 5, the facility failed to accurately document Resident 5's inability to perform sit-to-stand transfers and ambulation for 10 feet during multiple dates from 4/2026 to 6/2026. These failures resulted in inaccurate medical records for the provisions of care to Resident 3 and 5 and lack of guidance for completing documentation in the medical record. Findings: a. During a review of Resident 3's Face Sheet (admission record details), the Face Sheet indicated the facility re-admitted Resident 3 on 4/29/2026 with diagnoses including cellulitis (skin infection that causes swelling and redness) of both lower limbs, heart failure, chronic obstructive pulmonary disease ([COPD] long-term lung disease causing difficulty in breathing), muscle weakness, and morbid obesity (extremely high amount of body fat that seriously threatens health and well-being).During a review of Resident 3's Minimum Data Set ([MDS] a federally mandated resident assessment tool), dated 3/23/2026, the MDS indicated Resident 3 had clear speech, understood verbal content, expressed ideas and wants, and had moderately impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 3 was dependent (helper does all the effort, resident does none of the effort to complete the activity, or the assistance of two or more helpers is required to complete the activity) for toileting, showering, lower body dressing. The MDS indicated Resident 3 required partial/moderate assistance (helper does less than half the effort) for rolling from the back to both sides in bed and transferring from lying to sitting at the side of the bed and required substantial/maximal assistance (helper does more than half the effort) for chair/bed-to-chair transfer. Resident 3's MDS indicated transferring from sit-to-stand and walking 10 feet were not applicable (not attempted and the resident did not perform the activity prior to the current illness, exacerbation, or injury).1. During a review of Resident 3's Documentation Survey Report (record of nursing assistant tasks), dated 4/2026, the Documentation Survey Report indicated Resident 3 was dependent for sit-to-stand transfers and walking 10 feet on 4/4/2026, 4/5/2026, 4/6/2026, 4/7/2026, 4/14/2026, 4/18/2026, 4/19/2026, 4/20/2026, and 4/21/2026. During a review of Resident 3's Documentation Survey Report, dated 5/2026, the Documentation Survey Report indicated Resident 3 was dependent for sit-to-stand transfers and walking 10 feet on 5/1/2026, 5/2/2026, 5/3/2026, 5/4/2026, 5/5/2026, 5/8/2026, 5/9/2026, 5/10/2026, 5/11/2026, 5/12/2026, 5/13/2026, 5/22/2026, 5/23/2026, 5/24/2026, 5/25/2026, 5/29/2026, 5/30/2026, and 5/31/2026.During a review of Resident 3's PT Evaluation and Plan of Treatment, dated 5/22/2026, the PT Evaluation indicated Resident 3 was dependent for chair/bed-to-chair transfers. Resident 3's PT Evaluation also indicated that sit-to-stand transfers and walking 10 feet were not applicable. The PT Evaluation indicated Resident 3 was unable to sit supported in a wheelchair and included a short-term goal for Resident 3 to sit supported in a wheelchair for two hours.During a review of Resident 3's Documentation Survey Report, dated 6/2026, the Documentation Survey Report indicated Resident 3 was dependent for sit-to-stand transfers and walking 10 feet on 6/1/2026, 6/5/2026, 6/6/2026, 6/10/2026, 6/11/2026, 6/14/2026, 6/18/2026, 6/21/2026, 6/22/2026, 6/23/2026, and 6/24/2026.During a concurrent observation and interview on 6/22/2026 at 12:51 p.m. with Resident 3 in the resident's room, Resident 3 was awake and lying in bed with the head-of-bed (HOB) fully upright and both legs outstretched. During an observation on 6/23/2026 at 8:15 a.m. in Resident 3's room, Resident 3 was awake and lying in bed with the HOB fully upright.During an interview on 6/23/2026 at 2:09 p.m. with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated Resident 3 required a mechanical lift to transfer from the bed to the wheelchair.During an observation on 6/24/2026 at 8:59 a.m. in Resident 3's room, Resident 3 was lying in bed with the HOB fully upright. During a concurrent interview and record review on 6/24/2026 at 2:40 p.m. with Certified Nursing Assistant 2 (CNA 2), Resident 3's Documentation Survey Report for sit-to-stand transfers, dated 6/2026, was reviewed. CNA 2 stated Resident 3 was unable to perform sit-to-stand transfers. CNA 2 stated the Documentation Survey Report indicated Resident 3 was dependent for sit-to-stand transfers because Resident 3 was unable to perform sit-to-stand transfers. During an interview on 6/25/2026 at 11:19 a.m. with PTA 1 and the Director of Rehabilitation (DOR), PTA 1 stated Resident 3 had been bed bound (person spends most or all of the time in bed which prevents them from standing, walking, or moving independently) for five years prior to admission to the facility. The DOR and PTA 1 stated Resident 3 was unable to stand and walk. During a concurrent interview and record review on 6/25/2026 at 1:08 p.m. with the Director of Staff Development (DSD), Resident 3's Documentation Survey Reports for sit-to-stand transfers and walking 10 feet, dated 4/2026 to 6/2026, were reviewed. The DSD stated Resident 3's Documentation Survey Reports for 4/2026 to 6/2026 should have indicated sit-to-stand transfers and walking 10 feet were not attempted or not performed because Resident 3 was unable to stand and walk. During a concurrent interview and record review on 6/25/2026 at 2:01 p.m. with the Director of Nursing (DON), Resident 3's Documentation Survey Reports for sit-to-stand transfers and walking 10 feet, dated 4/2026 to 6/2026, were reviewed. The DON stated medical records (in general) should include complete and accurate documentation regarding a resident's health information. The DON reviewed Resident 3's Documentation Survey Report for sit-to-stand transfers and walking 10 feet and stated the medical record was inaccurate because Resident 3 was unable to perform sit-to-stand transfers and walk. 2. During a review of Resident 3's PT Evaluation and Plan of Treatment, dated 5/22/2026, the PT Evaluation indicated Resident 3 was unable to sit supported in a wheelchair and included a short-term goal for Resident 3 to sit supported in a wheelchair for two hours.During a review of Resident 3'a PT Treatment Encounter Notes, dated 5/27/2026 and 6/2/2026 completed by PTA 1, the PT Treatment Encounter Notes indicated Resident 3 participated in therapeutic exercises and functional group activities. The PT Treatment Encounter Notes indicated the goal of the group was to successfully progress the resident with individual treatment plan/goals by addressing patient's strength impairments and balance deficits.During a review of Resident 3's PT Discharge summary, dated [DATE] and completed by the Director of Rehabilitation (DOR), the PT Discharge Summary indicated Resident 3 tolerated sitting supported in a wheelchair for two hours.During a concurrent observation and interview on 6/22/2026 at 12:51 p.m. with Resident 3 in the resident's room, Resident 3 was lying awake in bed with the HOB fully upright and both legs outstretched. Resident 3 stated PTA 1 trying to obtain a custom wheelchair for Resident 3's personal use since the facility's larger wheelchair was not available. Resident 3 stated feeling very upset that a wheelchair was not available for Resident 3 to go outside. During an interview on 6/23/2026 at 2:16 p.m. with CNA 2 in Resident 3's room, CNA 2 stated Resident 3 was transferred to a wheelchair about two months ago.During an interview on 6/23/2026 at 2:18 p.m. with PTA 1, PTA 1 stated Resident 3 was transferred to wheelchair about two months ago and will be measured for a custom wheelchair.During a concurrent interview and record review on 6/24/2026 at 9:46 a.m. with the DOR, Resident 3's PT Evaluation, dated 5/22/2026, and PT Discharge summary, dated [DATE], were reviewed. The DOR stated Resident 3 was unable to tolerate sitting in a wheelchair during the PT Evaluation but achieved two hours of sitting in the wheelchair upon discharge from PT. The DOR stated Resident 3 required a mechanical lift with two to three people to transfer Resident 3 from the bed to a bariatric wheelchair (wheelchair for larger individuals). During a concurrent interview and record review on 6/24/2026 at 10:40 a.m. with PTA 1, Resident 3's PT Treatment Encounter Notes from 5/22/2026 to 6/2/2026 and the PT Discharge summary, dated [DATE], were reviewed. PTA 1 stated Resident 3 transferred from the bed to the bariatric wheelchair on 5/27/2026 and 6/2/2026. PTA 1 stated the PT Treatment Encounter Notes, dated 5/27/2026 and 6/2/2026, did not indicate the amount of time Resident 3 tolerated sitting up in the wheelchair. PTA 1 stated Resident 3's PT Discharge Summary indicated Resident 3 tolerated sitting up in the wheelchair for two hours because PTA 1 verbally communicated Resident 3's sitting tolerance upon discharge from PT on 6/5/2026. During an interview on 6/25/2026 at 11:19 a.m. with PTA 1 in the presence of the DOR, PTA 1 stated Resident 3's sitting tolerance of two hours was verbally communicated to the DOR. PTA 1 stated Resident 3's medical record did not have documented evidence Resident 3 sat in a wheelchair for two hours prior to discharge from PT services. During an interview on 6/25/2026 at 4:27 p.m. with the Administrator (ADM), the ADM stated that the facility's policy and procedures (P&P) (in general) included guidance to staff in providing care for the residents. The ADM stated the facility's expectation was for the staff to complete accurate documentation in the residents' medical record. The ADM stated the facility's expectation for staff to complete accurate documentation was not included in a P&P because the facility did not have a P&P for medical record documentation.b. During a review of Resident 5's Face Sheet, the Face Sheet indicated the facility originally admitted Resident 5 on 12/13/2022 and readmitted on [DATE] with diagnoses including traumatic subarachnoid hemorrhage (type of stroke where bleeding occurs in the fluid-filled space between the brain and the tissues covering the brain), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) affecting the left nondominant side, aphasia (disorder that makes it difficult to speak), dysphagia (difficulty swallowing), and contractures (a stiffening/shortening at any joint that reduces the joint's range of motion) of muscle.During a review of Resident 5's Documentation Survey Report, dated 4/2026, the Documentation Survey Report indicated Resident 3 was dependent for sit-to-stand transfers and walking 10 feet on 4/1/2026, 4/4/2026, 4/5/2026, 4/6/2026, 4/7/2026, 4/10/2026, 4/13/2026, 4/14/2026, 4/16/2026, 4/25/2026, 4/29/2026, and 4/30/2026.During a review of Resident 5's MDS, dated [DATE], the MDS indicated Resident 5 had no speech and severely impaired cognition. The MDS indicated Resident 5 had ROM limitation in both arms and legs and was dependent for hygiene, toileting, bathing, dressing, rolling from the back to both sides in bed, and chair/bed-to-chair transfers. Resident 5's MDS indicated sit-to-stand transfers and walking 10 feet were not attempted and the resident did not perform this activity.During a review of Resident 5's Documentation Survey Report, dated 5/2026, the Documentation Survey Report indicated Resident 3 was dependent for sit-to-stand transfers and walking 10 feet on 5/1/2026, 5/2/2026, 5/3/2026, 5/4/2026, 5/6/2026, 5/7/2026, 5/10/2026, 5/12/2026, and 5/27/2026.During a review of Resident 5's Documentation Survey Report, dated 6/2026, the Documentation Survey Report indicated Resident 3 was dependent for sit-to-stand transfers and walking 10 feet on 6/2/2026, 6/5/2026, 6/6/2026, 6/7/2026, 6/8/2026, 6/9/2026, 6/11/2026, 6/12/2026, 6/14/2026, 6/15/2026, 6/17/2026, 6/18/2026, 6/19/2026, 6/20/2026, 6/22/2026, 6/23/2026, and 6/24/2026.During an observation on 6/22/2026 at 10:43 a.m. in Resident 5's room, Resident 5 was awake while lying in bed and unable to speak. During an observation on 6/23/2026 at 9:24 a.m. in Resident 5's room, Resident 5 was awake while lying in bed and unable to speak.During a concurrent interview and record review on 6/25/2026 at 10:52 a.m. with Certified Nursing Assistant 1 (CNA 1), Resident 5's Documentation Survey Report for sit-to-stand transfers, dated 6/2026, was reviewed. CNA 1 stated Resident 5 was dependent with the mechanical lift and two-person assistance to transfer from the bed to Resident 5's wheelchair or shower chair. CNA 1 stated Resident 5 was unable to stand. CNA 1 stated Resident 5's Documentation Survey Report for 6/2026 was not accurate because Resident 5 was unable to stand.During a concurrent interview and record review on 6/25/2026 at 1:23 p.m. with the DSD, Resident 5's Documentation Survey Report for sit-to-stand transfers and walking 10 feet, dated 4/2026 to 6/2026, were reviewed. The DSD stated Resident 5's Documentation Survey Report for 4/2026 to 6/2026 should have indicated sit-to-stand transfers and walking 10 feet were not attempted or not performed because Resident 5 was unable to stand and walk. During a concurrent interview and record review on 6/25/2026 at 2:01 p.m. with the DON, Resident 5's Documentation Survey Report for sit-to-stand transfers and walking 10 feet, dated 4/2026 to 6/2026, were reviewed. The DON stated medical records (in general) should include complete and accurate documentation regarding a resident's health information. The DON reviewed Resident 5's Documentation Survey Report for sit-to-stand transfers and walking 10 feet and stated the medical record was inaccurate because Resident 5 was unable to perform sit-to-stand transfers and walk. During an interview on 6/25/2026 at 4:27 p.m. with the ADM, the ADM stated that the facility's P&P (in general) included guidance to staff in providing care for the residents. The ADM stated the facility's expectation was for the staff to complete accurate documentation in the residents' medical record. The ADM stated the facility's expectation for staff to complete accurate documentation was not included in a P&P because the facility did not have a P&P for medical record documentation.

Based on interview and record review, the facility failed to provide a written bed hold notice upon transfer for one of one sampled residents (Resident 68). This deficient practice had the potential to result in the resident or responsible party not knowing their rights and not being able to return to the facility.Findings: During a review of Resident 68's admission Record, the admission Record indicated Resident 68 was initially admitted to the facility on [DATE] with diagnoses including leukemia (illness that affects blood cells) and fractures (break) of the left humerus (long bone in upper arm), maxilla (bone that forms the upper jaw), and ribs. The admission Record indicated Resident 68 was transferred to a general acute care hospital (GACH) on 4/10/2026. During a review of Resident 68's History and Physical (H&P), dated 4/10/2026, the H&P indicated Resident 68 did not have the capacity to understand and make decisions. During a review of Resident 68's Minimum Data Set (MDS - a resident assessment tool), dated 4/10/2026, the MDS indicated Resident 68 had severe cognitive (ability to learn, reason, remember, understand, and make decisions) impairment, was dependent for eating, oral hygiene, toileting hygiene, bathing, and dressing. During a concurrent interview and record review on 6/25/2026 at 1:07 p.m., with Registered Nurse Supervisor (RNS) 2, Resident 68's Bed Hold Notification dated 4/10/2026 was reviewed. RNS 2 stated the Bed Hold Notification should be signed by the resident or responsible party on admission and upon transfer. RNS 2 stated Resident 68's Bed Hold Notification was not completed in writing upon transfer. RNS 2 stated the section To be completed upon transfer was blank. RNS 2 stated Resident 68's medical record did not indicate that the responsible party was notified of the seven day bed hold in writing. During an interview on 6/25/2026 at 3:32 p.m., with the Director of Nursing (DON), the DON stated facility staff should explain the bed hold process to the resident and/or responsible party on admission and upon transfer.During a review of the facility's policy and procedure (P&P), titled Bed Hold, revised April 2025, the P&P indicated it is the policy of this facility to inform the resident or resident's representative in writing of the right to exercise the bed hold provision of (7) days upon admission and provide a second notice before transfer to a general acute care hospital or before the resident goes on therapeutic leave. In the event of an emergency transfer, the second notice will be provided within 24 hours. This applies to all residents, regardless of their payment source. A copy of this notification shall become a part of the resident's health record at the time of transfer.

Based on observation, interview, and record review, the licensed nursing staff failed to meet professional standards and clarify the doctor's orders and plan of care for one of five sample residents (Resident 30). This deficient practice placed Resident 30 at risk for experiencing unmanaged pain. Findings During a review of Resident 30's admission Record, the admission Record indicated Resident 30 was originally admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with diagnoses including pain in left knee, unilateral (limited to only one side of the body) osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) in right knee, and Systemic Inflammatory Response Syndrome (SIRS, is a widespread severe inflammatory response triggered by a major stressor such as severe infection, trauma, burns, or lack of blood flow (ischemia) of non-infectious origin with acute organ dysfunction (life-threatening medical emergency where one or more organs can no longer function without medical intervention). During a review of Resident 30's Minimum Data Set (MDS, a resident assessment tool), dated 4/7/2026, the MDS indicated Resident 30 was mildly cognitively (ability to make decisions of daily living) impaired. The MDS indicated Resident 30 was dependent on lying to sitting on side of bed, personal hygiene, upper (above waist) and lower (below waist) body dressing, bathing, toileting hygiene, required substantial assistance (Helper does more than half) for sit to lying, required partial assistance (Helper does less than half) for rolling left to right, and required supervision for eating and oral hygiene. The MDS indicated Resident 30 had impairments on both sides of the lower (hip/leg) extremities.During a review of Resident 30's order summary report, the order summary report indicated Norco Oral Tablet (Hydrocodone-Acetaminophen, medication used to treat moderate to severe pain) 5-325 milligram (unit of measure of mass), give 1 tablet by mouth every six hours as needed for pain with a start date of 4/2/2026.During a review of Resident 30's history and physical (H&P) dated 4/8/2026, the H&P indicated Resident 30 had the capacity to understand and make decisions.During a review of Resident 30's Physical Medicine and Rehabilitation (PM&R) document dated 6/14/2026, the PM&R indicated to continue Norco Oral Tablet 5-325 mg every four hours. During an interview on 6/22/2026 at 11:20 a.m., with Resident 30, Resident 30 stated he does get Norco 1 tablet and it helps a little but indicated it does not do any good for him as it wears off quickly. During a concurrent interview and record review on 6/25/2026 at 2:55 p.m., with Registered Nurse Supervisor (RNS) 2, Resident 30's order summary report dated 7/1/2026 and PM&R dated 6/14/2026 were reviewed. RNS 2 stated there was conflicting information because Resident 30 had an order for Norco 5-325 mg 1 tablet every 6 hours as needed for severe pain with start date 4/2/2026and Resident 30's PM&R indicating, Norco Oral Tablet 5-325 mg every four hours. RNS 2 stated the orders should have been clarified with the doctor if the order was for every 4 hours or every 6 hours. RNS 2 stated confusion may arise as the resident could have been told that the pain medication was for every 4 hours but the order was for every 6 hours and indicated the residents pain level would be uncontrolled without clarification. During an interview on 6/25/2026 at 4:54 p.m. with the Director of Nursing (DON), the DON stated licensed staff must clarify whether Resident 30's pain medication should be given every four or six hours to ensure proper pain management.During a review of the facility's policy and procedures (P&P) titled, Recognition and Management of Pain dated 1/2022, the P&P indicated it is the policy of this facility to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.During a review of the facility's P&P titled, Physician Orders revised date 11/2018, the P&P did not indicate procedures for clarifying orders when there is a discrepancy between the order and the plan of care from the doctor's notes.

