Every finding on record at Studio City Rehabilitation Center

Based on interview and record review, the facility failed to ensure the Lead Respiratory Therapist (Lead RT) maintain accurate and complete record for three of three sampled staff (Registered Nurse 1 [RN 1], Respiratory Therapist 1 [RT 1] and RT 2), by failing:1. To ensure the Lead RT documented and completed RN 1, RT 1 and RT 2's Ventilator and Nebulizer Key Competency Checklist to indicate if the three staff (RN 1, RT 1 and RT 2) were able to demonstrate proper knowledge, use and application of ventilator (a medical device to help support or replace breathing) and handheld nebulizer (HHN- a small machine that turns liquid medicine into a mist that can be easily inhaled).2. To ensure the Lead RT documented the exact date of observation for RN 1, RT 1 and RT 2's tracheostomy (a surgically created hole [stoma] in the neck leading directly into the windpipe [trachea] to provide an airway, often using a tube to help with breathing) tube changes in the annual Tracheostomy Tube Change Competency Checklist.These failures had the potential to affect the necessary care provided to meet residents' needs safely.Findingsa. During a review of RN 1's Key Competency Checklist for Respiratory Care-Hand Held Nebulizer (HHN), dated and signed by RN 1 and the Lead RT on 3/19/2026, the Key Competency Checklist was left blank, The Key Competency Checklist for Respiratory Care- HHN, did not indicate if RN 1 had met or not the ability to safely and effectively perform HHN therapy.During a review of RN 1's Key Competency Checklist for Respiratory Care-Ventilator, dated and signed by RN 1 and the Lead RT on 3/19/2026, the Key Competency Checklist was left blank. The Key Competency Checklist for Respiratory Care-Ventilator, did not indicate if RN 1 had met or not the ability to demonstrate proper knowledge, use and application of the ventilator.During a review of RT 1's Key Competency Checklist for Respiratory Care-HHN, dated and signed by RT 1 and the Lead RT on 4/14/2026, the Key Competency Checklist was left blank and did not indicate if RT 1 had met or not the ability to safely and effectively perform HHN therapy.During a review of RT 1's Key Competency Checklist for Respiratory Care-Ventilator, dated and signed by RT 1 and the Lead RT on 4/14/2026, the Key Competency Checklist was left blank and did not indicate if RT 1 had met or not the ability to demonstrate proper knowledge, use and application of the ventilator.During a review of RT 2's Key Competency Checklist for Respiratory Care-HHN, dated and signed by RT 2 and the Lead RT on 4/14/2026, the Key Competency Checklist was left blank and did not indicate if RT 2 had met or not the ability to safely and effectively perform HHN therapy.During a review of RT 2's Key Competency Checklist for Respiratory Care-Ventilator, dated and signed by RT 2 and the Lead RT on 4/14/2026, the Key Competency Checklist was left blank and did not indicate if RT 2 had met or not the ability to demonstrate proper knowledge, use and application of the ventilator.During a concurrent interview and record on 4/30/2026, at 10:15 a.m., with the Lead RT, RN 1's, Key Competency Checklist for Respiratory Care-Ventilator and HHN dated 3/19/2026, and RT 1, and RT 2's Key Competency Checklist for Respiratory Care-Ventilator and HHN dated 4/14/2026, were reviewed. The Lead RT stated he (Lead RT) left the competency question for ventilator and HHN blank. The Lead RT stated RN 1, RT 1 and RT 2 were competent in ventilator and HHN use but he (Lead RT) did not document that they were competent. The Lead RT stated he (Lead RT) should have completely answered all the questions in the competency checklist to show that RN 1, RT 1 and RT 2 were competent (having the necessary ability, knowledge, skills, or capacity to do something successfully or to a required standard) in the use of the HHN and ventilator.b. During a review of RN 1's Subacute Skills Checklist-Respiratory Care-Validation and Competency for Tracheostomy Tube Change Competency, dated and signed by RN 1 and the Lead RT on 3/19/2026, the Subacute Skills Checklist indicated the Lead RT observed RN 1 for one tracheostomy tube change using the simulator (tools and technologies that create realistic, artificial clinical scenarios for training healthcare professionals) and observed three residents tracheostomy tube change on 3/19/2026.During a review of Tracheostomy Tube Change scheduled for 3/2026, the schedule indicated on 3/19/2026, only one resident (Resident 2) was on the schedule and had tracheostomy tube change on 3/19/2026.During a review of RT 1's Subacute Skills Checklist-Respiratory Care-Validation and Competency for Tracheostomy Tube Change Competency, dated and signed by RT 1 and the Lead RT on 4/14/2026, the Subacute Skills Checklist indicated the Lead RT observed RT 1 for one tracheostomy tube change using the simulator and observed three resident tracheostomy tube change on 4/14/2026.During a review of RT 2's Subacute Skills Checklist-Respiratory Care-Validation and Competency for Tracheostomy Tube Change Competency, dated and signed by RT 2 and the Lead RT on 4/14/2026, the Subacute Skills Checklist indicated the Lead RT observed RT 2 for