Based on interview and record review, the facility failed to address the following for one of five sampled residents (Resident 3): 1. Failed to ensure Resident 3's foley catheter (f/c: a hollow tube inserted into the bladder to drain or collect urine) urine output was monitored and documented.2. Failed to implement Resident 3's care plan for monitoring R for edema (swelling caused by excess fluid trapped in the body's tissues) and urine output. These deficient practices placed Resident 3 at risk for complications related to unmanaged fluid balance. Findings During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with diagnoses including congestive heart failure (CHF, a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), cellulitis (a skin infection that causes swelling and redness) of left and right lower limb, and generalized edema (swelling caused by excess fluid trapped in the body's tissues).During a review of Resident 3's history and physical (H&P) dated 4/30/2026, the H&P indicated Resident 3 had the capacity to make medical decisions.During a review of Resident 3's care plan, titled, Resident refusal of indwelling foley catheter change dated 5/23/2026, the care plan interventions indicated observe catheter function, urine output, and signs/symptoms of complications.During a review of Resident 3's care plan, titled, Has hypertension (high blood pressure) dated 5/23/2026, the care plan interventions indicated monitor for and document any edema and monitor/document abnormalities for urinary output.During a review of Resident 3's care plan, titled, Has impaired circulation related to (r/t) hyperlipidemia (high amounts of lipids (fat) dated 5/23/2026, the care plan interventions indicated inspect foot/ankle/calf skin for changes: weeping, edema, tenderness.During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool), dated 5/25/2026, the MDS indicated Resident 3 was dependent on on staff for bathing, lower body (below waist) dressing, sit to lying, chair/bed-to-chair transfer, toilet transfer, and required substantial assistance (Helper does more than half) for eating and oral hygiene.During a review of Resident 3's order summary report, dated 6/24/2026, the order summary report indicated Resident 3's medication included Furosemide (brand name Lasix [medication that enables the body to get rid of excess fluids) oral tablet 20 milligram (mg, unit of mass) give two (2) tablets by mouth two times a day for fluid overload. During a concurrent interview and record review on 6/24/2026 at 2:09 p.m., with the Registered Dietitian (RD), Resident 3 medical records were reviewed. The RD stated on 6/17/2026, Resident 3's Lasix was increased from once a day to twice a day. The RD stated Resident 3's weights should be monitored to ensure Resident 3 did not get fluid overload and assess to see if medication dosage needs to be changed. The RD stated without monitoring the fluid output, the blood pressure (amount of force the blood uses to get through the arteries (thick, muscular, elastic blood vessels that carry blood away from the heart to the rest of the body) could be affected and cause electrolyte (essential minerals necessary for the body to operate) imbalance. During a concurrent interview and record review on 6/25/2026 at 3:30 p.m. with Registered Nurse Supervisor (RNS) 2, Resident 3's medical records were reviewed. RNS 2 stated staff are required to follow care plans, as they function as orders, and indicated the purpose of a care plan was to guide staff in understanding the resident and providing care specific to the residents' condition. RNS 2 stated they would not notice any sudden changes if they did not follow the care plan. RNS 2 stated according to Resident 3's care plans titled Is on diuretic therapy (Furosemide) r/t fluid overload dated 5/23/2026, indicated the interventions included to monitor for signs and symptoms (s/s) of dehydration: decreased or no urine output. RNS 2 stated the care plan titled Has renal insufficiency (kidneys (bean shaped organ below the rib cage) cannot properly filter waste and fluids from your blood) r/t chronic kidney disease (CKD, (gradual loss of kidney function to filter waste and excess fluid from the blood) dated 5/30/2026 indicated to monitor/document/report to the doctor as needed for the following s/sx: edema and weight gain of over two pounds (lbs) a day. RNS 2 stated based on Resident 3's care plans, the care plans are not being implemented. RNS 2 stated there were no orders to monitor urine output and indicated they should have one since Resident 3 was on Lasix and would want to know the output to see if she was removing fluids and not retaining. RNS 2 stated there was no fluid output documented in the tasks (section where the Certified Nursing Assistant (CNA) documented fluid output).During an interview on 6/25/2026 at 4:47 p.m. with the Director of Nursing (DON), the DON stated when a resident had a diagnosis of CHF, and was taking Lasix the facility staff should monitor for fluid overload and weight gain. The DON stated monitoring a resident's edema allows staff to determine whether the condition was improving or getting worse, and if the medication should change increase or decrease.The DON stated that when a resident was on Lasix, they would want to monitor their output to determine whether the resident was retaining fluids or to see if the medication was working. The DON stated that care plans are resident centered and are designed to provide individualized care tailored to the resident's needs in order to minimize or resolve identified issues. The DON stated care plans need to be followed to ensure the interventions are implemented and to determine whether those interventions are effective. The DON stated they would not know if the interventions were effective if they do not follow the care plan.During a review of the facility's policy and procedures (P&P) titled, Comprehensive Resident Centered Care Plan: Care Planning revised date 1/2021, the P&P indicated is it the policy of this facility that the interdisciplinary team (IDT, healthcare team consisting of various specialties that share and combine their knowledge and information to create the best possible care plan for the resident) shall develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identifies in the comprehensive assessment.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 61) was positioned above 30 degrees while enteral feeding (G-tube - the delivery of nutrients through a feeding tube directly into the stomach, duodenum, or jejunum) was being delivered.This failure had the potential to place the resident at risk for aspiration (accidental breathing of food, liquid, or stomach contents to the airway and lungs).Findings:During an observation on 6/22/2026 at 3:12 p.m., Resident 61 was lying in bed supine, halfway down the bed. The resident's head was against the back rest of the bed with the neck bent forward.During an interview on 6/22/2026 at 3:20 p.m. with Certified Nurse Assistant (CNA) 4, CNA 4 stated, Resident 61 was lying lower than what she should be when the tube feeding was running. CNA 4 stated when the resident needs to be repositioned, the tube feeding (medical device used to provide liquid nourishment, fluids, and medications by bypassing oral intake) should be turned off.During a concurrent observation and interview on 6/22/2026 at 3:25 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 assessed the resident upon entering the room and stated that the resident should not be lying supine, was at less than 30 degrees while enteral feeding was being delivered. The LVN paused the tube feeding and indicated the need to obtain additional assistance to safely elevate the resident from the supine position. LVN 1 stated that the tube feeding should not be on when the resident was lying flat because it can lead to aspiration and choking.During an interview on 6/25/2026 at 2:33 p.m. with the Director of Nursing (DON), the DON stated the importance of making sure the residents' head was elevated above 30-45 degrees was to prevent aspiration. The DON stated the resident should never be lying flat.During a review of the facility's policy and procedure (P&P) titled Gastrostomy Tube Care and Management, revised 12/2023 indicated, Before every feeding, verify the tube position. If feeding is continuous, check the position every shift and as needed using aspiration of gastric contents, air auscultation, X-ray examination, or external graduation marks.

Based on observation, interview, and record review, the facility failed to implement non-pharmacological interventions for one of one sampled resident (Resident) 26 prior to administering pain medication.This failure had the potential to place the resident at risk for the increased use of unnecessary medications.Findings:During an interview and record review on 6/24/2026 at 10:14 a.m. with Licensed Vocational Nurse (LVN) 2, Medication Administration Report (MAR), for month of June was reviewed. The MAR indicated that no non-pharmacological interventions were implemented for the entire month of June for Resident 26. Licensed Vocational Nurse (LVN) 2 stated there should be documentation of non-pharmacological interventions before giving the medication because we need to make sure we are not giving unnecessary medications.During an interview and record review on 6/25/2026 at 9:50 a.m. with Licensed Vocational Nurse (LVN) 4, the MAR and Progress Notes for month of June were reviewed. The MAR and Progress Notes indicated that no non-pharmacological interventions were implemented for the entire month of June for Resident 26. LVN 4 stated non-pharmacological interventions should be implemented first because that can minimize the amount of medication being given to a resident.During an interview and record review on 6/25/2026 at 2:22 p.m. with the Director of Nursing (DON), the MAR for month of June and Progress Notes for month of June were reviewed. The MAR and Progress notes indicated that the implementation of non-pharmacological interventions were not documented. The DON stated providing non-pharmacological interventions before giving pain medications should be implemented first. The DON stated the nurses were not accurately assessing resident's pain by not checking non-pharmacological interventions first.During a review of the facility's policy and procedure (P&P) titled, Nursing Administration: Recognition and Management of Pain, dated 1/2022 indicated The interdisciplinary care plan will reflect the location and type of pain, pharmacological, and non-pharmacological interventions, with evaluation and revision as indicated.

Based on observation and interview, the facility failed to ensure one of 24 sampled residents (Resident 9) dialysis subclavical (anatomical structure situated directly beneath the clavicle (collarbone) port was covered. This deficient practice had the potential to delay or lack of identifying complications (such as pain, infection, accidental trauma, and dislodgement) of the dialysis access site and could lead to a delay provision of dialysis treatment. Findings During an observation on 6/23/2026 at 8:34 a.m., Resident 9's right dialysis port, located beneath the collarbone, was noted to be exposed with tape residue present. During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was originally admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with diagnoses including dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), dementia (a progressive state of decline in mental abilities), and cognitive communication deficit. During a review of Resident 9's history and physical (H&P) dated 8/16/2025, the H&P indicated Resident 9 had fluctuating capacity to understand and make decisions. During a review of Resident 9's Minimum Data Set (MDS, a resident assessment tool), dated 5/15/2026, the MDS indicated Resident 9 was moderately cognitively impaired. The MDS indicated Resident 9 was dependent on sit to lying, required substantial assistance (Helper does more than half) for lower body (below waist) dressing, bathing, toileting hygiene, required partial assistance (helper does less than half the effort) for oral hygiene, upper body (above waist), personal hygiene, chair/bed-to-chair transfer, toilet transfer, supervision for lying to sitting on side of bed, sit to stand, and required set up for eating and rolling left and right. The MDS indicated Resident 9 had impairments on one side of the upper (shoulder/arm) extremity and impairments on both sides of the lower (hip/leg) extremities. During a concurrent observation and interview on 6/23/2026 at 8:46 a.m. with the Director of Staff Development (DSD), the DSD stated Resident 9's dialysis port has a lot of tape residue on it and was not covered. The DSD stated that any licensed personnel could put the dressing on and indicated the dialysis port should be covered to prevent infection from occurring. The DSD stated that the site should be routinely checked for redness, swelling, or other issues, and that leaving the port uncovered could potentially result in infection or other adverse outcomes. During an interview on 6/25/2026 at 3:22 p.m. with Registered Nurse Supervisor (RNS) 2, RNS 2 stated the dialysis port assessments were done by the Registered Nurses (RN), and the Licensed Vocational Nurses (LVN) could check if the bandage for the dialysis port was intact. During an interview on 6/25/2026 at 5:04 p.m., with the Director of Nursing (DON), the DON stated that the dialysis port should always be covered to prevent infection or foreign material from entering the access site. During a review of the facility's policy and procedures (P&P) titled, Dialysis (Renal), Pre- and Post-Care, revised date12/2023, the P&P indicated dialysis access should be assessed upon return to the facility.any problems with a resident's access should be addressed immediately.

Based on observation and interview, the facility staff failed to implement its policy and procedure (P&P) titled, Infection Prevention and Control Program: Infection Prevention-Foley Catheter and Central Lines revised 12/2024, for one out of 24 sampled residents (Resident 9) by failing to ensure staff took off the non-sterile gloves (everyday disposable gloves that are clean and safe for general use, but have not undergone special treatments to kill all microorganisms) prior to putting on sterile gloves to apply a clean dressing on Resident 9's dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) subclavical part of the body situated directly beneath the collarbone) port (surgically created site that allows blood to safely flow through a dialysis machine for filtering) This deficient practice had the potential to transmit infectious microorganisms and increase the risk of infection for the residents.Findings:During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including dialysis, dementia (a progressive state of decline in mental abilities), and cognitive communication deficit.During a review of Resident 9's history and physical (H&P) dated 8/16/2025, the H&P indicated Resident 9 had fluctuating capacity to understand and make decisions. During a review of Resident 9's Minimum Data Set (MDS, a resident assessment tool), dated 5/15/2026, the MDS indicated Resident 9 was moderately cognitively (ability to make decisions of daily living) impaired. The MDS indicated Resident 9 was dependent on facility staff for sit to lying, required substantial assistance (Helper does more than half) for lower body (below waist) dressing, bathing, toileting hygiene, required partial assistance (helper does less than half the effort) for oral hygiene, upper body (above waist), personal hygiene, chair/bed-to-chair transfer, toilet transfer, supervision for lying to sitting on side of bed, sit to stand, and required set up for eating and rolling left and right. The MDS indicated Resident 9 had impairments on one side of the upper (shoulder/arm) extremity and impairments on both sides of the lower (hip/leg) extremities.During an observation on 6/23/2026 at 9:36 a.m., with Registered Nurse Supervisor (RNS) 1, RNS 1 put on a pair of non-sterile gloves (gloves and unbuttoned Resident 9's shirt to have a better view of the dialysis port. RNS 1 continued to put on sterile gloves (disposable medical gloves that are completely free of all germs and living microorganisms) over the non-sterile contaminated gloves. RNS 1 did not take the non-sterile gloves off, and perform hand hygiene before putting on the sterile gloves.During an interview on 6/23/2026 at 9:51 a.m., with RNS 1, RNS 1 stated while wearing the non sterile gloves she sanitized her work area. RNS 1 stated she did not, but should have taken off the non sterile gloves and perform hand hygiene before putting on the sterile gloves to change Resident 9's port dressing. RNS 1 stated sterile gloves were worn to ensure the field was sterile as breaking sterile field could cause cross contamination and infection of Resident 9's dialysis port.During an interview on 6/25/2026 at 4:52 p.m. with the Director of Nursing (DON), the DON stated changing dressing for a dialysis port must be performed using a sterile procedure (a strict set of medical practices used to eliminate all microorganisms such as bacteria and viruses from an area). The DON stated it was not acceptable to put sterile gloves over contaminated non sterile gloves, as doing so breaks the sterile field and increases the risk of infection.During a review of the facility's policy and procedures (P&P) titled, Infection Prevention and Control Program: Infection Prevention-Foley Catheter and Central Lines revised date12/2024, the P&P indicated it is the policy of the facility to ensure that appropriate infection prevention and control measures are taken to prevent the spread of infection in accordance with State and Federal Regulations, and national guidelines. Perform hand hygiene prior to accessing a central line of performing a dressing change and don a mask and clean or sterile gloves.

Based on observation, interview and record review the facility failed to ensure one of three sampled residents (Resident 1) was admitted back to the facility after Resident 5 was evaluated and cleared by the General Acute Care hospital (GACH) to return to the facility on 6/5/2026.These deficient practices resulted in a delayed admission from the GACH back to the facility from 6/5/2026 to 6/12/2026 and had the potential to cause psychosocial harm top Resident 1.Findings:During review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 1 with diagnoses of but not limited to acute respiratory failure, chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), muscle weakness and type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 2/25/2026, the MDS indicated Resident 1 had the ability to express wants, ideas and was able to make self understood. The MDS indicated Resident 1 had the ability to understand others. The MDS indicated Resident 1 was dependent (helper does all of the effort) on nursing staff for toileting, showering, dressing, sitting up, lying down, and rolling from left to right.During review of Resident 1's Progress Notes dated 5/13/2026 timed at 6:14 p.m., the Progress Note indicated Resident 1 complained of chest pain radiating to the back with pain scale seven out of 10 (0 out of 10 a numeric pain scale with zero meaning no pain and 10 meaning the worst pain imaginable). The note indicated Resident 1 was transferred to GACH for further evaluation.During an observation on 6/13/2026 at 10:46 a.m., multiple empty female beds were available for admission in the facility.During a phone interview on 6/13/2026 at 12:36 p.m., with the Community Liaison (CL), CL stated she was responsible for communicating with the GACH to review records and ensure admissions were appropriate for residents returning to the facility. The CL stated on 6/5/2026 she received a call from the GACH asking whether the facility would accept Resident 1 back. She stated she informed GACH Resident 1 could return when ready. The CL stated she requested Resident 1's medical records so the Director of Nursing (DON) could review them. She stated the DON reviewed the records and informed her it was appropriate to accept Resident 1 back to the facility. The CL stated she went to the GACH on 6/5/2026 but did not speak with Resident 1 or any GACH staff. She later spoke with the GACH case manager by phone on 6/12/2026 and explained there had been a misunderstanding regarding her statement that the facility would not readmit Resident 1. The CL apologized and stated she should have arranged for Resident 1 to return once the DON had reviewed the Resident 1's records on 6/5/2026. She stated the delay in Resident 1's readmission should not have occurred. The CL stated she did not want to hold residents in the GACH if it was safe and appropriate for them to return to the facility.During a concurrent interview and record review on 6/13/2026 at 3:09 p.m., with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled admission Criteria, revised 5/2024 was reviewed. The P&P indicated the facility would admit residents whose medical and nursing care could be adequately provided. The DON stated the facility's P&P was not followed when determining whether to accept Resident 1 back to the facility and stated she was not sure what occurred. The DON stated the facility will readmit Resident 1 to the facility on 6/13/2026.During a review of the facility's policy and procedure (P&P) titled admission Criteria, revised 5/2024, the P&P indicated It is the policy of this facility to admit only those residents whose medical and nursing care can be adequately provided.

Based on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant (CNA 1) documented Resident 1's refusal to allow belongings to be inventoried for one of three sampled residents (Resident 1). This failure resulted in the facility being unable to determine the contents of Resident 1's backpack, including the amount of cash Resident 1 later reported missing.Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnoses including chronic obstructive pulmonary disease ([COPD] a chronic lung disease causing difficulty in breathing) with acute exacerbation (sudden worsening of breathing symptoms), left lower limb cellulitis (a skin infection that causes swelling and redness), and muscle weakness (reduced muscle strength). During a review of Resident 1's History and Physical (H&P), dated 4/14/2026, the H&P indicated Resident 1 was able to make her own medical decisions.During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 4/17/2026, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired. The MDS indicated Resident 1required partial to moderate assistance (helper does less than half the effort) from staff for eating, oral hygiene, and personal hygiene and required substantial to maximum assistance (helper does more than half the effort) from staff for toileting, bathing, and dressing. The MDS further indicated Resident 1 felt it was somewhat important to take care of her personal belongings or things.During a telephone interview on 4/24/2026 at 9:02 a.m., with the Complainant, the Complainant stated she visited Resident 1 at the facility regarding Resident 1's insurance recertification. The Complainant stated Resident 1 searched her backpack for paperwork and noticed a white envelope with an unknown amount of cash was missing from the backpack. The Complainant stated Resident 1 was admitted to a General Acute Care Hospital (GACH) on 4/10/2026 and transferred from the GACH to the facility on 4/13/2026. The Complainant stated Resident 1 did not notice the envelope was missing until the Complainant's visit on 4/22/2026. The Complainant stated Resident 1 recalled she went to the bank before her hospitalization on 4/10/2026 and withdrew approximately $200 in cash. The Complainant stated Resident 1 reported the white envelope contained an unknown number of $20 bills. The Complainant stated Resident 1 did not know when the money went missing and did not remember having the money while at the GACH.During a review of Resident 1's undated Resident Clothing and Possessions Form (Inventory List), the Inventory List indicated Resident 1 had the following items upon admission: one blouse, one sweater, four toilet articles, one pair of glasses, one pair of leggings, one backpack, one cell phone, one phone charger, one book (Bible), one cane, and important documents. The Inventory List did not indicate the contents of Resident 1's backpack nor was there documentation indicating Resident 1 refused to have the contents of the backpack inventoried. During a concurrent observation, interview, and record review on 4/24/2026 at 1:05 p.m., with Resident 1, while in Resident 1's room, the resident's Inventory List was reviewed. Resident 1 was observed sitting at her bedside with a flower-patterned backpack on the bedside table behind her. Resident 1 stated she was visited by a social worker on 4/22/2026 regarding insurance paperwork. Resident 1 stated she searched her backpack for the paperwork and discovered a white letter-sized envelope with money was missing from the backpack. Resident 1 stated she did not know how much money was missing. Resident 1 stated she recalled going to the bank before she went to the GACH and withdrew approximately $600 from the bank. Resident 1 stated she combined the $600 with money from another source to pay her rent. Resident 1 stated she withdrew several $20 bills and had money left over after she paid her rent, but she was unsure of the amount. Resident 1 stated she had the backpack while at the GACH. Resident 1 reviewed the items on the Inventory List and confirmed the items were in her possession. Resident 1 stated she remembered signing the Inventory List but did not remember informing the facility she had money in the backpack. Resident 1 stated she did not report the missing money to the facility. Resident 1 stated she was unsure whether the money went missing at the facility or at the GACH. Resident 1 stated she did not give the money to anyone for safekeeping. Resident 1 stated she last saw the money in the envelope approximately two days after she was admitted to the facility. Resident 1 stated the backpack was kept on the bedside table, and the backpack was not put away while she slept or when she left the room.During a telephone interview on 4/24/2026 at 2:08 p.m., with Family Member (FM) 1, FM 1 stated Resident 1 was self-responsible and FM 1was not present when Resident 1 was admitted to the facility. FM 1 stated Resident 1 had the backpack in her possession when she was transferred from the GACH to the facility. FM 1 stated the Complainant informed FM 1 on 4/22/2026 of Resident 1's missing money. FM 1 stated the Complainant advised her to pick up the remaining money Resident 1 still had in her possession for safekeeping. FM 1 stated she went to the facility with another family member on 4/22/2026 to retrieve Resident 1's money. FM 1 stated the money was counted with Resident 1 and Resident 1 had a total of $504 in her backpack. FM 1 stated Resident 1 informed her she also had she had a white envelope full of $20 bills that was missing from the backpack. FM 1 stated she took the $504 home with her. FM 1 stated she was unaware Resident 1 had money in her backpack and Resident 1 did not know how much money was in the envelope.During an interview on 4/24/2026 at 3:04 p.m., with the Social Services Director (SSD), the SSD stated the facility completes an Inventory List of the resident's personal property upon admission. The SSD stated the resident's property is reviewed with the residents and a CNA, then documented on the Inventory List. The SSD stated the resident and/or responsible party signs and dates the Inventory List for verification. The SSD stated if a resident's personal property came up missing, the facility would review the resident's Inventory List. The SSD stated the facility bases the resident's personal property on the Inventory List, but if the missing item was not on the Inventory List, the facility would still investigate the missing property. The SSD stated she was not aware of Resident 1 reporting missing money. The SSD stated when a resident's personal property was missing, the missing property should be reported to her right away.During an interview on 4/24/2026 at 3:36 p.m., with the Director of Staff Development (DSD), the DSD stated the inventory was completed upon admission or the next day, and the facility followed up to ensure the Inventory List was completed. The DSD stated a chart review was completed to ensure the Inventory List was completed. The DSD stated nursing staff were trained on how to complete the Inventory List for residents. The DSD stated all Inventory Lists were required to be dated. The DSD stated the CNA should have asked Resident 1 what was inside the backpack. The DSD stated the CNA should have notified the charge nurse or Registered Nurse (RN) if Resident 1 refused to have the contents of the backpack inventoried. The DSD stated the refusal should have been documented on the Inventory List and in the Nursing Progress Notes. The DSD stated the Charge Nurse (unknown), or Registered Nurse (unknown) would have encouraged and educated Resident 1 regarding the importance of inventorying the contents of the backpack, so if anything came up missing, the facility could replace the missing items.During a concurrent interview and record review on 4/24/2026 at 4:01 p.m., with CNA 1, Resident 1's Inventory List was reviewed. CNA 1 stated she completed Inventory Lists for new admissions during her shift. CNA 1 stated she brought the Inventory List to the resident's room and informed the resident she would inventory the resident's personal belongings. CNA 1 stated she asked residents if she could open bags or backpacks. CNA 1 stated if a resident agreed, CNA 1 checked the contents of the bag or backpack, and if a resident refused, CNA 1 reported the refusal to the charge nurse. CNA 1 reviewed Resident 1's Inventory List and acknowledged she did not date the Inventory List. CNA 1 stated she remembered the Inventory List was completed on Resident 1's first day of admission. CNA 1 stated she checked the backpack on the Inventory List but did not go inside the backpack because Resident 1 refused. CNA 1 stated she lifted Resident 1's backpack and noticed the backpack was heavy, but Resident 1 stated the backpack only contained important documents. CNA 1 stated Resident 1 informed her she did not have money or a wallet inside the backpack. CNA 1 stated she reported Resident 1's refusal to a Charge Nurse but did not remember who the charge nurse was. CNA 1 stated Resident 1 was by herself when CNA 1 completed the Inventory List. CNA 1 stated she did not document Resident 1's refusal to have the backpack contents inventoried on the Inventory List. CNA 1 stated she should have documented the refusal and admitted it was her mistake. CNA 1 stated it was important to document the refusal because the resident may have something important in the backpack, and it was not documented on the Inventory List.During a review of Resident 1's Nursing Progress Notes, dated 4/13/2026, there was no documentation indicating Resident 1 refused to have the contents of the backpack inventoried during the admission inventory process nor documentation indicating staff educated Resident 1 regarding the importance of inventorying the contents of the backpack.During an interview on 4/27/2026 at 4:39 p.m., with the Director of Nursing (DON), the DON stated it was important to document the contents of Resident 1's backpack or document Resident 1's refusal to have the backpack inventoried. The DON stated it was important to document education provided to Resident 1 regarding the importance of having her belongings inventoried to prevent missing items. The DON stated it was important to document the contents of Resident 1's backpack because the facility was unable to determine how much money Resident 1 had. The DON stated nursing staff should have documented Resident 1 was educated regarding the risks of keeping valuables in a backpack at bedside when the backpack contents were not inventoried. The DON stated staff should document the contents of a resident's belongings or document the resident was educated regarding the risks of not inventorying items left at bedside.During a review of the facility's Policy and Procedure (P&P) titled, Guidelines for admission Documentation, revised 8/2020, the P&P indicated it was the responsibility of the nursing center to account for all personal belongings of the resident. The P&P indicated a personal inventory list was made on admission and became part of the chart. The P&P indicated family and/or the resident was cautioned about keeping valuables in the rooms. During a review of the facility's P&P titled, Theft & Loss, revised 1/2013, the P&P indicated a written resident personal property inventory was recorded on an appropriate form upon the resident's admission.

Based on observation, interview, and record review, the facility failed to ensure a safe and unobstructed egress and flooding of water from under the exit door for four of four sampled residents (Resident's 1, 3, 6 and 7) when staff positioned Resident 1's bed partially blocking the exit door and when heavy rain allowed water to enter through the exit door, creating an unsafe exit route. This deficient practice had the potential to impede the safe evacuation for Residents 1, 3, 6, and 7 during an emergency and placed residents, staff and visitors to slip and fall from the water on the floor. Findings:a. During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including displaced transverse fracture (when a bone is broken horizontally into two pieces, and the pieces have separated) of the right patella (kneecap). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 2/3/2026, the MDS indicated Resident 1's cognition (the ability to think and reason) was moderately impaired and required supervision or touch assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activities) by staff to complete her activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 1's Census List (resident information of admission and discharge) dated 2/17/2026, the Census List indicated Resident 1 was assigned to her current bed since 2/12/2026.During an observation on 2/17/2026 at 2:13 p.m. in Resident 1's room, Resident 1's bed was observed with the head of the bed positioned halfway blocking an exit door which had a sign indicating, Exit WARNING!! ALARM WILL SOUND EMERGENCY EXIT ONLY! During an interview on 2/17/2026 at 2:13 p.m., Resident 1 stated she has been in her current bed for about six to seven days. Resident 1 stated on 2/16/2026 her clothing became wet when water flooded the floor. Resident 1 stated the water probably came in from under the exit door because it was raining. Resident 1 stated when her clothes became wet, she feared they could develop mildew and odors, so she hung them on the chair to dry.b. During a review of Resident 3's Face Sheet, the Face Sheet indicated Resident 3 was admitted to the facility on [DATE] with diagnosis including cerebral infarction ([stroke] loss of blood flow to a part of the brain). During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3's cognition was severely impaired and was fully dependent on staff to complete her ADLs. c. During a review of Resident 6's Face Sheet, the Face Sheet indicated Resident 6 was admitted to the facility on [DATE] hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or reduced ability to move on one side of the body) following a cerebral infarction affecting the right dominant side. During a review of Resident 6's MDS dated [DATE], the MDS indicated Resident 6's cognition was severely impaired and required substantial/maximal assistance or partial/moderate assistance from staff to complete her ADLs. d. During a review of Resident 7's Face Sheet, the Face Sheet indicated Resident 7 was admitted to the facility on [DATE] with diagnosis including urinary tract infection (UTI). During a review of Resident 7's MDS dated [DATE], the MDS indicated Resident 7's cognition was severely impaired and required substantial/maximal assistance or partial/moderate assistance from staff to complete her ADLs.During an observation on 2/17/2026 at 2:13 p.m. in Resident's 1, 3, 6, and 7's room, Resident 1's bed was observed with the head of the bed positioned halfway blocking an exit door which had a sign indicating, Exit WARNING!! ALARM WILL SOUND EMERGENCY EXIT ONLY! During a review of the facility's undated Disaster and Evacuation Plan, the facility's Disaster and Evacuation Plan indicated there was an exit door located in Resident's 1,3,6, and 7's room which lead to a back patio. During a concurrent observation and interview on 2/17/2026 at 3:15 p.m. and subsequent interview at 4:53 p.m., with the Maintenance Supervisor (MS) in Resident's 1, 3, 6, and 7's room, the Exit Door was observed unlocked. The MS was observed pressing the push bar (panic hardware, allowing fast, easy egress (exit) during emergencies by pushing a horizontal bar which releases the latch) and opened the door, which lead to a back patio area. The MS stated Resident 1's bed was partially blocking the exit door, and her bed would have to be moved so the exit door was fully accessible for persons to exit in an emergency. The MS stated the flooding by Resident 1's bed was reported to him the previous day, after it had already occurred. The MS stated when he arrived in the room, the housekeeper had already mopped the area and towels had been placed to absorb the remaining water, and the floor was mostly dry by the time he assessed it. The MS stated the flooding occurred because of heavy rain allowed water to enter the room from under the exit door and some of Resident 1's clothing became wet because she kept her belongings on the floor. The MS stated he did not make any changes to the door to prevent any future flooding of water into the room. During an interview on 2/17/2026 at 4:59 p.m., the Director of Nursing (DON) explained that even though the exit door by Resident 1's bed is marked as an exit on the floor map, it is not included in the emergency exit plan, and staff are not trained to use it during emergencies. The DON stated the flooding near Resident 1's bed was reported to her on 2/17/2026 and stated that having an exit door by the bed could impact the resident's safety.During an interview on 2/17/2026 at 5:30 p.m., the Administrator (ADM) stated the door by Resident 1's bed is not considered an emergency exit and Resident 1's bed is usually more to the right of the door. The ADM stated Resident 1 will be moved to another bed assignment. During a review of the facility's Policy and Procedure (P&P) titled, Fire and Disaster Policy/Procedure, dated 11/29/2018, the P&P indicated the facility is equipped with two or more exit ways, they are remote from each other and are identified on the floor plans posted throughout the facility. The P&P indicated it is the responsibility of all personnel to always keep exit ways clear, exit doors should never be blocked, not even for a few moments.

Based on observation, interview and record review, the facility failed to provide a quality living environment for one of the four sampled residents (Resident 1) when Resident 1 was placed in a bed in front of a flood-prone exit door. This deficient practice resulted in Resident 1's clothing becoming wet and had the potential for unnecessary damage to her clothing, which could cause emotional distress to Resident 1. Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including displaced transverse fracture (when a bone is broken horizontally into two pieces, and the pieces have separated) of the right patella (kneecap).During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 2/3/2026, the MDS indicated Resident 1's cognition (the ability to think and reason) was moderately impaired and required supervision or touch assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activities) by staff to complete her activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily).During an observation on 2/17/2026 at 2:13 p.m. in Resident 1's room, Resident 1's bed was observed with the head of the bed positioned halfway blocking an exit door which had a sign indicating, Exit WARNING!! ALARM WILL SOUND EMERGENCY EXIT ONLY! Resident 1 was observed placing a towel on the back of a chair which was located next to her bed, then continued to hang one pair of pants and two shirts on top of the towel.During an interview on 2/17/2026 at 2:13 p.m., Resident 1 stated she has been in her current bed for about six to seven days. Resident 1 stated on 2/16/2026 her clothing became wet when water flooded the floor. Resident 1 stated the water probably came in from under the exit door because it was raining. Resident 1 stated when her clothes became wet, she feared they could develop mildew and odors, so she hung them on the chair to dry. During a concurrent observation and interview on 2/17/2026 at 3:15 p.m. and subsequent interview at 4:53 p.m., with the Maintenance Supervisor (MS) in Resident 1's room, the Exit Door was observed unlocked. The MS was observed pressing the push bar (panic hardware, allowing fast, easy egress (exit) during emergencies by pushing a horizontal bar which releases the latch) and opened the door, which lead to a back patio area. The MS stated the flooding by Resident 1's bed was reported to him the previous day, after it had already occurred. The MS stated when he arrived in the room, the housekeeper had already mopped the area and towels had been placed to absorb the remaining water, and the floor was mostly dry by the time he assessed it. The MS stated the flooding occurred because of heavy rain allowed water to enter the room from under the exit door and some of Resident 1's clothing became wet because she kept her belongings on the floor. The MS stated he did not make any changes to the door to prevent any future flooding of water into the room. During an interview on 2/17/2026 at 4:59 p.m., the Director of Nursing (DON) stated the flooding near Resident 1's bed was reported to her today (2/17/2026) and stated that having an exit door by the bed could impact the resident's safety.During an interview on 2/17/2026 at 5:30 p.m., the Administrator (ADM) stated her belongings would not have been wet if her bed was not positioned by the exit door. The ADM stated Resident 1 will be moved to another bed assignment.During a review of the facility's Policy and Procedure (P&P) titled Resident's Rights, dated 10/2016, the P&P indicated residents have the right to a safe, clean, comfortable and homelike environment.

Based on interview and record review, the facility failed to provide toileting hygiene care after a bowel movement for one of three sampled residents (Resident 25). This failure had the potential to result in Resident 25 developing further skin breakdown. Findings: During a review of Resident 25's Admission record, the Admission record indicated Resident 25 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including acute respiratory failure (diffculty or inability to breath), pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) Stage 3 (Full-thickness loss of skin. Dead and black tissue may be visible) of right buttock, and neuromuscular dysfunction of bladder (condition where the nerves controlling bladder function are damaged, leading to impaired bladder muscle coordination resulting in difficulty urinating or incontinence). During a review of Resident 25's History and Physical (H&P), dated 3/24/2025, the H&P indicated Resident 25 had the capacity to understand and make decisions with Power of Attorney (POA- legal authority to make decisions on another person's behalf) assistance. During a review of Resident 25 ' s Minimum Data Set (MDS - a resident assessment tool), dated 3/7/2025, the MDS indicated Resident 25 had moderate cognitive (ability to learn, reason, remember, understand, and make decisions) impairment, required maximal assistance (helper does more than half the effort) for eating and personal hygiene and was dependent (helper does all of the effort) for toileting hygiene, showering, bathing, and dressing. During an interview on 4/27/2025 at 5:36 p.m., with emergency personnel (EP), the EP stated Resident 25 was transported from the facility. EP stated Resident 25 had soiled incontinence briefs and had not been changed or showered in a while. During an interview on 5/2/2025 at 10:16 a.m., with Certified Nurse Assistant (CNA) 5, CNA 5 stated the cleaning of a dependent resident after a bowel movement is documented as dependent under the CNA task titled, GG toilet hygiene. During an interview on 5/2/2025 at 10:42 a.m., with CNA 4, CNA 4 stated the cleaning of a dependent resident after a bowel movement is documented as a sponge bath under the CNA task titled, bathing. During a concurrent interview and record review on 5/2/2025 at 1:04 p.m., with the Assistant Director of Nursing (ADON), Resident 25 ' s CNA task flowsheet was reviewed. The ADON stated Resident 25 ' s last bowel movement was on 4/26/2025 at 10:38 p.m. The ADON stated there is not a separate CNA task to document that a dependent resident was cleaned after a bowel movement. The ADON stated if a bowel movement was documented in the Bowel Movement/Bowel Continence CNA task, it is assumed that toileting hygiene was provided. The ADON stated a sponge bath is not the same as toileting hygiene. During an interview on 5/2/2025 at 4:12 p.m., with the Director of Staff Development (DSD), the DSD stated the CNA task titled, Bowel Movement/Bowel Continence captured the following information: Date/time of occurrence, size of bowel movement (none, small, medium, or large), consistency of bowel movement (Formed/soft/normal, loose/diarrhea, constipated/hard, putty like), and bowel continence (continent, incontinent, or no bowel movement). The DSD stated it is not clear in the Bowel Movement/Bowel Continence task what if any, toileting hygiene care was provided to a resident. During a concurrent interview and record review on 5/2/2025 at 4:45 p.m., with the MDS Coordinator (MDSC), Resident 25 ' s CNA task flowsheet was reviewed. The MDSC stated the GG toileting Hygiene CNA task reflects the time and type of care the CNA provided to a resident, for example Dependent means the helper does all of the effort. The MDSC stated Resident 25 ' s last bowel movement was 4/26/2025 at 10:38 p.m. and the last toileting hygiene was documented on 4/26/2025 at 5:51 p.m. During an interview on 5/2/2025 at 5:05p.m. with the Director of Nursing (DON), the DON stated if a staff member is documenting the bowel movement for a dependent resident, the expectation is that the staff member will provided the toileting hygiene. The DON stated if Resident 25 does not receive proper toileting hygiene, it will delay Resident 25 ' s pressure ulcer healing process and put them at risk for further skin breakdown. During a review of the facility ' s policy and procedure (P&P), titled Quality of Care - ADL, Services to carry out, revised November 2007, the P&P indicated residents who are unable to carry out activities of daily living (ADL) will receive services to maintain: good nutrition, grooming, personal hygiene, and oral hygiene.