one tracheostomy tube change using the simulator and observed three resident tracheostomy tube change on 4/14/2026.During a review of Tracheostomy Tube Change scheduled for 4/2026, the schedule indicated on 4/14/2026, only one resident (Resident 3) was on the schedule and had tracheostomy tube change on 4/14/2026.During a concurrent interview and record review on 4/30/2026, at 10:18 a.m. with the Lead RT, Subacute Skills Checklist-Respiratory Care-Validation and Competency for Tracheostomy Tube Change Competency dated 3/19/2026, for RN 1 and dated 4/14/2026, for RT 1 and RT 2 were reviewed. The Lead RT stated he (Lead RT) documented one date for all four observations of tracheostomy tube change. The Lead RT stated he (Lead RT) should have documented the exact date he (Lead RT) observed the tracheostomy tube change. The Lead RT stated the dates of observation were inaccurate. The Lead RT stated the importance of accurate documentation was for tracking and maintaining accurate staff records. The Lead RT stated he (Lead RT) got lazy documenting the exact dates reason why there was only one date for all four tracheostomy tube change observation for the three staff (RN 1, RT 1 and RT 2).During an interview on 5/1/2026, at 9:28 a.m., with the Director of Nursing (DON), the DON stated the Lead RT should completely answer the competency checklist for ventilator and HHN and should have documented exact date of observation for tracheostomy tube changes. The DON stated if the competency was incomplete, it would show that the three staff (RN 1, RT 1 and RT 2) were not trained and competent on the ventilator, HHN and tracheostomy tube changes. The DON stated it would show inaccurate competency checklist and could create confusion in staff record.During a review of the Lead RT's Job Description, signed and dated by the Lead RT on 7/16/2024, the Job Description indicated, Supervisory Responsibilities: Directly supervises the Respiratory Therapist. Carries out supervisory responsibilities in accordance with the organization's policies and applicable laws. Responsibilities include, interviewing, hiring, and training employees; planning, assigning and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems.Competencies: To perform the job successfully, an individual should demonstrate the following competencies: .Professionalism: .Follows through on commitments.Quality: Demonstrates accuracy and thoroughness.

Based on interview and record review, the facility failed to develop and implement a person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for one of three sampled residents (Resident 1) by failing to develop a care plan for tracheostomy tube (a surgically created hole [stoma] in the neck leading directly into the windpipe [trachea] to provide an airway, often using a tube to help with breathing) change after admission on [DATE].This failure had potential for delays in the delivery of necessary care and services to Resident 1.Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 1/30/2026, with diagnoses that included unspecified (unconfirmed) acute and chronic respiratory failure, malignant neoplasm (a cancerous tumor characterized by uncontrolled cell growth, invasion of surrounding tissues, and the ability to spread [metastasize] to other parts of the body) of lip, oral cavity and pharynx (a hollow, muscular tube in the neck that serves as the throat), with tracheostomy and dependent on ventilator (a medical device to help support or replace breathing).During a review of Resident 1's Order Summary Report, dated 1/30/2026, the Order Summary Report indicated change tracheostomy tube every month starting on the last day of the month and ending on the last day of the month, every month. Start date on 2/28/2026. During a review of Resident 1's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 3/26/2026, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 4/2/2026, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 1 was dependent on staff for oral hygiene, upper body dressing and mobility. The MDS indicated Resident 1 had continuous oxygen therapy (the medical use of extra oxygen delivered through a machine [concentrator] or tank, flowing non-stop into a resident) with tracheostomy and ventilator.During a concurrent interview and record review on 4/30/2026, at 12:30 p.m., with the Director of Nursing (DON), Resident 1's Care Plans were reviewed. The DON stated there should have been a care plan developed for Resident 1's routine tracheostomy tube changes as indicated in the physician order.During an interview on 5/5/2026, at 11:17 a.m., with the DON, facility's policy and procedure (P&P), titled, Comprehensive Person-Centered Care Plan, dated 3/2023, and last reviewed on 4/15/2026, the P&P, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The DON stated the facility failed to develop a care plan for routine tracheostomy tube change as per physician order as scheduled on 2/28/2026, after Resident 1's admission on [DATE]. The DON stated all treatment, and procedure should have a care plan. The DON stated the care plan list all the interventions that will be provided to Resident 1 to address medical needs. The DON stated that without the care plan it affects the information relayed among staff. The DON stated the comprehensive care plan should have been developed within 21 days after admission of what services will be provided to Resident 1.