Based on observation, interview, and record review, the facility failed to provide services to improve or maintain range of motion ([ROM] full movement potential of a joint) and mobility (ability to move) for three of five sampled residents (Resident 40, 4, and 34) with ROM and mobility concerns by failing to: 1. Provide Resident 40 with a Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) screening or evaluation in accordance with the PT Job Description when the facility identified Resident 40's decline in ability to perform sit-to-stand (ability to come to a standing position from sitting) transfers on 10/4/2024. 2. Provide Resident 40 with interventions to improve the ability to perform sit-to-stand transfers on 10/4/2024 in accordance with facility's policy and procedure (P&P) for Quality of Care titled, ROM and Contracture (a stiffening/shortening at any joint that reduces the joint's range of motion) Prevention. 3. Provide Resident 40 with active assistive range of motion ([AAROM] use of muscles surrounding the joint to perform the exercise but requires some help from a person or equipment) to both arms and legs on 4/15/2025 in accordance with the physician order for Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility), dated 10/4/2024. 4. Provide Resident 40 with a right-hand splint (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) to prevent further ROM decline in accordance with the facility's P&P for Quality of Care titled, ROM and Contracture Prevention. 5. Accurately assess Resident 4's right-hand during the Joint Mobility Evaluation ([JME] brief assessment of a resident's range of motion in both arms and both legs), dated 4/14/25. 6. Provide Resident 4 with passive range of motion ([PROM] movement of a joint through the ROM with no effort from person) exercises to both wrists during the Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) session on 4/15/25 in accordance with the physician's order, dated 10/25/2023. 7. Provide Resident 34 with ROM exercises to both wrists, hands, and ankles during the RNA session on 4/15/25 in accordance with the physician's order, dated 12/9/2024. These failures resulted in Resident 40 losing the ability to stand and had the potential for Resident 40 to experience further ROM decline in the right hand, causing Resident 40 to feel frustrated and debilitated. These failures also had the potential for Resident 4 and 34 to experience a ROM decline in both arms and legs. Findings: During a review of Resident 40's Admission Record, the Admission Record indicated Resident 40 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including muscle weakness, diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), peripheral vascular disease ([PVD] a slow progressive narrowing of the blood flow to the arms and legs), and difficulty walking. During a review of Resident 40's physician order, dated 12/16/2023, the physician order indicated for the RNA to provide Resident 40 with AAROM to both arms and legs, four times a week as tolerated. During a review of Resident 40's physician order, dated 1/27/2024 and revised 4/10/2024, the physician order indicated for the RNA to provide Resident 40 with sit-to-stand transfers using the front wheeled walker ([FWW] an assistive device with two front wheels used for stability when walking), four times per week as tolerated. During a review of Resident 40's Restorative Nursing records (record of daily RNA sessions) from 4/10/2024 to 10/4/2024, the RNA records indicated Resident 40 received AAROM to both arms and legs, four times per week, and sit-to-stand with the FWW, four times per week as tolerated. During a review of Resident 40's RNA Weekly Progress Report (summary of RNA sessions for the given week with written narrative comments), dated 5/2/2024, the RNA Weekly Progress Report comments indicated Resident 40 performed sit-to-stand transfers with two-person assistance and held a standing position for 20-35 seconds. During a review of Resident 40's RNA Weekly Progress Report, dated 5/9/2024, the RNA Weekly Progress Report comments indicated Resident 40 performed sit-to-stand transfers using a FWW and held a standing position for 10 seconds. During a review of Resident 40's RNA Weekly Progress Report, dated 5/16/2024, the RNA Weekly Progress Report comments indicated Resident 40 performed sit-to-stand transfers two-person assistance and held a standing position for 30-60 seconds. During a review of Resident 40's RNA Weekly Progress Report, dated 6/6/2024, the RNA Weekly Progress Report indicated Resident 40 performed two repetitions of sit-to-stand transfers using a FWW with two-person assistance. During a review of Resident 40's quarterly Joint Mobility Evaluation ([JME] brief assessment of a resident's range of motion in both arms and both legs), dated 6/28/2024, the JME indicated Resident 40's current intervention included RNA for AAROM of both arms and legs, four times per week, and sit-to-stand, four times per week. The JME indicated Resident 40 had moderate ROM limitations (50-75 percent [%] ROM intact; 25-50% ROM loss) in both shoulders for flexion (raising arms upward in front of the body), the right shoulder for abduction (raising arm upward at the side of the body), the right fingers, and both hips. The JME indicated Resident 40 had minimum ROM limitations (75-100% ROM intact; 0-25% ROM loss) in the left shoulder for abduction, the right elbow, the left fingers, and both knees. During a review of Resident 40's RNA Weekly Progress Report, dated 7/4/2024, 7/11/2024, 7/18/2024, and 7/25/2024, the RNA Weekly Progress Reports indicated Resident 40 performed three repetitions of sit-to-stand transfers using a FWW and two-person assistance. During a review of Resident 40's RNA Weekly Progress Report, dated 8/1/2024, 8/8/2024, 8/15/2024, 8/22/2024, and 8/29/2024, the RNA Weekly Progress Reports indicated Resident 40 performed three repetitions of sit-to-stand transfers using a FWW and two-person assistance. During a review of Resident 40's RNA Weekly Progress Report, dated 9/5/2024 and 9/19/2024, the RNA Weekly Progress Report indicated Resident 40 performed two to three repetitions of sit-to-stand transfers using a FWW. During a review of Resident 40's RNA Weekly Progress Report, dated 9/26/2024, the RNA Weekly Progress Report indicated Resident 40 performed three sets of sit-to-stand transfers using a FWW. During a review of Resident 40's quarterly JME, dated 10/1/2024, the JME indicated Resident 40's current intervention included RNA for AAROM of both arms and legs, four times per week, and sit-to-stand, four times per week. The JME indicated Resident 40 had moderate ROM limitations in both shoulders for flexion, the right shoulder for abduction, the right fingers, and both hips. The JME indicated Resident 40 had minimum ROM limitations in the left shoulder into abduction, the right elbow, the left fingers, and both knees. The JME indicated Resident 40 did not have any changes in ROM since the last assessment on 6/28/2024. During a review of Resident 40's Progress Notes, a late entry Progress Note, dated 10/4/2024 at 11:08 a.m. by the Assistant Director of Rehabilitation (ADOR), the Progress Notes indicated Resident 40 had decreased strength and stability during two-person transfers with the Certified Nursing Assistants (CNAs). The Progress Note indicated the ADOR educated Resident 40 on the benefits and safety with the use of a mechanical lift (device used to lift and/or transfer a person's entire body from one surface to another surface) and/or sit-to-stand mechanical lift (device used to lift a person from a sitting position to a standing position to transfer from one surface to another surface) to reduce risk for fall and/or injury to Resident 40 or staff. During a review of Resident 40's physician order, dated 10/4/2024 at 11:10 a.m. by Physical Therapist 1 (PT 1), the physician order indicated to discontinue Resident 40's RNA to perform sit-to-stand transfers with a FWW, four times per week as tolerated. During a review of Resident 40's Change in Condition (CIC) Evaluation, dated 10/4/2024 at 11:34 a.m. entered by Licensed Vocational Nurse 4 (LVN 4), the CIC Evaluation indicated Resident 40 had a decline with RNA for sit-to-stand transfers. The CIC Evaluation indicated Resident 40 was unable to perform the sit-to-stand transfer and safely put back to bed. The CIC Evaluation indicated Resident 40's family member (FM 1) was notified on 10/4/2024 at 11:53 a.m. The CIC Evaluation also indicated Resident 40's Nurse Practitioner (NP) 1 was notified of the decline in sit-to-stand transfers on 10/4/2024 at 11:34 a.m. The CIC Evaluation indicated NP 1 provided recommendations to continue to monitor and did not provide any new orders. During a review of Resident 40's Progress Notes, a late entry Progress Note, dated 10/4/2024 at 11:35 AM (entered on 10/11/2024 at 1:03 p.m.) by the Assistant Director of Nursing (ADON), the Progress note indicated NP 1 provided a new RNA order to provide Resident 40 with AAROM to both arms and legs, every day, five days per week as tolerated. During a review of Resident 40's physician's order, dated 10/4/2024, the physician's order indicated for RNA to provide AAROM to both arms and legs, every day, five times per week as tolerated. During a review of Resident 40's Interdisciplinary Team ([IDT] group of individuals from different professional disciplines who collaborate to address a shared problem or goal for a resident) Care Plan Review, dated 12/17/2024, the IDT-Care Plan Review was not completed. During a review of Resident 40's quarterly JME, dated 1/1/2025, the JME indicated Resident 40's current intervention indicated RNA for AAROM of both arms and legs, four times per week, and sit-to-stand, four times per week. The JME indicated Resident 40 had moderate ROM limitations in both shoulders for flexion, both shoulders for abduction, and the right fingers. The JME indicated Resident 40 had minimum ROM limitations in the right elbow, the left fingers, both hips, and both knees. The JME indicated Resident 40 had improvement in both hips and a decline in the left shoulder for abduction. The JME indicated for Resident 40 to continue with the RNA program for ROM and monitor (unspecified). During a review of Resident 40's Minimum Data Set ([MDS] a resident assessment tool), dated 2/7/2025, the MDS indicated Resident 40 had clear speech, expressed ideas and wants, understood verbal content, and had intact cognition (clear ability to think, understand, learn, and remember). The MDS indicated Resident 40 had functional ROM limitations (limited ability to move a joint that interferes with daily functioning or places the resident at risk of injury) in one arm and both legs. The MDS indicated Resident 40 required setup or clean-up assistance for eating, substantial/maximal assistance (helper does more than half the effort) for bathing, dressing, rolling to either side in bed, and moving from lying in bed to sitting at the side of the bed, and dependent (helper does all the effort, resident does none of the effort to complete the activity, or the assistance of two or more helpers is required to complete the activity) for chair/bed-to-chair transfers. During an interview on 4/14/2025 at 9:42 a.m., with the Director of Rehabilitation (DOR), the DOR stated the purpose of PT (in general) included returning residents to their prior level of function with therapeutic exercises (movement prescribed to correct impairments and restore muscle function), gait (manner of walking) training, and strengthening. The DOR stated RNA was a maintenance program to maintain a resident's level of mobility which included the provision of ROM exercises, ambulation (the act of walking), and application of splints. The DOR stated maintaining a resident's mobility (in general) provided the resident with dignity (quality of being worthy of honor or respect) and quality of life. During a review of Resident 40's quarterly JME, dated 4/14/2025 at 2:31 p.m., the JME indicated Resident 40's current intervention included RNA for AAROM of both arms and legs, five times per week. The JME indicated Resident 40 had moderate ROM limitations in the right shoulder for flexion, both shoulders for abduction, and the right fingers. The JME indicated Resident 40 had minimum ROM limitations in the left shoulder into flexion, the right elbow, the left fingers, both hips, and both knees. The JME indicated Resident 40 had improvement in left shoulder flexion from moderate limitations to minimum ROM limitations since the last assessment on 1/1/2025. During a concurrent observation and interview on 4/15/2025 at 9:01 a.m. with Resident 40 in the bedroom, Resident 40 was lying awake in bed with the head-of-bed (HOB) elevated and had fluent speech. Resident 40 moved both arms at the shoulder, elbow, and wrist joints without any assistance. Resident 40 stated both hands used to look normal and constantly felt cold. The large knuckles of each finger on Resident 40's right-hand was observed in a bent position and unable to fully straighten. The middle joint of each finger on Resident 40s right-hand were hyperextended (excessive backward bending), which caused the tip joints of each finger to slightly bend. Resident 40 bent the right-hand fingers but was unable to make a full fist. Resident 40 stated both hands were normal until about one year ago when both hands started feeling cold. Resident 40 stated the facility has never provided any splints to the right-hand. Resident 40 was observed with more active movement in the left-hand than the right-hand. Resident 40 moved the left-hand into a fist and extended the fingers. Resident 40's left-hand had minimal ROM limitations when extending the fingers, which included hyperextension of the large knuckles of the index and ring fingers, a slight bend in the middle joints of each finger, and abduction (movement away from the other fingers) of the small finger. Resident 40 stated both hands made him feel handicapped. Resident 40 stated the RNAs performed exercises to both hips, knees, ankles, shoulders, elbows, and hands. A folded-up manual wheelchair was observed on the right side of Resident 40's bed. A FWW was also observed leaning against the wall next to Resident 40's nightstand. Resident 40 stated the facility transferred him to the wheelchair during the weekdays using a sit-to-stand mechanical lift. Resident 40 stated he used to walk with the therapists from the therapy room and down the hallway using the FWW but stated the facility had not attempted to walk with him anymore for over one year. During an observation on 4/15/2025 at 9:54 a.m. with Restorative Nursing Aide 2 (RNA 2), Resident 40's RNA session was observed. Resident 40 was lying awake in bed with the HOB elevated. RNA 2 lowered the HOB to place Resident 40's bed in a flat position. RNA 2 performed ROM exercises to both legs, including hip flexion (bending the leg at the hip joint toward the body) with the knee extended (straight), hip abduction (moving the leg at the hip joint away from the body), hip flexion with knee flexion, and right ankle dorsiflexion (bending the ankle toward the body). RNA 2 performed ROM exercises to Resident 40's right arm, including shoulder flexion, elbow flexion and extension, wrist rotation, thumb extension and flexion, and right-hand flexion. RNA 2 was unable to completely extend Resident 40's right elbow and the right fingers at the large knuckles. RNA 2 performed ROM exercises to Resident 40's left arm, including shoulder flexion, elbow flexion and extension, wrist rotation, and thumb extension and flexion. RNA 2 encouraged Resident 40 to perform active range of motion ([AROM] performance of ROM of a joint without any assistance or effort of another person) of the left hand into complete finger extension and flexion. During an interview on 4/15/2025 at 10:16 a.m., with RNA 2, RNA 2 stated she provided passive range of motion ([PROM] movement of a joint through the ROM with no effort from person) to both of Resident 40's arms and legs and AROM the left hand during the RNA session. RNA 2 stated she used to perform sit-to-stand transfers with Resident 40, but the therapist (unspecified) changed Resident 40's RNA program to ROM since it was unsafe for Resident 40 to perform sit-to-stand. During an interview on 4/15/2025 at 2:27 p.m., with the DOR, the DOR described PROM exercises as ROM provided to residents who did not have the physical ability to perform ROM exercises. The DOR stated AAROM exercises were when the resident can perform the ROM exercises but required assistance to finish or initiate the motion. During a concurrent interview and record review on 4/15/2025 at 3:29 p.m., with the DOR, Resident 40's physician's orders for RNA were reviewed. The DOR stated Resident 40 had a physician's order, dated 1/26/2024 and re-ordered on 4/10/2024, for the RNA to perform sit-to-stand transfers, four times per week. The DOR stated Resident 40's physician's order for RNA to perform sit-to-stand transfers was discontinued on 10/4/2024. The DOR stated the physician's order, dated 10/4/2024, indicated for RNA to provide Resident 40 with AAROM to both arms and legs, five times per week. During an interview and record review on 4/15/2025 at 4:15 p.m., with the DOR, Resident 40's CIC Evaluation, dated 10/4/2024, was reviewed. The DOR stated LVN 4 completed the CIC Evaluation but no longer worked at the facility. The DOR stated the CIC Evaluation indicated Resident 40 had a decline due to the resident's inability to perform sit-to-stand transfers. The DOR stated the CIC Evaluation indicated NP 1 was notified, did not provide any new orders, and continue to monitor Resident 40. The DOR stated Resident 40 did not receive a Rehab Screen (brief assessment to determine if a therapy evaluation was needed) on 10/4/2024. During an interview on 4/16/2025 at 10:57 a.m., with Resident 40, Resident 40 stated the facility did not inform him when they stopped RNA for sit-to-stand transfers. Resident 40 did not recall performing sit-to-stand transfers with the RNAs that often. Resident 40 stated he did not ask any questions and went along with the RNA program. Resident 40 stated there was one occurrence (unspecified date) when the RNAs thought the resident was going to fall. Resident 40 stated PT 1, who did not work at the facility anymore, observed the RNAs assist the resident with the sit-to-stand transfer, told Resident 40 that he was not strong enough to do the transfer, and told Resident 40 the sit-to-stand mechanical lift would be used for transfers. Resident 40 stated he did not discuss stopping RNA for sit-to-stand transfers with NP 1 and did not receive any additional therapy to maintain his ability to stand. During a telephone interview on 4/16/2025 at 11:19 a.m., with FM 1, FM 1 stated Resident 40's right-hand had limited motion for at least one year. FM 1 stated Resident 40 was left-handed and constantly felt cold in both hands. FM 1 stated Resident 40 used the left-hand more often and kept the right-hand clenched in a fist under the blanket. FM 1 was aware that the facility stopped physically transferring Resident 40 to the wheelchair and used the sit-to-stand mechanical lift for transfers. FM 1 stated she was not aware the facility stopped the RNA program for Resident 40 to perform sit-to-stand transfers. During an interview on 4/16/2025 at 12:49 p.m., with RNA 2, RNA 2 stated Resident 40 used to require two-person assistance during RNA for sit-to-stand transfers. RNA 2 stated Resident 40's ability to maintain his standing balance would vary. RNA 2 stated Resident 40's inability to stand during RNA sessions was reported to the charge nurse (unable to recall which nurse) and the DOR. RNA 2 stated either PT 1 (no longer worked at the facility) or Occupational Therapist 1 ([OT] professional aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) changed Resident 40's RNA program to discontinue sit-to-stand transfers. During an observation on 4/16/2025 at 1:25 p.m., with Certified Nursing Assistant 4 (CNA 4) and RNA 2 in Resident 40's room, Resident 40's transfer from the bed to the wheelchair using the sit-to-stand mechanical lift was observed. RNA 2 stood on the right side of the bed while CNA 4 stood on the left side of the bed. Both CNA 4 and RNA 2 assisted Resident 40 from lying in bed to sitting on the right side of the bed. RNA 2 and CNA 4 placed and fastened a cloth sling around Resident 40's waist. Cloth loops were sewn onto the cloth sling. RNA 2 fastened the loop to a right-sided hook on the sit-to-stand mechanical lift and then attached another loop to a left-sided hook on the sit-to-stand mechanical lift. RNA 2 used a controller to lift Resident 40 from a seated position at the edge of the bed to a standing position. Resident 40's knees were extended but Resident 40 did not stand upright. Both of Resident 40's hips were bent and positioned behind Resident 40's torso (main part of the body comprised of the chest, abdomen, pelvis, and back) and legs. RNA 2 turned the sit-to-stand mechanical lift toward Resident 40's wheelchair. CNA 4 secured Resident 40's wheelchair as RNA 2 lowered Resident 40 into a seated position. During an interview on 4/16/2025 at 1:47 p.m., with Occupational Therapist 2 (OT 2), OT 2 stated ROM loss could be prevented with ROM exercises and application of splints. OT 2 stated splints prevented the development of contractures (a stiffening/shortening at any joint that reduces the joint's range of motion) and prevented further contractures if a resident already had contractures. During an observation and interview on 4/16/2025 at 2:04 p.m., with OT 2, Resident 40's hands were observed while Resident 40 sat in the wheelchair. OT 2 stated the large knuckles of Resident 40's right-hand were in a bent position to approximately 60 degrees (normal 0-90 degrees), the middle joints of each finger were hyperextended, and the tip joints of each finger were bent. OT 2 asked Resident 40 to make a fist with the right-hand. OT 2 stated Resident 40's right-hand fingers slightly bent with the thumb having the most motion. OT 2 asked Resident 40 to move the left-hand into a fist and to touch the thumb to the tip of each finger. OT 2 stated Resident 40's left-hand motion was within functional limits (sufficient joint movement without significant limitation). During an interview on 4/16/2025 at 2:12 p.m., with OT 2, OT 2 stated Resident 40's right hand was not normal due to significant limitation in the large knuckles and hyperextension of the middle joints. OT 2 stated Resident 40 would benefit from a splint to prevent further contractures in the right hand. During a telephone interview on 4/16/2025 at 4:06 p.m., with Resident 40's physician (MD 1), MD 1 stated he would try to determine the reason for a resident's decline (in general) to perform sit-to-stand transfers with RNA and usually recommended additional therapy to improve mobility after a discussion with the resident if the facility notified MD 1 of a decline. MD 1 stated he would absolutely recommend additional therapy for Resident 40 if Resident 40 experienced a decline in the ability to perform sit-to-stand transfers with RNA. MD 1 stated the therapists usually contacted MD 1 directly for additional therapy orders but did not contact MD 1 regarding Resident 40. MD 1 stated NP 1 usually assessed the residents at the facility. During an interview on 4/17/2025 at 10:06 a.m., with Resident 40, Resident 40 stated he felt frustrated that he could not stand anymore. Resident 40 stated he did not have a choice and would find a way to stand by himself even if it was not safe. During an interview on 4/17/2025 at 10:18 a.m., with the Director of Nursing (DON) and the DOR, the DON stated the DON, and the Director of Staff Development (DSD) oversaw the RNA program. The DON stated the RNA program maintained a resident's mobility after a resident's discharge from therapy services. The DOR stated maintaining a resident's mobility (in general) was important to a resident's quality of life. The DOR stated the facility needed to perform an assessment if a resident experienced a decline in mobility while on RNA to determine the reason for the decline. The DON stated the assessment of a resident's decline would include an interview with the resident, an interview with the RNA, and a discussion during the IDT meeting to determine if there was a true decline. During an interview and record review on 4/17/2025 at 10:42 a.m., with the DON, ADON, and DOR, Resident 40's discontinued physician's order for RNA to perform sit-to-stand, dated 10/4/2024, CIC Evaluation, dated 10/4/2024, physician order for RNA to perform AAROM to both arms and legs, dated 10/4/2024, physician (MD) progress notes from 10/2024, and nurse practitioner (NP) progress notes from 10/2024 and 11/5/2024, were reviewed. The ADON stated Resident 40's decline in performing sit-to-stand transfers with RNA was reported to LVN 4, who no longer worked at the facility. The ADON stated NP 1 was notified of Resident 40's decline with RNA and NP 1 recommended to monitor Resident 40. The DON reviewed Resident 40's discontinued physician order for RNA and stated PT 1 discontinued the RNA order for sit-to-stand in the electronic medical record. The ADON stated she spoke to NP 1 in-person on 10/4/2024 (unspecified time) and the conversation with NP 1 was documented on 10/11/2024 as a late entry. The ADON stated NP 1 recommended to discontinue Resident 40's RNA for sit-to-stand transfers after NP 1 spoke with Resident 40. The ADON stated NP 1 recommended for Resident 40 to receive RNA for AAROM to both arms and legs. The ADON reviewed Resident 40's NP progress notes, including all of NP 1's progress notes, and did not locate any documentation from 10/2024 regarding Resident 40's decline with sit-to-stand transfers. The ADON reviewed Resident 40's NP 1's progress note, dated 11/5/2024, which did not include Resident 40's decline with RNA for sit-to-stand transfers. The ADON reviewed Resident 40's MD progress notes and did not locate any documentation from 10/2024 regarding Resident 40's decline with sit-to-stand transfers. During an interview and record review on 4/17/2025 at 11:05 a.m., with the DON and the DOR, Resident 40's Rehab Screen documentation was reviewed. The DOR stated Resident 40 experienced a decline in mobility since the RNA program was changed from sit-to-stand transfers to AAROM to both arms and legs. The DOR stated Resident 40 did not receive a Rehab Screen when the decline in mobility was identified on 10/4/2024. The DON stated the facility did not provide any intervention after Resident 40's decline on 10/4/2024 to maintain Resident 40's ability to perform sit-to-stand transfers. During an interview and record review on 4/17/2025 at 11:18 a.m., with the DON and the DOR, Resident 40's IDT meeting notes, including the IDT-Care Plan Review dated 12/17/2024, were reviewed. The DON stated there was no documentation the IDT discussed Resident 40's decline in mobility when the decline was identified on 10/4/2024. The DON stated Resident 40's IDT-Care Plan Review, dated 12/17/2024, was not completed. During an interview on 4/17/2025 at 11:39 a.m., with the DON, the DON stated PT 1 discontinued Resident 40's RNA order for sit-to-stand transfer (on 10/4/2024). The DON stated the PT would be the best person to maintain Resident 40's mobility. During an interview on 4/17/2025 at 11:59 a.m., with the DON and the DOR, the facility's P&P for Quality of Care titled, ROM and Contracture Prevention, was reviewed which indicated the facility ensured residents received services, care and equipment to maintain and/or improve their highest level of ROM and mobility unless a reduction is clinical unavoidable. The DON stated Resident 40's highest practicable level of mobility was to perform sit-to-stand. The DON declined to answer the question regarding whether Resident 40's decline in mobility was preventable. During a concurrent observation and interview on 4/17/2025 at 1:07 p.m. with RNA 2 and the DOR, Resident 40 sat in the wheelchair while RNA 2 wheeled Resident 40 into the hallway facing the hallway's siderail. The DOR placed a vinyl gait belt (assistive device placed around a person's waist to assist with safe transferring between surfaces or while walking) around Resident 40's waist. The DOR was standing on the left side of Resident 40 while RNA 2 was on the right side. Resident 40 extended both arms and grabbed the hallway siderail as the DOR and RNA 2 physically assisted Resident 40 upward toward standing. Resident 40's hips were bent and positioned behind Resident 40's torso and legs in a squatting position. The DOR attempted to physically push both of Resident 40's hips upward and forward but Resident 40 did not stand upright. The DOR and RNA 2 assisted Resident 40 back to sitting in the wheelchair and appeared physically tired. The DOR and RNA 2 stated Resident 40 required complete physical assistance to attempt to stand. RNA 2 stated Resident 40 used to stand before with maximum assistance of two-persons. Resident 40 stated, That's the perfect word, 'before,' because I have not stood in a while. During a telephone interview on 4/17/2025 at 1:57 p.m. with NP 1, NP 1 stated she did not recall the facility reporting Resident 40's inability to perform sit-to-stand with RNA. NP 1 stated the facility would typically request a therapy evaluation if a resident (in general) had decline in mobility. NP 1 stated a therapy evaluation would have been approved if the facility requested it for Resident 40's decline in ability to perform sit-to-stand. During a concurrent interview and record review with Restorative Nursing Aide 1 (RNA 1) and RNA 2 on 4/17/2025 at 2:20 p.m., Resident 40's RNA Weekly Progress Reports from 5/2024 to 10/2024 were reviewed. RNA 2 stated Resident 40 used to require full physical assistance to perform sit-to-stand, stood upright, and required physical assistance to maintain the standing position. RNA 1 stated Resident 40's ability to perform sit-to-stand changed every session. RNA 1 reviewed Resident 40's RNA Weekly Progress Report, dated 5/2/2024, which indicated Resident 40 stood for 20-35 seconds. RNA 1 stated Resident 40 stood upright for 20-35 seconds with full physical assistance from both RNAs. RNA 1 reviewed Resident 40's RNA Weekly Progress Report, dated 5/9/2024, which indicated Resident 40 stood for 10 seconds with good balance. RNA 1 stated Resident 40 had good balance because he stood more upright than usual and did not need as much assistance from RNAs. RNA 1 reviewed Resident 40's RNA Weekly Progress Report, dated 5/16/2024, and stated Resident 40 required two-person assistance for the sit-to-stand transfer and assistance to maintain standing for 30-60 seconds. Both RNA 1 and RNA 2 reviewed Resident 40's RNA Weekly Progress Reports from 6/2024 to 9/2024 and stated Resident 40 required two-person assistance to perform sit-to-stand transfers and to maintain standing. RNA 1 stated Resident 40 was unable to stand fully on 10/4/2024 which was reported to the charge nurse, the DOR, and the PT (unspecified). RNA 1 and RNA 2 stated the therapists would usually do a screen and determined the next steps. b. During a review of Resident 4's Admission Record (AR), the AR indicated Resident 4 was admitted on [DATE] with diagnoses including vascular dementia (impaired supply of blood to the brain causing progressive state of decline in mental abilities), dysphagia (difficulty swallowing), and difficulty in walki [TRUNCATED]

50144 Based on observation, interview and record review the facility failed to ensure the resident who had a suspected deep tissue pressure injury (SDTI, suspected pressure injury where damage is occurring beneath the skin, but the surface skin may still appear intact. It's characterized by a purple or maroon localized area of discolored skin or a blood-filled blister due to damage to underlying soft tissues from pressure) to a right heel and left heel blister did not progress to unstageable (actual pressure injury covered by slough [(pale yellow, thick, tissue with fiber) and/or eschar [a piece of dead tissue that is cast off from the surface of the skin] pressure injury for one of 16 sampled residents (Resident 35). The facility failed to: 1. Ensure Resident 35's right heel SDTI did not decline to an unstageable pressure injury2. 2. Monitored and documented the presence of a left heel SDTI upon Resident 35's admission. 3. Documented weekly left heel SDTI wound assessments in Resident 35's medical record. 4. Referred Resident 35 to a wound care practitioner. 5. Provided Resident 35 with offload (minimizing or removing weight placed on the foot to help prevent and heal ulcer) measures including low air loss (LAL) mattrass and elevate heels over a pillow or heel protector boots, and provide supplements such as additional protein, Zinc, Vitamin C and a Multivitamin to promote left heel SDTI wound healing. 6. Notify Resident 35's physician when the left heel blister (a painful skin condition where fluid fills a space between layers of skin) was reclassified as a left heel SDTI on 3/26/2025. 7. Notify Resident 35's physician and complete a change of condition (COC) assessment when Resident 35's left heel SDTI was noted to have a foul (bad) odor, an area of eschar, and slough on 4/14/2025. 8. Ensure the interdisciplinary team (IDT, brings together knowledge from different health care disciplines to help people receive the care they need) including the Director of Nursing (DON), the treatment nurse (TXN) 1, and the registered dietician (RD) met and discussed interventions to promote Resident 35's left heel SDTI wound healing. These deficient practices resulted in Resident 35's left heel blister and right heel SDTI to progress to unstageable pressure injuries on 4/14/2025 and causing the resident pain. Resident 35 was admitted to a general acute care hospital (GACH) on 4/17/2025 with a chief complaint of heel pain and a primary diagnosis of a left heel unstageable pressure injury injury Resident 35 was treated with Vancomycin (medication to treat infection) intravenously (IV, into the vein) bacteria wound infections, Morphine for pain, and was given one liter of Normal Saline (medical grade saline solution) solution for hydration in the emergency department (ED) on 4/17/2025. Findings: During a review of Resident 35's Admission Record, the Admission Record indicated Resident 35 was admitted to the facility on [DATE] from the GACH with diagnoses of left femur (thigh bone) fracture (broken leg bone), fall, muscle weakness, difficulty in walking, joint replacement surgery, and type 2 diabetes (happens when the body cannot use insulin correctly and sugar builds up in the blood). During a review of Resident 35's GACH's Wound Care Consult notes dated 3/23/2025 the Wound Care Consult notes indicated Resident 35 had Stage II (may present as an intact blister)/ DTI with an intact fluid filled blister) measured 6.0 cm in length by 6.0 cm in width and a right heel SDTI with erythema (redness) measured 3.0 cm in length by 3.0 cm in width. The Wound Care Consult notes indicated Resident 35 required Pressure Injury Prevention Protocol including a waffle seat cushion (an air pressure redistribution cushion), or a low air loss mattress, turning and repositioning every two hours, and offload the heels over a pillow or heel protector boots. During a review of Resident 35's Initial Admission Record dated 3/23/2025, the initial Admission Record indicated treatment nurse (TXN) 2 conducted a skin integrity check. The Admission Record indicated TXN 2 notified the physician (unspecified) of Resident 35's, left heel blister and right heel SDTI. Resident 35's Initial Admission Record did not indicate a description, including the appearance and measurements of the left heel blister and the right heel SDTI upon admission. During a review of the Admission Report- Skin Check (paper document) undated, the Skin Check document indicated Resident 35 had a right heel SDTI measured 1.5 cm in length by 0.5 cm in width and a 3.0 cm by 6.0 cm left heel blister. During a review of Resident 35's H&P dated 3/24/2025, the H&P (a thorough medal history from the patient obtained by a physician during a physical examination) indicated Resident 35 was able to make her own medical decisions. The H&P indicated Resident 35 was sent to the facility status post (after) left hip surgery due to a left hip fracture. The H&P indicated Resident 35 did not have any concerning rashes or lesions (wounds) at the time but did have a left hip surgical site. The H&P included a plan to monitor the wound (surgical site) per facility protocol and obtain a wound care evaluation as needed. The H&P indicated the facility's care staff was instructed to call the physician for any COC. During a review of Resident 35's care plan titled, Actual impairment to skin integrity related to left heel blister and left heel protector boot (cushioned boot that floats the heel to aid in healing of pressure injuries) dated 3/25/2025, the care plan indicated the goals for Resident 35 included reducing the risk for impairment to skin integrity by (body) positioning techniques, and adaptive equipment. The care plan interventions included avoiding scratching, keeping body parts from excessive moisture, keeping fingernails short, educating resident/ family/ and caregivers of causative factors and measures to prevent skin injury, and encouraging good nutrition and hydration to promote healthier skin. On 4/15/2025 the care plan for the left heel blister was updated to include, on 3/26/2025: patient was reassessed by TXN 1, the left heel blister was classified as SDTI with purple tissue. On 4/15/2025 the care plan interventions were updated to include left heel SDTI treatment as ordered, monitor/ document location, size and treatment of the skin injury, report abnormalities, failure to heal and signs and symptoms of infection to the physician, monitor for skin breakdown and off-load (minimizing or removing weight placed on the foot to help prevent and heal ulcers) as tolerated. During a review of Resident 35's Order Summary Report, the report indicated the following physician's wound care orders: - On 3/25/2025 for left heel blister, cleanse with NS pat dry, apply antibacterial ointment then apply gauze and wrap with kerlix (type of dressing). Every day shift. The order was discontinued on 3/26/2025. - On 3/25/2025 for right heel SDTI cleanse with NS, pat dry, apply oil emulsion dressing wrap (gauze wound dressing impregnated with a blend of oil and water), in kerlix. Ever day shift. The order was discontinued on 4/16/2025. - On 3/25/2025 for bilateral (both) heel apply protector boots as tolerated or as patient allows. Every day shift. -On 3/26/2025 for left heel SDTI: cleanse with NS, pat dry, apply sure prep (skin barrier ointment), apply abdominal (ABD) pad and cover with rolled gauze. Offload as tolerated, monitor for skin breakdown and notify the physician of any changes every day shift. The order was discontinued on 4/14/2025. -On 4/14/2025 for left heel SDTI: cleanse with NS, pat dry, apply Medihoney, calcium alginate dressing (ideal for wounds with moderate to heavy exudate [fluid that leaks out of blood vessels into nearby tissues]), dry dressing and cover with rolled gauze. Offload as tolerated, monitor for skin breakdown and notify the physician of any changes every day shift. The order was discontinued 4/16/2025. - On 4/14/2025 wound culture of the left heel, one time only. -On 4/16/2025 wound care consult for SDTI. -On 4/16/2025 for left heel unstageable pressure injury: cleanse with NS, pat dry, apply Medihoney, calcium alginate, dry dressing and cover with rolled gauze. Offload as tolerated, monitor for any signs for skin breakdown and notify the physician of any changes. -On 4/16/2025 for right heel unstageable pressure injury: cleanse with NS, pat dry, apply Medihoney, calcium alginate, dry dressing and cover with rolled gauze. Offload as tolerated, monitor for any signs for skin breakdown and notify the physician of any changes. During a review of Resident 35's Skin/ Wound Note dated 3/26/2025 (three days after admission), the note indicated Resident 35 was reassessed by TXN 1 and the left heel blister was classified as an SDTI with purple tissue. The note did not indicate measurements or a complete wound assessment describing the characteristics of the wound. The note did not indicate the physician was notified of the classified wound type or new treatment orders. Resident 35 did not have weekly Skin/Wound assessments documented in her medical record including all wounds and their progress as indicated in the facility's Wound Management and Prevention policy and procedure (P/P). During a review of Resident 35's MDS, dated [DATE], the MDS indicated Resident 35 had moderate cognitive impairment and required substantial/ maximal assistance (helper does more than half the effort) for bed mobility including rolling from left to right. The MDS indicated Resident 35 was at risk for pressure injuries and had two deep tissue injuries and zero unstageable pressure injuries with slough or eschar. During an observation on 4/14/2025 at 10 a.m., Resident 35 was lying in bed with her feet elevated on one pillow. Resident 35 did not have heel protector boots on, Resident 35 was not lying on a low air loss mattress. During an interview on 4/14/2025 at 10:11 a.m., Family Member (FM) 2 stated she was upset because Resident 35's left heel wound was getting worse. During an observation on 4/14/2025 at 1:44 p.m., TXN 1 was in Resident 35's room speaking to FM 3 at the bedside. Resident 35 was lying in bed crying in pain, saying her left foot hurt. Resident 35 was informing FM 3 she had chills (the feeling of being cold, though not necessarily in a cold environment, often accompanied by shivering or shaking). TXN 1 was obtaining a wound culture swab of Resident 35's left foot wound due to the foul odor of the wound. Resident 35's left heel was observed with the following and described by TXN 1 as: a large area of dark purple or black appearing eschar, surrounded by a pinkish red area of granulation tissue, and a small amount of yellowish white slough. During a review of Resident 35's wound culture (medical test to determine the kind of infectious agent), obtained from left foot on 4/14/2025, the wound culture results indicated Resident 35 had moderate growth of Proteus Mirablis (a gram-negative bacteria that can cause wound infections). During an interview on 4/15/2025 at 9:03 a.m., TXN 1 stated Resident 35's wounds were not being treated by a wound care practitioner. TXN 1 stated she noticed a change in appearance to Resident 35's left heel wound and a little bit of odor, so she obtained the wound culture on 4/14/2025. TXN 1 reviewed her wound care binder at the nurse's station where she tracked residents' wound progress but there was no information about Resident 35 in her wound care binder. TXN 1 reviewed Resident 35's medical record and stated there were no weekly skin/ wound documentation in the chart including measurements and appearance of the wounds. TXN 1 reviewed Resident 35's LN-Initial Admission Assessment from 3/23/2025 and stated the documentation lacked a description of the wound appearance and the measurements of the wound. TXN 1 stated the initial assessment of the left heel wound indicated it was a left heel blister. TXN 1 stated when she assessed Resident 35 herself on 3/26/2025, she noted the wound to be a SDTI with 100% of the wound being purple boggy (a wound where the surrounding tissue feels soft, spongy, and possibly mushy to the touch, often due to increased fluid content) tissue. TXN 1 stated based on the documentation in the chart she did not have a good baseline (assessment of the wound upon admission) from admission to see if there had already been a decline in the wound status since admission because the documentation was lacking wound characteristics, so she reclassified the wound as an SDTI based on her assessment from 3/26/2025. During an interview on 4/16/2025 at 8:04 a.m., with FM 1, FM 1 stated when she was visiting Resident 35 on the evening of 4/13/2025, Resident 35 was complaining of pain to her left foot, and she noted a smell in Resident 35's room so she ripped off Resident 35's sock and bandage that was wrapped around the left heel. FM 1 stated she was shocked to see Resident 35's left heel wound looked worse, and the wound smelled. FM 1 stated she alerted staff (unknown) to the issue on 4/13/2025 and two staff came in to look at the wound and wrap it back up, but she was unsure who the staff were. FM 1 stated the wound looked much worse than it did when Resident 35 was admitted . FM 1 stated a wound culture was taken the next day (4/14/2025) but she did not know the results yet. FM 1 stated Resident 35 was complaining of worsening left heel pain for a few days. FM 1 stated Resident 1 was admitted from the GACH with heel protector boots and when she would go visit Resident 35, they would not be on and would be in Resident 35's closet and sometimes Resident 35's heels would be touching the bed. During an interview on 4/16/2025 at 11:16 a.m., TXN 1 stated Resident 35's left heel wound had a change in status on 4/14/2025. The wound had some drainage and had a smell, so the facility obtained an order for a wound culture. TXN 1 stated she did not inform the physician of the change in appearance of the wound; they just requested a wound culture due to the smell. TXN 1 stated Resident 35's left heel wound now had eschar or necrotic tissue which was not good for wound healing and usually needed to be debrided but debridement was not in her scope of practice so Resident 35 needed a wound care consultation. TXN 1 stated she had yet to request an order for a wound care consultation for Resident 35's wound because the results of the wound culture were not back yet. TXN 1 stated when a wound has eschar, they do not know how bad the wound really was underneath, and the wound could have been worse. TXN 1 stated DTIs could deteriorate rapidly with any pressure due to the fragility of the skin and it was important to be proactive with interventions and offload the heels for the best chance for wound healing. TXN 1 stated it was important to have accurate baseline assessments of wounds and wound interventions should be implemented immediately to keep the wound healthy, infection free, mitigate pain, and promote healing. TXN 1 stated it was the facility's policy to document weekly on the wound progress. TXN 1 stated it was important to have a description of the wound including all the wound characteristics and measurements upon baseline so the facility could have an accurate baseline to track the progress of the wound and to ensure the resident receives the proper interventions to prevent a decline in the wound. TXN 1 stated she reviewed Resident 35's care plans and the care plans were not updated until 4/15/2025 to include the reclassified SDTI staging of the left heel wound and to offload the heels. TXN 1 stated the care plan should have been updated when she reclassified the left heel wound as a SDTI on 3/26/2025. TXN 1 stated a comprehensive person-centered care plan for each wound was important because the facility needed to identify the problem, assess the risk associated with the problem, and implement interventions to prevent a decline in the wound and to promote wound healing. TXN 1 stated she was upset with herself because she did not perform a COC assessment and notify the physician of Resident 35's decline in wound appearance on 4/14/2025. TXN 1 stated there was a possibility of delay in care and treatment if the physician was not notified right away of a wound decline. TXN 1 stated she had not called Resident 1's physician to discuss Resident 35's wound status since she had been caring for Resident 35's wounds. During an interview on 4/16/2025 at 2:21 p.m., with the physician assistant (PA) 1 who was in the facility, PA 1 stated he had just been informed Resident 35 had worsening wounds. PA 1 stated he was going to put an order for Resident 35 to be seen by a wound care practitioner. PA 1 stated the physician or himself should have been notified right away of any new or changing wounds. PA 1 stated it was important residents with wounds that have eschar were seen by a wound care consultant so the appropriate interventions could be placed. During an interview on 4/16/2025 at 2:25 p.m., TXN 1 stated she was now staging Resident 35's left heel wound as an unstageable pressure injury due to the wound characteristics (slough and eschar). TXN 1 stated the definition of an unstageable pressure injury was the wound couldn't be staged. During an observation on 4/16/2025 at 2:42 p.m., TXN 1 measured the wound on Resident 35's left heel, the wound measured 6.5 cm length by 7.0 cm in width with a separate discoloration (redness) on the inner ankle. The wound had a large purplish black center, yellowish white area surrounding the dark area as well as a small area of granulation tissue (new pinkish red tissue). TXN 1 removed the dressing from the right heel and revealed a 3.3 cm in length by 5.0 cm in width wound that was purple with a translucent center. TXN 1 indicated she would be reclassifying the right heel wound as an unstageable pressure injury as well completing a COC for bilateral heels. During a review of Resident 35's COC evaluation dated 4/16/2025, the COC indicated Resident 35 had developed pain in both heels. Resident 35's left and right hells SDTI were reclassified as Unstageable pressure injuries. The left heel unstageable pressure injury measured 6.5 cm in length by 7.0 cm in width with 75 percent (%) of wound covered in eschar, 20% slough, and 5% granulation tissue with medial (inside) ankle discoloration. The right heel unstageable pressure injury measured 3.3 cm in length by 5.0 cm in width with purple intact tissue. The COC indicated FM 2 was requesting an x-ray (a type of diagnostic test using radiation that creates a picture of the inside of the body) of both feet to rule out effects to the bone. During a review of Resident 35's Nursing Progress Note dated 4/17/2025, the Progress Note indicated Resident 35 verbalized she was unable to sleep well the night prior due to left heel pain and had moderate pain at the time of evaluation on the left heel. The Progress Note indicated nursing offered Resident 35 to be transferred to the GACH for further evaluation of her pressure injury wounds and Resident 35 agreed to the transfer. During a review of Resident 35's Skin/ Wound Note dated 4/17/2025, the Skin/ Wound Note indicated treatment was halted due to patient expressing pain. The note indicated wound care was not resumed due to Resident 35's condition and pain level and Resident 35 was transferred to the GACH. During an interview on 4/17/2025 at 2:33 p.m., the DON stated she was not aware of Resident 35's wounds until this interview. The DON stated it was important she was notified of wound and the wound decline so she could review the chart and ensure the resident was receiving all appropriate interventions. The DON stated wounds needed to be assessed upon admission, for any changes, and weekly and all assessments needed to be recorded in the resident's chart. The DON stated the IDT had not met to discuss Resident 35's wounds. The DON stated there was a possibility the wounds could decline if the IDT did not meet to discuss important interventions needed. The DON reviewed Resident 35's medical record and stated weekly skin/ wound assessments had not been completed. The DON stated the LN- initial admission assessment should have included a wound description and measurements, and the initial assessment indicated Resident 35 was admitted with a left heel blister. The DON stated the physician should have been notified that the left heel blister was reclassified as a SDTI on 3/26/2025 but there was no evidence in the chart that the physician was informed. The DON stated it was important the physician was aware of wound changes so they could order any necessary interventions. The DON stated there was no COC or notification of the physician documented in Resident 35's chart related to the wound appearance and decline on 4/14/2025. The DON stated the treatment nurses (TXN 1 and TXN 2) were not competent in wound documentation and tracking as evidenced by the lack of documentation in Resident 35's chart and the failure to complete a COC when a decline in the wound was noted on 4/14/2025. The DON stated Resident 35 did not have an order for an LAL mattress. The DON stated Resident 35 had not been seen by a wound care consult. The DON stated the importance of a wound care consultation was to ensure they followed the progression of the wound closely, performed any necessary debridement's, and implemented interventions to help prevent a decline in the wound. The DON stated there was no evidence in Resident 35's chart that registered dietician was aware of Resident 35's wounds. During an interview on 4/17/2025 at 2:25 p.m., the case manager (CM) stated she requested an authorization for a wound care consultation for Resident 35 for the first time on 4/16/2025 when the order was placed. During a review of Resident 35's Registered Dietician Note dated 4/18/2025, Registered Dietician Note indicated Resident 35 had bilateral heel unstageable pressure injuries. The note indicated a nurse (unknown) had received a new physicians order (4/17/2025) for multivitamins with minerals, Vitamin C 500 mg, and Zinc 220 mg for 14 days and RD 2 recommended ProStat (liquid protein) 30 ml twice a day for wound healing. During a review of Resident 35's GACH's Wound Care Consult dated 4/18/2025, the GACH Wound Care Consult indicated Resident 35 was sent from the facility for worsening wounds to bilateral heels and bilateral heel pain. The Wound Care Consult indicated Resident 35 received Vancomycin, Morphine 4.0 mg intravenously (IV-into the vein), and 1.0 liter of NS in the ED. The Wound Care Consult indicated FM 2 reported Resident 35 had worsening wound to the left heel for one week with odor. The Wound Care Consult indicated Podiatry (the treatment of the feet and their ailments) was consulted for the left heel unstageable pressure injury. During an interview on 4/18/2025 at 7:26 a.m., FM 1 stated Resident 35 had been transferred to the GACH the night prior due to her wounds and was receiving IV fluids, pain medication, and antibiotics. FM 1 stated they were waiting for a specialist to come and look at Resident 35's heels to discuss if surgery was required to treat the wounds. FM 1 stated Resident 35 was feeling very anxious and upset because she thought they might have to cut her left foot off due to the wound. During an interview on 4/18/2025 at 1:17 p.m., RD 2 stated she was just made aware of Resident 35's wounds and was not aware that Resident 35 had wounds upon admission. RD 2 stated nutritional consultation was important for residents with wounds because they require more protein to promote wound healing. RD 2 stated there is a nutritional regimen they usually implement for wound healing that includes Vitamin C, Zinc, Multivitamins with minerals and ProStat (liquid protein) but it was not added for Resident 35 until 4/18/2025. During a review of the facility's P/P titled Change of Condition Reporting dated 4/2021, the P/P indicated changes in resident condition were to be reported to the physician and it was to be documented in the eInteract Change of Condition and/ or in the nurse's progress notes, the plan of care was to be updated. The P/P indicated any attempts to contact the physician would be documented in the resident's medical record. During a review of the facility's P/P titled Wound Management and Prevention dated 8/1/2021, the P/P indicated it was the facility's policy to ensure any resident that entered the facility had appropriate preventative measure taken to ensure the resident did not develop pressure ulcers, or that residents admitted with wound did not develop signs and symptoms of infection. The P/P indicated a plan of care was to be initiated to address areas of actual skin breakdown and the care plan was to be reviewed and revised as needed. The P/P indicated a report of all the wounds and their progress would be updated by the treatment nurse weekly. The P/P indicated the RD was to provide nutritional support when appropriate. During a review of the facility's Job Description- Director of Nursing dated 10/2021, the job description indicated the DON was to review nursing personnel medical record documentation to ensure that it was appropriately and accurately descriptive of the nursing care provided. The DON was to manage and direct all aspects of the nursing services department. The DON was to assist in the development of preliminary and comprehensive assessments of the nursing needs of each resident. During a review of the facility's Job Description- Treatment Nurse dated 12/17/2021, the job description indicated the treatment nurse was to make written and oral reports/ recommendations to the attending physician, Medical Director, or the DON concerning the status and care of the residents. The treatment nurse was to work with the IDT to develop a comprehensive assessment and care plan for all assigned residents. Examine the resident and or his/ her records and charts, and discriminate between normal and abnormal findings, to recognize when to refer the resident to a physician for evaluation, supervision, or directions. Initiate requests for consultation or referral.

Based on observation, interview and record review the facility failed to: 1.Ensure one out of six sampled residents (Resident 2) was free from mental abuse (the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation). 2.Implement the facility Policy and Procedure (P&P) titled Abuse: Prevention of and Prohibition Against revised 12/2023, that indicated each resident had the right to be free of abuse. The P/P indicated the facility was to ensure the health and safety of each resident with regards to visitors, such as family members, friends, or other individuals subject to the resident's right to deny or withdraw consent at any time and to reasonable clinical and safety restrictions, by allowing Resident 2's alleged abuser, Family Member 4 (FM 4) access to Resident 2, when FM 4 came into the facility, and Resident 2's room and tried to force Resident 2 to talk to him (FM 4). As a result, Resident 2 suffered emotional distress requiring a new physician's order for Ativan (medication used to treat anxiety [a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities]) after Resident 2's alleged abuser, FM 4 gained access to the facility on [DATE], proceeded to Resident 2's room and tried opening Resident 2's bedside curtains while she was receiving perineal (peri) care (washing the genitals). (Cross reference F609 and F610) Findings: During a review of Resident 2's Admission Record, the Admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including confirmed physical abuse, major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), and anxiety disorder. During a review of Resident 2's History and Physical (H&P) dated 3/15/2025, the H&P indicated Resident 2 was admitted to the facility from a general acute care hospital (GACH) due to adult physical abuse causing traumatic ecchymosis (bruising). The H&P indicated Adult Protective Services (APS - a government agency that investigates allegations of a vulnerable adult being or having been abused, neglected, or exploited by their caregivers), and the police had been notified of the abuse by the GACH. The H&P indicated it was unclear if Resident 2 was able to make her own medical decisions and she was making medical decisions with the help of her sister (FM 5). The H&P indicated do not give any information to FM 4, in the plan of treatment. During a review of Resident 2's care plan titled, At risk for re-traumatization related to (r/t) history of physical abuse by a close family member initiated on 3/18/2025, the Care Plan goals included Resident 2 would have no evidence of emotional, physical, and psychological problems. The Care Plan interventions included encouraging Resident 2 to attend care conferences, to express preferences and participate in the care planning process. During a review of Resident 2's Interdisciplinary Team (IDT, brings together knowledge from different health care disciplines to help people receive the care they need)- Care Plan Review dated 3/18/2025, the IDT Care Plan Review indicated Resident 2 had an APS case against FM 4 for physical abuse. The IDT Care Plan Review indicated Resident 2 expressed that she did not want any calls or visits from FM 4. Resident 2 also expressed she felt threatened by FM 4, and FM 4 should also be banned from calling or visiting her. Resident 2 expressed she did not want to be discharged home with FM 4 because of the abuse. The IDT documentation indicated FM 4 was verbally, emotionally, financially, and physically abusive towards Resident 2 for years and multiple police reports were filed but Resident 2 always took FM 4 back in until the last event (date no specified) that led to her most recent hospitalization and she decided to press charges against FM 4 and not return to their apartment. During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool) dated 3/21/2025, the MDS indicated Resident 2's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. The MDS indicated Resident 2 was not receiving any medications for anxiety. During a review of Resident 2's Case Manager (CM) Progress Notes dated 3/18/2025, the Case Manager Progress Notes indicated the CM was notified FM 4 was at the facility to visit Resident 2. The CM Progress Notes indicated the CM had been notified by Resident 2 that she did not want visits from FM 4. The CM Progress Notes indicated the CM notified FM 4 of Resident 2's wishes, and FM 4 proceeded to walk towards Resident 2's room stating, that is a lie! I was just there yesterday, and I took a train and two buses to get here. The CM Progress Notes indicated the CM asked FM 4 to wait in the lobby so she (CM) could confirm Resident 2's wishes, and Resident 2 again stated she did not want any calls or visits from FM 4. The CM Progress Notes indicated the CM relayed the message to FM 4, and he became agitated using profanity (bad words). The CM Progress Notes indicated the Police had to be called before FM 4 agreed to leave the facility. The CM Progress Notes indicated Resident 2's chart was updated, and staffing was made aware of Resident 2's wishes to not have visits from FM 4. During a review of Resident 2's Social Services Summary Note dated 3/21/2025, the Social Services Summary Note indicated Resident 2 was verbally responsive with capacity to understand and make decisions. The Social Services Summary Note indicated Resident 2 was unable to sleep well, had anxiety and worries about FM 4 who was physically abusive towards her. During a review of Resident 2's CM Note dated 4/8/2025, the CM Note indicated after lunch (lunch was served by 12:30 p.m.) on 4/8/2025 the CM was notified FM 4 was outside of Resident 2's room. The CM reminded FM 4 of Resident 2's wishes, and he became hostile and aggressive pushing past the CM and two other staff (unknown) to enter Resident 2's room. The CM Note indicated Resident 2's privacy curtain was pulled around Resident 2's bed for privacy and FM 4 proceeded to try and pull back the curtain as nursing staff (Licensed Vocational Nurse [LVN]3) was holding it shut. FM 4 was shouting to Resident 2, It's me FM 4, stop saying you do not want to see me. I came here to see you, tell them it is okay for me to see you, tell them it is okay for me to be here. The CM Note indicated Resident 2 was physically shaking her head No and Resident 2 was visually upset and tearful as she kept her eyes closed and continued shaking her head No. The CM Note indicated staff (unknown) intervened to prevent further interaction with Resident 2 and the police were called. FM 4 was escorted out of the building by two male staff (unknown) as FM 4 was verbally cursing profanities. During a review of Resident 2's Change in Condition (COC) evaluation dated 4/8/2025, the COC indicated Resident 2 was experiencing emotional distress. The COC indicated Resident 2 reported feeling anxious after the visit from FM 4 and emotional support was provided. MD 3 was notified and ordered; 1. monitor Resident 2 for emotional distress and 2. Ativan oral tablet 0.5 milligrams (mg) by mouth every eight hours as needed for anxiety manifested by verbalization of anxiousness with mild tremors for three days. 3. Psych consultation related to depression and anxiety. During a review of Resident 2's Care Plan titled Potential for psychosocial well-being problem related to family discord (disagreement, or difference in opinion) dated 4/8/2025, the Care Plan goals included for Resident 2 not having any further indications of psychosocial wellbeing problems. The Care Plan interventions included allowing Resident 2 time to answer questions and to verbalize feelings and fears, consultation with behavioral health, and when conflict arises removing Resident 2 to a calm, safe environment and allowing Resident 2 to vent and share her feelings. During a review of Resident 2's medication administration record (MAR), the MAR indicated Resident 2 was given Ativan 0.5 mg one time on 4/9/2025 for feeling anxious. During a review of Resident 2's Medication Administration Note dated 4/9/2025, the Medication Administration Note indicated Resident 2 was visibly shaken and anxious. Resident 2 was requesting anti-anxiety medications and Resident 2 was given Ativan 0.5 mg. During a review of Resident 2's COC (Condition) Follow-up dated 4/9/2025, the COC Follow-Up indicated Resident 2 had increased anxiety due to FM 4 and Resident 2 was calmer after receiving the Ativan 0.5 mg. During an observation and concurrent interview on 4/14/2025 at 9:50 a.m., Resident 2's name was displayed at the entrance of her door. Resident 2 stated her mind was always wandering, and did not work like it used to. During an interview on 4/15/2025 at 3:17 p.m., Resident 2 declined to elaborate on how FM 4 abused her prior to her admission to the facility. Resident 2 stated she was scared just hearing FM 4's voice when he got into the facility and the situation was mentally exhausting, but she prayed for FM 4 every day and just wanted to move forward with her life. Resident 2 stated the facility provided her with a number to call for therapy, but she had yet to set up an appointment. During an interview on 4/17/2025 at 10:20 a.m., with the CM, the CM stated Resident 2 had come to their facility after a stay in the GACH from sustaining injuries due to being physically assaulted by FM 4. The CM stated Resident 2 had an open APS case against FM 4 prior to her admission to the facility. The CM stated Resident 2 had been dealing with the abuse for several years until she decided to cut ties with FM 4 when she was admitted to the GACH. The CM stated FM 4 had snuck into the facility two times that they know of; on 3/18/2025 and 4/8/2025. The CM stated Resident 2 became visibly shaken up just by the mention of FM 4 being in the vicinity of the facility. The CM stated the first instance FM 4 entered the facility on 3/18/2025, she (the CM) was alerted a male was in Resident 2's room being disruptive so she went to investigate and informed FM 4 he was not welcome at the facility, Resident 2 did not wish to see him, and the police were called. The CM stated the second time he came back to the facility on [DATE], FM 4 was immediately spotted by staff, staff tried to stop him from entering Resident 2's room but he pushed his way into the room and was trying to pull the privacy curtain open, but LVN 3 was holding the privacy curtain shut. The CM stated Resident 2 was receiving peri care, and her privates were exposed while FM 4 was trying to pull the privacy curtain open. The CM stated FM 2's voice was very aggressive, very loud, caused a huge commotion and he was yelling to Resident 2, God dammit you know you want to see me, why are you telling them you do not want to see me! and Resident 2 was crying and very shaken up by the occurrence. The CM stated the way FM 4 was talking, acting, and the tone of voice he was using was verbally and emotionally abusive. The CM stated the abuse coordinator (administrator [ADM]) was aware of the situation that occurred on 4/8/2025. The CM stated she brought it up during a morning meeting with department heads that in GACHs, victims of violence do not have their names outside of their rooms for patient safety and the CM thought it would be a good idea to implement but she does not know what the facility did with that information. The CM stated she believed FM 4 found out what room Resident 2 was in by looking for and finding her name posted outside of her doorway. The CM stated they offered assistance to call a behavioral health self-referral number to set up an appointment for therapy, but the resident declined. During an interview on 4/17/2025 at 10:54 a.m., with the Social Services Director (SSD), the SSD stated Resident 2 became upset at the mention of FM 4's name so they had to respect her and not ask any questions because Resident 2 did not want to talk about any of the details. During an interview on 4/17/2025 at 1:42 p.m., with LVN 3, LVN 3 stated on 4/8/2025 FM 4 bypassed all the safety checks in the facility and snuck into the facility behind another resident's family member (unknown). LVN 3 stated she knew a Certified Nursing Assistant (CNA) (unknown) was providing peri care to Resident 2 at the time, so LVN 3 entered Resident 2's room to check on the resident before FM 4 abruptly made his way past the CM (who was at the doorway of Resident 2's room) and was trying to pull Resident 2's privacy curtain open. LVN 3 stated she was pleading with FM 4 to give Resident 2 some privacy and to let the staff get Resident 2 decent, but FM 4 was cussing at the staff, saying F (fuck), F the police and shouting at Resident 2 to let FM 4 in. LVN 3 stated FM 4 was shouting multiple things at Resident 2, but she couldn't exactly remember everything that was said. LVN 3 stated Resident 2 was visibly in fear, shaking, and traumatized. LVN 3 stated the interaction was verbal abuse and emotional abuse by the way he was talking to Resident 2 and the response Resident 2 had to the interaction. LVN 3 stated Resident 2 ended up needing Ativan because she was so shaken up. LVN 3 stated the abuse coordinator (ADM) was aware of the situation but was not sure if the incident was reported to necessary agencies other than the police because the police were called. During an interview on 4/18/2025 at 10:36 a.m., with the ADM, the ADM stated she was the abuse coordinator for the facility. The ADM stated the facility was informed an open APS case was filed against FM 4 for the abuse Resident 2 sustained. The ADM stated the police were called after the first incident 3/18/2025 and staff were notified not to let FM 4 in and to call the police if they saw him. The ADM stated the second incident on 4/8/2025 she was incorrectly informed after the incident had happened, that FM 4 did not enter Resident 2's room and staff were able to stop him from entering the room. The ADM stated from what she learned about the 4/8/2025 incident FM 4 was aggressive towards staff and just stated he wanted to see Resident 2, so she did not believe it was abuse but rather family dynamics. The ADM stated the incident was not reported to the state agency and a thorough investigation was not done but if she knew FM 4 entered the room and the details of the interaction she may have done things differently. The ADM read the details in Resident 2's medical record including the CM notes and COC dated 4/8/2025. The ADM stated she was not aware FM 4 entered Resident 2's room, was shouting towards Resident 2, and Resident 2 was shaking her head no and crying. The ADM stated it was important staff members reported accurate descriptions of events because that determined the course of action she takes and if an incident needed to be reported to the state agency. The ADM stated she unfortunately never spoke to Resident 2 herself regarding the situation. The ADM stated according to the facility's policy and procedure (P/P) titled Abuse: Prevention of and Prohibition Against definition of mental abuse, mental abuse included harassment. The ADM stated if there was an allegation of abuse, the incident needed to be thoroughly investigated and reported to the state agency right away. The ADM stated Resident 2 remained in the same room from the time of admission (3/16/2025) to the time of discharge (4/17/2025) and she could not find any evidence in Resident 2's chart she was offered a room change after the first incident on 3/18/2025, and the second incident on 4/8/2025 of FM 4 forcing his way into Resident 2's room for her safety. The ADM stated after the second incident on 4/8/2025, she (ADM) became worried about Resident 2's safety so she had the CM reach out to Resident 2's insurance to request a transfer to another facility but Resident 2's insurance declined. During a review of the facility's P/P titled Abuse: Prevention of and Prohibition Against revised 12/2023, the P/P indicated each resident had the right to be free of abuse. The P/P indicated abuse was the willful (the individual acted deliberately) infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. The P/P indicated the facility was to ensure the health and safety of each resident with regards to visitors, such as family members, friends, or other individuals subject to the resident's right to deny or withdraw consent at any time and to reasonable clinical and safety restrictions. The P/P indicated mental abuse included, but was not limited to humiliation, harassment, and threats of punishment or deprivation. The P/P indicated the facility was to protect the resident from further abuse by making room changes as needed.

Based on interview and record review, the facility's nursing staff failed to ensure one of four sampled residents (Resident 1), who required an extensive two-person physical assist during toileting, was supervised while in the bathroom. CNA 2 left Resident 1 alone in the bathroom while she attended to another resident. Resident 1 became frustrated when no one came to his assistance, attempted to leave the bathroom, and fell from the shower chair As a result of Resident 1 falling from the shower chair he hit the floor causing pain to his back, right hip, and right leg. Resident 1 was transferred to a General Acute Care Hospital (GACH) where he was diagnosed with a fracture of the vertebrae (a series of small bones that form the backbone). Findings: During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of cerebral infarction (stroke), hemiplegia (paralysis to one side of the body), hemiparesis (a slight paralysis or weakness on one side of the body), diabetes mellitus ([DM] a chronic condition associated with abnormally high levels of sugar in the blood) and hypertension ([HTN] high blood pressure). During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 9/14/2022, the MDS indicated Resident 1 was able to make independent decisions that were reasonable and consistent and Resident 1 required an extensive two-person physical assist to complete his activities of daily living ([ADLs] task such as eating, bathing, dressing, grooming and toileting). The MDS indicated Resident 1 was not steady when moving from a seated to standing position, moving on and off the toilet, surface to surface transfers, and could only stabilize with staff assistance. During a review of Resident 1's Fall Risk Evaluation (FRE) dated 9/14/2023, the FRE indicated Resident 1 was a medium risk for falls due to balance problems while walking and/or standing, use of psychotropic (drug that affect a person's mental state) medication, use of hypoglycemics (drugs that lowers blood sugar levels) and use of antihypertensive (drugs that lowers the blood pressure) medications. During a review of Resident 1's Care Plan (CP), dated 12/14/2022, the CP indicated Resident 1 has actual self-care performance deficits related to his disease process. The CP's goal was for Resident 1 to be supervised and assisted during his ADLs. The CP's interventions indicated Resident 1 required extensive assistance to transfer onto and off of the toilet with one to two staff support. During a review of Resident 1's CP, dated 12/14/2022, the CP indicated Resident 1 had impaired physical functioning, impulsive behavior, and poor safety awareness. The CPs goal indicated Resident 1 was to have minimal injury and/or would not sustain serious injury. The CP's interventions indicated to provide a safe environment and reminders to Resident 1 of safety precautions. During a review of Resident 1's Situation Background Assessment Recommendation ([SBAR] a tool and a guide to communicate a patient's information with other healthcare professionals) dated 10/7/2022 and timed at 4:40 p.m., the SBAR indicated Resident 1 was heard screaming for help at 3:45 p.m., (10/7/2023) and found sitting on the floor by the bathroom door after scooting in the bathroom chair and was in no pain and discomfort. During a review of Resident 1's Diagnostic Result (DR) dated 10/13/2023 and timed at 5:16 p.m., the DR indicated Resident 1's x-ray of his right femur (hipbone) and the right femur (thigh bone) were negative for a fracture (break in the bone) or dislocation (bones pushed out of their proper place). During a review of Resident 1's Progress Notes (PN) dated 10/21/2022 and timed at 2:32 p.m., by the Nurse Practitioner, the PN indicated Resident 1 had no initial injury from Resident 1's fall on 10/7/2022 but began complaining of right lower extremity/hip pain during mobility with physical therapy (PT). Due to continued complaints of pain an order was placed for an urgent CT ([computed tomography] a computerized x-ray in which a narrow beam of x-rays is aimed at ta patient and quickly rotated around the body) of the pelvis and right femur to rule of fracture. During a review of Resident 1's Physician's Order (PO), dated 10/21/2022, the PO indicated to transfer Resident 1 to a GACH's emergency room (ER) on 10/22/2022 for CT of the right hip and the right femur. During a review of Resident 1's Nurse Progress Notes (NPN) dated 10/22/2022 and timed at 4:32 p.m., the NPN indicated Resident 1 was transferred to the hospital for computerized scanning of the right hip and the right leg. During a review of the GACH Face Sheet, dated 10/22/2022, the Face Sheet indicated Resident 1 was admitted to the GACH on 10/22/2023 at 7:54 p.m. During a review of the GACH's CT scan dated 10/23/2022 and timed at 1:37 a.m., the CT scan indicated Resident 1 had an acute comminuted fracture (bone broken in two places) anterior column (directed forward) of the 4th lumbar spine with 15% loss of vertebral (backbone) height with no retropulsion (no displacement of bone into the spinal canal [a bony channel located in the vertebral column that protects the spinal cord and nerve roots]). During a review of GACH's Neurosurgery (surgery performed on the nervous system, especially the brain and spinal cord) Consult (NC) dated 10/25/2022 and timed at 6:10 p.m., the NC indicated an order for Resident 1 to wear a brace used to limit motion in the thoracic, lumbar (relating to the lower part of the back) and sacral (tailbone) regions of the spine) and an order for a lumbar MRI ([magnetic resonance imaging] a procedure that uses radio waves and a computer to make a series of detailed pictures of areas inside the body). During an observation and interview on 5/19/2023 at 11:51 a.m., Resident 1 was sitting in his bed and observed with a contracted (tightening of the muscles causing stiffness) right knee. Resident 1 stated his right leg felt stiffer since he fell , and he was frustrated because it was hard for him to sit up in his wheelchair and roll himself around the facility like he did before he fell . Resident 1 stated, CNA 2 helped him to the bathroom but left him there alone and said she would be back. Resident 1 stated he finished using the toilet and put on the call light, but CNA 2 did not come back right away (unknown amount of time). Resident 1 stated the shower chair he was sitting on was uncomfortable and he needed to be cleaned so he tried to leave the bathroom to find CNA 2. Resident 1 stated he tipped over out of the shower chair onto the floor and hit his bottom, back and maybe his right leg and right hip on the floor. During a telephone interview on 10/28/2022 at 7:38 a.m., with Resident 1's Responsible Party (RP), the RP stated Resident 1 was in the GACH and told him that he (Resident 1) was having extreme pain in his back. The RP stated he was concerned that Resident 1 wasn't being supervised and assisted by the nursing staff in the facility while he was using the toilet. The RP stated Resident 1 was alert but was unsteady on his feet and could be forgetful and impatient and required constant supervision. During a telephone interview on 10/26/2022 at 1:22 p.m., with CNA 2, CNA 2 stated Resident 1 needed maximum assist by 1 person when using the toilet. CNA 2 stated Resident 1 understood the need to use the call light although she observed Resident 1 was being more impatient and more frustrated with the nurses lately. CNA 2 stated she assisted Resident 1 to the bathroom and left him to go assist another resident in another room. CNA 2 stated when she was on her way back to assist Resident 1 in the bathroom, she heard Resident 1 scream, heard a sound of commotion (disturbing noise) and when she entered Resident 1's room, she found him sitting on the floor outside the bathroom. CNA 2 stated Resident 1 was freaking out (losing emotional control because of extreme shock and fear) and yelling for help. During an interview on 10/26/2022 at 11:23 a.m., with Restorative Nursing Assistant (RNA) 1, RNA 1 stated Resident 1 was alert and coherent but was impatient and the staff should not leave Resident 1 alone in the bathroom because Resident 1 may try to do things beyond his capacity. During an interview and a concurrent record review on 10/26/2022 at 11:32 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 required maximum assistance with ADL care. Prior to his fall, he could move in his bed using his left extremities (left arm and leg) however, after Resident 1 fell he mostly wanted to stay in bed, probably because of pain. During an interview on 10/26/2022 at 3:43 p.m., with Registered Nurse Supervisor (RNS) 2, RNS 2 stated Resident 1 required maximum assistance with 1 to 2 persons during ADL care and Resident 1 needed supervision and assistance while using the toilet and routine personal hygiene to always ensure Resident 1's safety. During an interview on 5/19/2023 at 12:25 p.m., with RNS 1, RNS 1 stated Resident 1 was readmitted at the facility on 10/30/2022 with an order to wear a back brace when he was out of bed. RNS 1 stated all nursing assistants were reminded during huddle at the start of the shift to ensure safety precautions for all residents, and it was a basic rule for all nurses to never leave a resident alone in the bathroom because the resident might forget to call for help, try to get up unassisted, perform tasks beyond their capabilities and end up falling and hurting themselves. During an interview on 5/19/2023 at 1:15 p.m., with the Administrator (ADM), the ADM stated there was no policy related to resident Supervision and/or accident prevention. During an interview on 5/19/2023 at 1:27 p.m., with the Director of Nursing Services (DNS), the DNS stated CNA 2 should not have left Resident 1 in the bathroom alone because of safety reasons. During a review of the facility's Policy and Procedure titled Quality of Care- ADL, Services to carry out, revised 11/2007, the P/P indicated the facility provides the appropriate treatment and services to the residents to maintain and improve their abilities and this includes but not limited to grooming and personal hygiene.

Based on observation, interview and record review, the facility failed to immediately inform and consult with the residents' physician when a resident experienced a significant change of condition ([COC] a clinical deviation from a resident's baseline) for two of 11 sampled residents (Residents 1 and 2) as follow: 1. On [DATE] at 4:30 a.m., Resident 1 first experienced a drop in oxygen saturation ([SPO2] a measure of how much oxygen the blood is carrying with normal reference range (NRR) being ,d+[DATE] percent [%]) of ,d+[DATE] % and required an increase need for oxygen (O2). 2. On [DATE] to [DATE], Resident 2's vital signs (clinical measurements, specifically pulse rate [heart rate], temperature, respiration rate [breathing rate], and blood pressure [(B/P) the amount of pressure in the arteries during contraction of the heart], that indicate the state of a person's essential body functions) were not within normal limit, which included elevated temperatures (hotness and coldness) of ,d+[DATE].3 degree Fahrenheit ([°F], a measurement of body temperature [NRR is ,d+[DATE] °F]), low B/P at ,d+[DATE] millimeter of mercury ([mmHg], a unit of measurement) below baseline (baseline ranged from ,d+[DATE] systolic and ,d+[DATE] diastolic), and a fluctuating heart rate from ,d+[DATE] beats per minute ([bpm] NRR ,d+[DATE] bpm) and the physician was not notified. These deficient practices of not notifying the physician of the residents' COC resulted in a delay of evaluation, care, and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 required a 911 was transferred to a general acute care hospital (GACH) in critical condition and required an immediate admission into the intensive care unit (higher level of care. Resident 2's condition worsened, and the physician was not notified, and the resident was found unresponsive and expired in the facility on [DATE] at 9:01 p.m. Findings: a.During a review of Resident 1's Admission Record, the record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Minimum Data Set (MDS), an assessment and care-planning tool, dated [DATE], the MDS indicated Resident 1 was moderately impaired with cognitive (thought process) skills for daily decision-making and required an extensive assistance from staff for activities of daily living ([ADL] such as eating toileting and grooming). During a review of a Resident 1's COC form, the COC form indicated on [DATE] at 9:32 a.m., Resident 1 had a low BP of ,d+[DATE] (NRR is ,d+[DATE]-,d+[DATE]) and a low SPO2 of 86 %, reported to resident's daughter and primary care clinician on [DATE] at 11:30 a.m. with recommendation to transfer to the hospital. During an observation, on [DATE] at 1:08 p.m., Resident 1 was observed lying in bed awake, appeared weak, pale, mild labored breathing (an abnormal respiration characterized by evidence of increased effort to breathe, including the use of accessory muscles of respiration, grunting, or nasal flaring), taking deep breaths at intervals, with the head of bed (HOB) elevated, and receiving oxygen 15 LPM (liters per minute) via a non-rebreather mask (mask which enables the delivery of high concentration of oxygen). During an observation on [DATE] at 1:16 p.m., an overhead announcement was heard to clear the hallway for 911. Resident 1 was in her room laying in her bed with the HOB elevated, the resident was awake, appeared pale and was taking deep breaths and breathing fast while on a non-rebreather mask. On [DATE] at 1:28 p.m., Resident 1 was transferred out of the facility to a GACH via 911 ambulance. During an interview on [DATE] at 2:33 p.m., Certified Nurse Assistant (CNA 1) stated on [DATE] at 7:15 a.m., during breakfast time, Resident 1 was receiving oxygen via nasal cannula [(NC] a lightweight tube with two prongs placed in the nose to deliver oxygen), no respiratory distress (difficulty breathing) noted and had no appetite, only eating 25 % (percent) of her meal. CNA 1 stated during her rounds at approximately 10 a.m., Resident 1 was having a hard time breathing. CNA 1 stated the Physical Therapist ([PT 1] who helps injured or ill people to improve movement and manage pain; an important part of preventive care, rehabilitation, and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN 1 and Registered Nurse (RN 1) came to assess Resident 1. During an interview on [DATE] at 2:55 p.m., RN 1 stated he received a report from RN 2 regarding Resident 1 exhibiting desaturation (decreased oxygen level) on [DATE] at 4:30 a.m. RN 1 stated he increased Resident 1's O2 to 10 LPM via NC. RN 1 stated during an assessment on [DATE] at 9:30 a.m., Resident 1 was alert, verbal, talking with clear speech and showed no signs of physical distress, but the SPO2 level was low at ,d+[DATE] %. RN 1 stated the O2 was changed from 4 LPM to 15 LPM via a non-rebreather mask. RN 1 stated he elevated Resident 1's HOB to improve her breathing and he continued to monitor Resident 1. During a concurrent interview and record review on [DATE] at 3 p.m., the Director of Staff development (DSD) stated, A decreased in SPO2 was a COC and the physician and the resident's family should have been notified and the COC should have been documented. During a review of Resident 1's progress notes, the DSD was unable to locate any records that indicated Resident 1 had an episode of distress from [DATE] to [DATE]. The DSD stated there was no documented vital signs for Resident 1 for the COC assessment and there were no notes that the physician and/or family were notified of the resident's COC. There were also no notes to reflect Resident 1's episodes of respiratory distress (difficulty breathing) or decrease of SPO2 on [DATE] on the 11 p.m. to 7 a.m. night shift. During an interview on [DATE] at 3:59 p.m., the Director of Rehabilitation ([DOR] directs the programs and staff of the rehabilitation services department) stated the Occupational Therapist ([OT 1] treat injured, ill, or disabled residents through the therapeutic use of everyday activities; help residents to develop, recover, improve, as well as maintain the skills needed for daily living and working) reported on [DATE] at 9:30 a.m., she was not able to perform an OT assessment on Resident 1 because the resident did not look good and was unable to participate with the assessment. The DOR stated Resident 1's oxygen saturation was low at 80% and OT 1 reported to Resident 1's condition to RN 1. During a telephone interview on [DATE] at 5:17 p.m., PT 1 stated she was not able to perform a PT evaluation for Resident 1, due to labored breathing and asked LVN 1 to assess the resident on [DATE] 9:30 a.m PT 1 stated LVN 1 and RN 1 checked the resident's SPO2 level, which was low at 80%. During a telephone interview on [DATE] at 6:50 a.m., RN 2 stated he received a report from LVN 5 on [DATE], Resident 1 was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RN 2 stated on [DATE] at 4:30 a.m., Resident 1's SPO2 was low at 80 to 85 % while receiving oxygen at 4 LPM via NC, so he increased the O2 to ,d+[DATE] LPM via NC which increased the SPO2 to 93 to 94 %. RN 2 stated he was unable to recall the exact level of Resident 1's O2 and did not notify the resident's family and/or physician. RN 2 stated he endorsed to RN 1 (charge nurse for next shift) to notify Resident 1's family and physician of the resident's COC. RN 2 stated he did not need to notify the family and physician on his shift, because Resident 1's condition had improved. RN 2 stated he did not receive an order to change Resident 1's O2 level, and did not chart the COC or assess Resident 1's vital signs because he was the only charge nurse on the night shift for 37 residents on [DATE]-[DATE]. During an interview on [DATE] at 9:34 a.m., OT 1 stated she went to Resident 1's room on [DATE] at approximately 9 a.m., to perform an OT assessment. OT 1 stated Resident 1 looked weak, tired, and had a low SPO2 level ranging from 86 to 87 % with O2 infusing via NC. OT 1 stated she asked the facility's Admission Coordinator (AC) to translate to ask Resident 1 how she felt. OT 1 stated the AC stated Resident 1 responded she felt better than she did the day prior. During a concurrent interview, the AC confirmed what OT 1 stated of how she felt. During an interview on [DATE] at 11:11 a.m., RN 1 stated he notified Physician 1 on [DATE] at 11:30 a.m., due to Resident 1 had a low SPO2 of ,d+[DATE]% while receiving 15 LPM O2 via non-rebreather mask and Physician 1 ordered to transfer resident to hospital via 911. RN 1 stated he thought Resident 1 should not be in a skilled nursing facility with fluctuating SPO2 level. RN 1 stated he should have called 911 at 11:30 a.m. and stated he did not know why he delayed Resident 1's transfer to the GACH. RN 1 stated a delay in transfer could have resulted in Resident 1 passing out and/or a respiratory arrest (stop breathing) and coded (stop breathing and heart stops) at the facility. RN 1 stated it was his mistake and he should have transferred the resident to the GACH right away. During an interview on [DATE] at 12 p.m., the Director of Nurses (DON) stated she was made aware by DSD that Resident 1 was having a low SPO2 level at 85% at 10:30 a.m. on [DATE] and told the DSD to notify the physician. The DON stated the nurse (RN 2) should have initiated a COC documentation and notified the physician and family of Resident 1's COC. The DON stated when a physician orders a transfer to a GACH via 911, the resident should be transferred to hospital as soon as possible. During a telephone interview on [DATE] at 12:47 p.m., Physician 1 stated he recived a text on [DATE] at 11:30 a.m. regarding Resident 1's low SPO2 of 85% on 100 % non-rebreather mask and ordered Resident 1 to be transferred to hospital via 911. Physician 1 stated he was scheduled to go to facility on [DATE] at 1 p.m., so when he arrived, he was surprised to see the resident was still there and did an assessment of Resident 1. Physician 1 stated upon assessment, Resident 1 had lots of crackles (crackles (sounds heard in a lung field that has fluid in the small airways), hypoxic on 100% non-rebreather mask, mild to moderate respiratory distress with the pneumonia worse. Physician 1 stated he ordered Resident 1 to be transferred to hospital via 911 so the resident can go to the hospital as fast as possible. During a review of Resident 1's Emergency Department (ED) physician notes, dated [DATE] and timed at 2:26 p.m., the ED note indicated Resident 1 arrived in critical condition with acute decompensation (failure of an organ to function, especially the heart) and possible cardiopulmonary arrest (loss of heart function and breathing). The B/P was ,d+[DATE], heart rate at 84 bpm (beats per minute [NRR is ,d+[DATE]]), respiratory rate at 39 (NRR is ,d+[DATE] per minute), SPO2 at 88%, and a temperature of 36.5 °F (Fahrenheit). The note indicated Resident 1 was tachypneic (abnormal rapid breathing), lungs with crackles diffusely (scattered), shows initial accessory muscle (refers to those that assist, but do not play a primary role, in breathing) use, no obvious retractions (a sign someone is working hard to breathe ). The chest x-ray showed patchy interstitial and airspace opacities, of the mid to lower lungs (acute pneumonia). Resident 1 required a [CONDITION(S)] (bi-level positive airway used to maintain a consistent breathing pattern). The note indicated upon Resident 1's initial arrival, the physician spoke to Resident 1's family, and the family stated the resident does not want to have an endotracheal intubation (process of inserting a tube, an endotracheal tube (ET), through the mouth and then into the airway for ventilation [for oxygen exchange]). Resident 1's GACH final diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 was admitted to Intensive Care Unit ([ICU] higher level of care) in critical condition. b. During a review of Resident 2's Face Sheet (admission record), the Face Sheet indicated the resident was admitted to the facility on [DATE]. Resident 2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 2's Minimum Data Set (MDS), dated [DATE], the MDS indicated Resident 2 was rarely/never understood and had severe impaired cognitive skills for daily decision-making. During a review of Resident 2's Physician Orders for Life sustaining treatment ([POLST] an approach to end-of-life planning based on conversations between residents, loved ones, and health care professionals), dated [DATE], the POLST indicated the resident wanted cardio pulmonary resuscitation ([CPR] a lifesaving procedures) and full treatment in case of an emergency. During a review of Resident 2's laboratory results record indicated on [DATE] at 6:45 p.m., Resident 2's COVID-19 test was positive. During a telephone interview on [DATE] at 1:05 p.m., CNA 1 stated she took care of Resident 2 on [DATE], [DATE] and [DATE] on the day shift (7 a.m. to 3 p.m.). CNA 1 stated Resident 2 was on the red zone (unit for COVID-19 positive residents) in the first week of [DATE] and had episodes of elevated body temperatures. CNA 1 stated they provided cooling measures by applying cold wash cloth on Resident 2's forehead, ice pack under the armpits and reported to charge nurse for that day. During a concurrent interview and review on [DATE] at 1:10 p.m., LVN 2 stated he took care of Resident 2 on [DATE], [DATE], [DATE], [DATE] and [DATE] on the 7 a.m. to 3 p.m. shift. LVN 2 stated Resident 2 had three-four days with episodes of elevated body temperatures of 101°F. LVN 2 stated antipyretic medications (used to prevent or reduce fever) was not administered to Resident 2. LVN 2 was questioned about a nurse's note entered on [DATE] indicating Tylenol (an [MEDICATION(S)] (pain reliever) and antipyretic (fever reducer) used for treating pain and fever associated with many conditions) was given to Resident 2, but LVN 2 stated it was a wrong entry, because he did not give Resident 2 Tylenol to reduce the fever. LVN 2 stated he did not notify the physician and/or Resident 2's family of the resident's COC because the resident's temperature decreased after cooling measures were done. During the review of Resident 2's physician's orders, LVN 2 verified there was no physician's order for Resident 2 to receive an antipyretic to decrease the body temperature. LVN 2 stated, A COC should be documented, physician and family notified, and a care plan should have been initiated for temperatures greater than 100°F. During a telephone interview on [DATE] at 6:20 a.m., LVN 3 stated she took care of Resident 2 on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] on the night shift (11 p.m. to 7 a.m.), LVN 3 stated Resident 2 was COVID-19 positive and was being monitored for fever but could not recall if Resident 2 had elevated temperatures on her shift. LVN 3 stated if a resident had a temperature greater than 100°F she would notify the physician and get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 2's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] °F on [DATE] at 12 a.m. and there was no documentation the physician was notified that an antipyretic was administered. As confirmed by the DSD and LVN 2 during a concurrent review of Resident 2's nurse's notes. During a concurrent interview and electronic record review on [DATE] at 1:35 p.m. with the Director of Staff Development (DSD), she stated the following vital signs documented on Resident 2's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] [DATE] at 4 p.m. BP ,d+[DATE], temp 98.2°F pulse 107 bpm, RR 16 [DATE] at 4 p.m. BP ,d+[DATE], temp 101.3°F, pulse 80 bpm, RR 16 [DATE] at 8 p.m. BP,d+[DATE], temp 101.3°F, pulse 80 bpm, RR 16 [DATE] at 8 p.m. BP ,d+[DATE], temp 101°F, pulse 90 bpm, RR 16 [DATE] at 8 a.m. BP ,d+[DATE], temp 100.4°F, pulse 102 bpm, RR 16 [DATE] at 12 p.m. BP ,d+[DATE], temp 100.4°F, pulse 102 bpm, RR 16 [DATE] at 4 p.m. BP,d+[DATE], temp 100.3°F, pulse 50 bpm, RR 16 The DSD stated when a resident had temperatures greater than 100°F, BP below and above baseline, HR less than 60 bpm and more than 100 bpm, nurses should complete a COC documentation, notify physician and family, and document interventions. The DSD stated there was no record found to indicate the physician and family were notified for Resident 2's abnormal vital signs, no order for antipyretic medication and no COC documentation when Resident 2 was having changes of condition from [DATE] to [DATE]. During an interview on [DATE] at 3:42 p.m., the Director of Nursing (DON) stated she was not aware Resident 2 was having fever from [DATE] to [DATE]. The DON stated, All antipyretic MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated the nurses should have notified the physician and requested for antipyretic for Resident 2's elevated temperature above 100°F. The DON stated the facility's policy and procedure (P/P) for elevated temperature or abnormal vital signs were to notify the physician, follow physician's orders, and document the assessment and interventions implemented. During an interview on [DATE] at 2:33 p.m., Physician 1 stated he did not recall if he was notified regarding Resident 2's abnormal vital signs, but stated if he was called, he would have ordered antipyretic medications, blood and urine culture (a test to find germs (such as bacteria) in the urine /blood that can cause an infection). Physician 1 stated he expected the nurses to notify him when residents had temperatures greater than 100°F and abnormal vital signs within one hour. During a review of Resident 2's physician order, dated [DATE], the orders indicated there was an order to monitor and record any COVID-19 symptoms, such as fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body ache, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea every four (4) hours and notify the physician if present. During a review of Resident 2 nurses' progress note (NPN), dated [DATE] and timed at 1:14 a.m., the NPN indicated RN 2 received a report from the prior shift indicating Resident 2 had a slight fever above his baseline. During a concurrent interview, RN 2 stated there was no documentation on the NPNs from the previous shift of Resident 2's COC. During a review of Resident 2's NPN, dated [DATE] and timed at 2:05 p.m., the NPN indicated that LVN 2 was monitoring Resident 2's low grade fever of 100°F, Tylenol (medication that reduced fever) was given and lowered the temperature to 98.1° F. A review of Resident 2's MAR for the month of ,d+[DATE] did not indicate documentation of an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 2's NPN, dated [DATE] and timed at 11:08 p.m., the NPN indicated on [DATE] at 8:50 p.m., LVN 4 noted Resident 2 was unresponsive, skin was warm and dry to touch, and had no pulse. Code blue (medical emergency such as cardiac or respiratory arrest) was initiated and 911 was called. The NPN indicated the paramedics arrived at 9 p.m. and assessed Resident 2 and declared the resident deceased at 9:01 p.m. During a review of the facility's undated P/P titled, Significant Change in Condition, Monitoring, included the following: 1.If, at any time, it is recognized by any one of the team members that the care needs of the resident have changed, the nurse supervisor should be made aware of and he/she will monitor. 2.Physician, resident, and responsible party will be notified of the significant change.

Based on interview and record review, the facility failed to follow its policy and ensure a safe and appropriate discharge home for one of three sampled residents (Resident 1). Resident 1, who had a history of [REDACTED]. (Cross referenced to F580). This deficient practice resulted in Resident 1 falling and passing out within 35 minutes of being discharged home from the facility. Findings: A review of Resident 1's Admission Face sheet indicated the resident was admitted to the facility on (MONTH) 20, (YEAR). Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a care screening and assessment tool, dated (MONTH) 29, (YEAR), indicated a Brief Interview for Mental Status (BIMS) score of 15 (12-15 = no impairment), which indicated that Resident 1 did not have problems with memory and cognition (thought process). The MDS indicated Resident 1 required extensive staff assistance with bed mobility and transfers and was totally dependent on staff for locomotion on and off of the unit. A review of Resident 1's undated care plan, indicated the resident wished to be discharged home. The staff's interventions included establishing a pre-discharge plan, evaluating the resident's progress, and revising the plan. A review of Resident 1's Discharge Instructions, dated (MONTH) 28, (YEAR) and timed at 12:57 p.m., indicated the resident was to be discharged home from the facility on (MONTH) 29, (YEAR). A review of Resident 1's Notice of Transfer/Discharge, dated (MONTH) 29, (YEAR), indicated the resident was being discharged home because Resident 1's health had improved sufficiently enough that the resident no longer required services provided by the facility. A review of Resident 1's Discharge Summary/Comprehensive Assessment, dated (MONTH) 29, (YEAR), indicated Resident 1's blood pressure (BP) upon discharge was 90/60 millimeters of mercury (mmHg) (Normal Reference Range (NRR) 120/80 mmHg). The assessment indicated Resident 1 was being discharged with family with a total of 42 pills of [MEDICATION NAME] (medication used to lower blood pressure). A review of a Nurses Progress Note, dated (MONTH) 29, (YEAR), and timed 3:55 p.m., indicated Resident 1 was discharged home with a family member. The note indicated Resident 1 had a safe discharge. A review of the general acute care hospital's (GACH) emergency room (ER) records, dated (MONTH) 29, (YEAR), indicated after Resident 1's discharge from the facility, Resident 1's family member (FM 1) drove the resident home and was attempting to remove the resident from the vehicle when the resident had a fall. According to the ER records, Resident 1 then had a syncopal (to pass out) episode and the family called 911 for emergency services. The ER records indicated upon paramedic arrival at 4:28 p.m., Resident 1's blood pressure was 70/50 mmHg and increased to 86/66 mmHg at 4:45 p.m. Resident 1 was then transferred to the GACH were it was documented that Resident 1 was weak, pale and was diagnosed with [REDACTED]. On (MONTH) 19, (YEAR) at 4:40 p.m., during a concurrent interview and record review, Resident 1's physician (MD 1) stated he was not notified by staff of Resident 1's BP prior to discharging the resident home. MD 1 stated it was not safe to discharge Resident 1 home with a BP of 90/50 mmHg and if he had been aware of the BP reading, he would not have sent Resident 1 home. MD 1 stated he would not have continued the dose of [MEDICATION NAME] and would have canceled the discharge home and sent the resident to the emergency room immediately. MD 1 stated sending Resident 1 home with a BP of 90/50 mmHg could have resulted in the resident passing out. MD 1 stated he did not have access to review resident vital signs and depended on the facility's staff for notification of any abnormal vital signs. According to MD 1, when Resident 1's BP was 86/58 mmHg on the night of (MONTH) 28, (YEAR), staff should have immediately called and notified the on-call physician. MD 1 was unable to locate any documentation of himself or the on-call physicians being notified of Resident 1's low blood pressure readings. A review of the facility's policy titled, Discharge or Transfer, with a revised date of 5/2007, indicated it was the policy of the facility to provide the Resident with a safe organized structured transfer and or discharge from the facility to include but not limited to hospital, another healthcare facility or home that will meet their highest practical level of medical, physical, and psychosocial well being.

Based on interview and record review, the facility's staff failed to follow its policy, a resident's plan of care, and professional standards of practice for one of three sampled residents (Resident 1). Resident 1, who had a history of [REDACTED]. pressure (BP) dropped to 86/58 millimeters of mercury (mmHG) (Normal Reference Range (NRR) 120/80 mmHg). (Cross referenced to F660). These deficient practices resulted in Resident 1's condition deteriorating, the resident falling and having a syncopal (to pass out) episode and a blood pressure of 70/50 mmHg within 35 minutes of being discharged home. Emergency services were called and Resident 1 was transferred to a general acute care hospital (GACH) for further evaluation and treatment. Findings: A review of Resident 1's Admission Face sheet indicated the resident was admitted to the facility on (MONTH) 20, (YEAR). Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a care screening and assessment tool, dated (MONTH) 29, (YEAR), indicated a Brief Interview for Mental Status (BIMS) score of 15 (12-15 = no impairment), which indicated that Resident 1 did not have problems with memory and cognition (thought process). The MDS indicated Resident 1 required extensive staff assistance with bed mobility and transfers and was totally dependent on staff for locomotion on and off of the unit. A review of Resident 1's physician's orders [REDACTED]. 1. (MONTH) 20, (YEAR), an order for [REDACTED]. 2. (MONTH) 29, (YEAR), an order to discharge Resident 1 home with a family member. A review of Resident 1's undated care plan, indicated the resident had hypertension and was receiving an antihypertensive medication (a medication used to lower blood pressure). The staff's interventions included administering an anti-hypertensive medication as ordered, monitoring the resident for medication side effects such as orthostatic [MEDICAL CONDITION] (low blood pressure that occurs when changing positions) and reporting side effects of the medication to the physician. A review of the (MONTH) (YEAR) Medication Administration Record [REDACTED] 1. (MONTH) 21, (YEAR), 9 a.m. dose of [MEDICATION NAME] was held. Resident 1's BP was documented low at 101/69 mmHg. 2. (MONTH) 23, (YEAR), 9 a.m. dose of [MEDICATION NAME] was held. Resident 1's BP was documented low at 100/86 mmHg. 3. (MONTH) 23, (YEAR), 5 p.m. dose of [MEDICATION NAME] was held. Resident 1's BP was documented low at 101/69 mmHg. 4. (MONTH) 24, (YEAR), 9 a.m. dose of [MEDICATION NAME] was held. Resident 1's BP was documented low at 105/60 mmHg. 5. (MONTH) 28, (YEAR), 5 p.m. dose of [MEDICATION NAME] was held. Resident 1's BP was documented low at 86/58 mmHg. 6. (MONTH) 29, (YEAR), 9 a.m. dose of [MEDICATION NAME] was held. Resident 1's BP was documented low at 90/60 mmHg. There was no documented evidence in Resident 1's medical record to indicate Resident 1 was assessed for signs of [MEDICAL CONDITION] and no documentation of the physician being notified of the resident's low blood pressure for any of the above dates. A review of Resident 1's Weights and Vitals Summary, indicated the following blood pressure readings: 1. (MONTH) 21, (YEAR), at 9:31 a.m., 101/69 mmHg. 2. (MONTH) 23, (YEAR), at 10:04 a.m., 102/78 mmHg. 3. (MONTH) 23, (YEAR), at 3:49 p.m., 100/86 mmHg. 4. (MONTH) 24, (YEAR), at 9:44 a.m., 105/60 mmHg. 5. (MONTH) 28, (YEAR), at 7:37 p.m., 86/58 mmHg. 6. (MONTH) 29, (YEAR), at 9:58 a.m., 90/60 mmHg. A review of Resident 1's physician progress notes [REDACTED]. A review of Resident 1's Discharge Instructions, dated (MONTH) 28, (YEAR) and timed at 12:57 p.m., indicated the resident was to be discharged home from the facility on (MONTH) 29, (YEAR). A review of Resident 1's Discharge Summary/Comprehensive Assessment, dated (MONTH) 29, (YEAR), indicated Resident 1's BP upon discharge was 90/60 mmHg. A review of the GACH's emergency room (ER) records indicated after Resident 1's discharge from the facility, Resident 1's family member (FM 1) drove the resident home and was attempting to remove the resident from the vehicle when the resident had a fall. According to the ER records, Resident 1 then had a syncopal episode and the family called 911 for emergency services. The ER records indicated upon paramedic arrival at 4:28 p.m., Resident 1's blood pressure was 70/50 mmHg and increased to 86/66 mmHg at 4:45 p.m. Resident 1 was then transferred to the GACH were it was documented that Resident 1 was weak, pale and was diagnosed with [REDACTED]. On (MONTH) 25, (YEAR) at 12:59 p.m., during a concurrent interview and record review, the facility's Physical Therapist (PT 1) stated Resident 1 was admitted for physical therapy and had initially improved while receiving physical therapy, but prior to being discharged from the facility, the resident regressed and required the same level of assistance needed when he initially arrived at the facility. PT 1 stated he did not attend the interdisciplinary team ((IDT) a group of different disciplines working together for a common goal of a resident) meetings for residents and was unsure if Resident 1's regression was discussed with the physician and the IDT. On (MONTH) 19, (YEAR) at 3:38 p.m., during a concurrent interview and record review, the Director of Nursing (DON) stated if a resident had a change in BP that was different from the resident's baseline, the BP was to be rechecked, the resident was to be assessed for signs and symptoms of [MEDICAL CONDITION] and the physician was to be notified right away. According to the DON, staff was to document all interventions in the resident's medical record. The DON stated Resident 1's physician should have been notified (prior to the resident being discharged ) of the resident's BP readings of 86/58 mmHg and 90/60 mmHg. The DON was unable to locate any documentation in Resident 1's medical record of the resident being assessed for signs and symptoms of [MEDICAL CONDITION], of the resident's BP being rechecked, or of the physician being notified of the low BP readings. On (MONTH) 19, (YEAR) at 4:40 p.m., during a concurrent interview and record review, Resident 1's physician (MD 1) stated he was not notified by staff of Resident 1's BP prior to discharging the resident home. MD 1 stated it was not safe to discharge Resident 1 home with a BP of 90/50 mmHg and if he had been aware of the BP reading, he would not have sent Resident 1 home. MD 1 stated he would not have continued the dose of [MEDICATION NAME] and would have canceled the discharge home and sent the resident to the emergency room immediately. MD 1 stated sending Resident 1 home with a BP of 90/50 mmHg could have resulted in the resident passing out. MD 1 stated he did not have access to review resident vital signs and depended on the facility's staff for notification of any abnormal vital signs. According to MD 1, when Resident 1's BP was 86/58 mmHg on the night of (MONTH) 28, (YEAR), staff should have immediately called and notified the on-call physician. MD 1 was unable to locate any documentation of himself or the on-call physicians being notified of Resident 1's low blood pressure readings. A review of the facility's policy titled, Change of Condition Reporting, with a revision date of (MONTH) 2007, indicated all changes in resident condition were to be communicated to the physician. According to the policy, licensed nurses would notify the primary physician of a resident's change in condition as soon as possible. The policy indicated all nursing actions would be documented in the resident's medical record. A review of the facility's policy titled, Blood Pressure, with a revision date of (MONTH) 2007, indicated staff would follow through with any necessary measures for abnormal blood pressure readings.

Based on interviews and record reviews, the facility failed to ensure that one out of three sampled residents (Resident 1) received care and services in accordance with the facility's policies and procedures and professional standards of practices, including but not limited to: 1. Failure to accurately perform [MEDICATION NAME] maneuver (also known as abdominal thrust, is a manual application of sudden upward pressure on the upper abdomen of a choking victim to force a foreign object from the trachea (wind pipe)) by initiating abdominal thrust (emergency technique to help clear airway) from the front of the resident on a sitting position by using both hands to push on the resident's stomach. 2. Failure to follow the facility policy on Choking, Obstructed Airway Clearance and emergency care and professional standards of practices on abdominal thrust and by the American Red Cross First Aid/CPR/AED, that indicated an abdominal thrust should be performed to a person in a sitting position, by positioning yourself behind the resident, grasping your fist with your other hand, placing in the resident's abdomen slightly above the navel (belly button) and below the ribcage, and making quick, upward and inward thrust with your fist. If the resident is too large for you to wrap your arms to give abdominal thrusts, perform chest thrust (chest compression) instead of abdominal thrust. These deficient practices resulted in a delay in removing the obstruction in the airway and Resident 1 was transferred to general acute care hospital (GACH), was intubated, (process of inserting a tube, called an endotracheal tube (ET), through the mouth into the airway) placed in intensive care unit (ICU) and died on [DATE] after being removed from the mechanical ventilator (a machine for artificial breathing) a day prior ([DATE]). (Crossed reference to F726) Findings: A review of Resident 1's Admission Face Sheet indicated the resident was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of a History and Physical (H/P) Examination, dated [DATE], indicated Resident 1 had fluctuating capacity to understand and make decisions. A review of a Nurse's Note, dated [DATE], and timed at 4:23 p.m., indicated the Assistant Director of Nursing (ADON) was at Resident 1's bedside with the family member (FM1) while the resident was eating ham sandwich. According to the note, the resident was choking but was able to cough and was encouraged to cough up what he was choking on, head of bed (HOB) was elevated and FM1 was told to go and get help. The ADON initiated [MEDICATION NAME] procedure and a staff member came in to relieve the ADON, but the foreign body was not removed. Resident 1 became unconscious (not awake), unable to breathe, with no pulse and code was called. A board was placed under the resident while lying flat and cardiopulmonary resuscitation ((CPR) chest compression and ventilation to revive the resident) was started, 911 was called. CPR was continued until the emergency response team arrived. The paramedics arrived and continued care and removed foreign objects (two pieces of bread and ham) from the resident's mouth. Resident 1 was intubated, provided with a shock (defibrillated (often called a counter shock) process in which an electronic device sends an electric shock to the heart to stop an extremely rapid, irregular heartbeat, and restore the normal heart rhythm). Resident 1's pulse was found and was transferred to General Acute Care Hospital (GACH- health care where a patient receives active but short-term treatment for [REDACTED]. Further review of the nurse's note for Resident 1 did not indicate exact time the symptoms of choking occurred, how and who performed the abdominal thrust, notification of the paramedics, and physician, and of the exact time paramedics responded to the facility's call. On [DATE] at 2:55 p.m., an interview was conducted with the facility's Director of Nursing (DON) who confirmed there were no documentation of the time frame of the incident and detailed information on what was done to the resident prior and after the paramedics came. A review of the Paramedics' Incident Report, dated [DATE], indicated the paramedics were notified by the facility at 3:28 p.m. and they arrived at the facility at 3:34 p.m., which indicated a complaint of [MEDICAL CONDITION] and foreign body. According to the Paramedic's Incident Report, Resident 1 was found lying face up in bed, unresponsive and in full [MEDICAL CONDITION] (loss of heart function) with CPR in progress by the staff. The note further indicated the resident's friend (FM1) on scene, stated the resident was eating a sandwich and suddenly began to choke. Food was removed from the resident's airway and an advanced airway was established by the Paramedics. The resident was given [MEDICATION NAME] (heart stimulant drug administered during CPR to reverse [MEDICAL CONDITION]) x3. The resident was defibrillated once at (120 joules (unit of electrical, mechanical, and thermal energy)). The resident had a return of spontaneous circulation and eventually transferred to GACH. A review of the GACH's emergency department (ED) provider notes, dated [DATE] and timed at 4:14 p.m., indicated resident was intubated and non-responsive, with a Glasgow Comma Scale of 3((GSC)summation of scores for eye, verbal, and motor responses; score of 3 indicated deep coma or a brain-dead state). Resident 1 presented in full cardiopulmonary arrest and was resuscitated. The Paramedic found resident to be in pulseless electrical activity ((PEA) refers to [MEDICAL CONDITION] in which the electrocardiogram shows a heart rhythm that should produce a pulse, but does not) with no respiration, and was immediately intubated and found with large amount of food in the hypopharynx (entrance into the esophagus), which the paramedic removed. The ED Note indicated the resident probably aspirated (foreign material inhaled into the airway) from food, once the resident was intubated his progress improved dramatically. The resident was placed on hypothermia (deliberate reduction of the core body temperature, in residents who do not regain consciousness after return of spontaneous circulation following a [MEDICAL CONDITION].) protocol and was placed on a ventilator. The ED Note indicated resident was admitted to Intensive Care Unit (ICU). A review of the GACH's Discharge Summary Report, dated [DATE] and timed at 2:25 p.m., indicated Resident 1 choked after swallowing a sandwich and was found by the paramedics in PEA, and requiring intubation found to have large amounts of food in the hypopharynx. After the hypothermia protocol, the resident was not waking up and started having [MEDICAL CONDITION] activity. The resident remained on mechanical ventilator, had very poor neurological (disorders of the nervous system, which included the brain, the spinal cord, and the nerves) prognosis. The resident did not have any cough/gag reflex and/or withdrawal to painful stimuli. The GACH's Ethics Committee recommended the resident be placed on Do Not Resuscitate (DNR). The resident was extubated (removal of a tube from the airway after intubation) on [DATE] and passed away on [DATE] at 12:25 p.m. On [DATE] at 12:10 p.m., during an interview, the ADON stated on [DATE], ADON went to Resident 1's room for a case management initial meeting and the FMI was at the resident's bedside. The ADON was unable to give the time of the meeting. ADON stated Resident 1 was sitting on the bed at a 45 degrees angle, calm and not in distress. The ADON stated approximately three minutes later, Resident 1 started coughing, she then pulled Resident 1 up and encourage the resident to cough, while patting the resident's back. Resident 1 coughed multiple times (approximately 20 times or less) and when the resident stopped coughing, the ADON initiated abdominal thrust (emergency technique to help clear someone's airway) from the front of the resident by using both hands to push on the resident's stomach. The ADON stated that she performed the abdominal thrust two times then the Occupational Therapist (OT 1) took over and continued the abdominal thrust from behind the resident for approximately 5 times. The ADON stated when Resident 1 became unconscious (state of not being awake) she instructed OT 1 to stop the procedure and she started to perform CPR. The ADON stated she performed 30 chest compression initially to the resident and two breaths were given by Licensed Vocational Nurse (LVN 1) with chest rise, and no object was found in the resident's mouth. ADON stated LVN 3 relieved her in performing CPR. The second round of CPR was done by LVN 3 with 30 chest compression and two breaths by LVN 2 with no chest rise observed. LVN 2 checked the resident's mouth and nothing was found. ADON stated CPR was performed until the paramedics arrived. A review of the ADON's handwritten declaration, dated [DATE], indicated when Resident 1 started coughing, she positioned Resident 1 in an upright seated position, Patted the back to encourage patient to cough to expectorate the foreign object. The declaration indicated Resident 1 coughed multiple times until he stopped coughing. The ADON initiated an abdominal thrust from the front by using both hands to push on the upper abdomen, right below the sternum (breastbone) while Resident 1 was in a sitting position. According to an online article, titled Abdominal Thrust, an abdominal thrust should be performed as follows: 1. If the person is sitting or standing, position yourself behind the person and reach your arms around his or her waist. 2. Place your fist, thumb side in, just above the person's navel (belly button). 3. Grasp the fist tightly with your hand. 4. Make quick, upward and inward thrust with your fist. 5. If the person is lying on his or her back, straddle the person facing the head. Push your grasped fist upward and inward in a movement similar to the one above. (https://medlineplus.gov/ency/article/ 7.htm) On [DATE] at 1:20 p.m., during an interview, LVN 3 stated that on [DATE], he heard code blue (emergency situation announced in a hospital or institution in which a patient is in cardiopulmonary arrest) paged to Resident 1's room, LVN was unable to recall the exact time of the incident. LVN 3 went to the resident's room and saw the ADON performing CPR on Resident 1. LVN 3 stated that he relieved the ADON and started to perform CPR for approximately ,[DATE] minutes prior to the paramedics' arrival. At 1:50 p.m. on [DATE], during an interview, the Minimum Data Sheet Nurse (MDS Nurse) stated that on [DATE] at approximately 3:00 p.m. she answered the call light in Resident 1's room. Resident 1 was in bed with HOB elevated, FM1 was at the bedside feeding Resident 1 graham crackers with no difficulty in swallowing. FM1 asked her to get the resident something to eat. The MDS Nurse stated that she checked Resident 1's diet on the computer, which indicated a regular diet and obtained a ham sandwich from the kitchen and gave it to FM 1 and left the room. The MDS Nurse stated that after 20 minutes, she saw FM1 outside Resident 1's room asking for help yelling Patient is choking, the nurse (ADON) needs help. The MDS Nurse stated that when she entered Resident 1's room, the resident was conscious (aware of and responding to surroundings) and trying to cough up in the presence of the ADON. On [DATE] at 12:05 p.m., during an interview, LVN 2 stated that on [DATE] he was assigned to care for Resident 1. LVN 2 stated approximately 3:00 p.m., he made rounds and saw Resident 1 sitting in bed with FM1 and the ADON in the room talking. LVN 2 stated he heard one staff calling for help in Resident 1's room. LVN 2 stated both he and LVN1 immediately went to Resident 1's room. LVN 2 stated that Resident 1 was found in a sitting position, but was not moving his arm. LVN 2 stated that he saw OT 1 putting the bed up because the bed was in low position, grabbed Resident 1 from behind and repositioned Resident 1. LVN 2 stated that OT 1 was behind Resident 1, grabbing from the back, putting pressure on the abdomen, but the food did not come out. LVN 2 indicated the ADON checked the pulse and stated to start CPR on Resident 1. LVN 2 stated that LVN 3 was performing the chest compression and he was administering air with an ambu bag (a medical device used to provide assisted ventilation). LVN 2 stated he checked the resident's mouth, but did not see food. LVN 2 stated CPR was continued until the paramedics came. On [DATE] at 1:45 p.m., during an interview, Occupational Therapist 1 (OT1) stated that on [DATE] he saw staff members going towards Resident 1's room and he went to find out what was going on. OT 1 stated he saw the ADON and the Assistant Director of Staff Development (ADSD) in Resident 1's room. OT1 indicated the ADSD was trying to position herself behind Resident 1, but the resident was too large. OT 1 stated the ADSD's arms were not long enough and she was struggling to do the abdominal thrust. At 2:05 p.m. on [DATE], during an interview, the ADSD stated that on [DATE], she was coming in the building from the laundry and saw the FM1 in the hallway asking for help My husband is choking, the lady (ADON) needs help then the FM1 grabbed Speech Therapist 1 (ST 1) inside Resident 1's room. The ADSD stated that when she went inside the room the ADON was there trying to put Resident 1's bed up because it was in a low position. The ADSD stated the resident was sitting on the bed with HOB elevated, making sounds agh, agh, trying to cough, moving his head from side to side, legs straight in the bed, and both arms down to the side. ADSD stated that she grabbed Resident 1 from the back and start compression, placed her hand in the middle stomach, put pressure inside and up. ADSD stated that Resident 1 was a little heavy and she was getting tired and that's when OT1 came and took over. On [DATE] at 3:05 p.m., during a telephone interview, physician (Physician 1) stated that there are two ways to perform [MEDICATION NAME] maneuver; if resident on sitting or standing position, stand behind the resident and if resident is lying on the bed, straddle the resident facing the head. Physician 1 stated that time is the essence when resident is choking. According to an online article, titled Abdominal Thrusts, a choking person's airway maybe blocked so that not enough oxygen reaches the lungs. Without oxygen, brain damage can occur in as little as ,[DATE] minutes. Rapid first aid for choking can save a person's life. (https://medlineplus.gov/ency/article/ 7.htm) On [DATE] at 3:15 p.m., during a telephone interview, the ADON stated Resident 1 was a big man, 6 feet tall but she did not know the resident's weight. The ADON stated Resident 1 was seated up, approximately 90 degrees angle and when resident stopped coughing, she was positioned on the right side of the resident when she initiated [MEDICATION NAME] maneuver by pressing resident's upper abdomen from the front by using her both hands. The ADON was asked if she had a chance to do it again would she do it any different, and she stated Not really. The ADON stated it was more effective and stronger performing abdominal thrust in front because the resident is larger than her. According to American Red Cross First Aid/CPR/AED, if the person is too large for you to wrap your arms to give abdominal thrusts, give chest thrust instead of abdominal thrust. To give chest thrust, position yourself behind the person as you would for abdominal thrust. Place the thumb side of your fist against the center of the person's breastbone. Then cover your fist with your other hand and pull straight back, giving a quick, inward thrust into the person's chest. https://redcross.enjoycpr.com/facpr.pdf, (page 33). A review of the facility's policy and procedure titled, Choking, Obstructed Airway Clearance revised date of ,[DATE] indicated it is the policy of this facility to clear airway of blockage of foreign object or food to stand behind the resident with your arms around his/her waist, grasp your fist with your other hand and place in the resident's abdomen slightly above the navel and below the ribcage, press your fist into the resident's abdomen with a quick, upward thrust. Document the date and exact time symptoms of obstruction noted, procedure performed, notification of paramedics (exact time), notification of attending physician (exact time), resident's response to procedure to relieve of obstruction, exact time paramedic responded to call. A review of the facility's policy and procedure titled, Emergency Care with revised date of ,[DATE] indicated it is the policy of this facility to provide emergency care to a resident in need of urgent service to record details and exact time of condition change of resident, initiation of emergency procedure and resident's response to emergency care and to record exact time the physician was called and responded to call.