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) who had history of acute and chronic respiratory failure (acute failure happens suddenly [minutes/hours] and is a life-threatening emergency, while chronic failure develops gradually over time due to ongoing lung damage), with tracheostomy (a surgically created opening [stoma] in the front of the neck leading into the trachea [windpipe] to assist with breathing) and dependent on ventilator (a medical device to help support or replace breathing), was provided with respiratory care consistent with professional standards of practice. The facility failed to ensure tracheostomy tube change performed before the 29th day per manufacturers guidelines (instruction manual created by the company that made a product that explains exactly how to install, use, clean, and fix the item safely and correctly) and monthly as per physician order. The facility did not change Resident 1's tracheostomy tube for 75 days since admission to the facility on [DATE]. This deficient practice had the potential to result in complications to Resident 1's tracheostomy tube change. On [DATE], Respiratory Therapist 1 (RT 1) and RT 2 changed Resident 1's tracheostomy tube but could not establish a patent (open, unobstructed, or allowing free passage) airway after three attempts and resulted to Resident 1's cessation (stopping) of breathing and heart rate (HR) on [DATE], at 8:54 a.m., and was pronounced dead on [DATE], at 9:18 a.m.Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on [DATE], with diagnoses that included unspecified (unconfirmed) acute and chronic respiratory failure, malignant neoplasm (a cancerous tumor characterized by uncontrolled cell growth, invasion of surrounding tissues, and the ability to spread [metastasize)] to other parts of the body) of lip, oral cavity and pharynx (a hollow, muscular tube in the neck that serves as the throat), with tracheostomy and dependent on ventilator.During a review of Resident 1's Order Summary Report, dated [DATE], the Order Summary Report indicated change tracheostomy tube every month starting on the last day of the month and ending on the last day of the month, every month. Start date on [DATE]. During a review of Resident 1's Order Summary Report, dated [DATE], the Order Summary Report indicated change tracheostomy tube every month starting on the 28th of the month and ending on the 28th every month. Start on [DATE].During a review of Resident 1's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated [DATE], the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's Order Summary Report, dated [DATE], the Order Summary Report indicated change tracheostomy tube every month starting on the 26th and ending on the 26th every month. Start date on [DATE].During a review of facility's Tracheostomy Tube Change schedule for 3/2026, the schedule did not include Resident 1.During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool) dated [DATE], the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 1 was dependent on staff for oral hygiene, upper body dressing and mobility. The MDS indicated Resident 1 had continuous oxygen therapy (the medical use of extra oxygen delivered through a machine [concentrator] or tank, flowing non-stop into a resident) with tracheostomy and ventilator.During a review of Resident 1's Licensed Nurses Note, dated [DATE], timed at 6:21 a.m., the Licensed Nurses Note indicated Resident 1 was in a stable condition, breathing normal with no shortness of breath, tracheostomy in place with no complications.During a review of Resident 1's Respiratory Therapy- Continuous Ventilator Flow Sheet, dated [DATE], timed at 8:01 a.m., the Respiratory Therapy- Continuous Ventilator Flow Sheet indicated Resident 6 was on Synchronized Intermittent Mandatory Ventilation (SIMV- a type of breathing support from a ventilator that combines mandatory [guaranteed] breaths with spontaneous [resident-initiated]) breaths ventilation on two liters per minute, saturating (amount of oxygen the red blood cells are carrying) at 97 percent (%- per one hundred), tracheostomy tube care initiated, insertions achieved but no patent airway achieved, Registered Nurse 1 (RN 1) notified. The Respiratory Therapy- Continuous Ventilator Flow Sheet indicated three attempts all with non-patent airway. Bag-Mask Ventilation (BMV- device used for life-saving technique used in emergency medicine and resuscitation to manually provide oxygen to a patient who is not breathing or not breathing adequately) at 100% applied to the upper airways and at 8:45 a.m., cardiopulmonary resuscitation (CPR- an emergency, life-saving procedure performed when the heart stops beating or breathing ceases. It combines chest compression and rescue breaths to maintain blood flow and oxygenation to vital organs, significantly increasing survival chances during cardiac arrest) performed. The Respiratory Therapy- Continuous Ventilator Flow Sheet indicated paramedics arrived, compression and tracheostomy tube changed attempts continued and with no patent airway formed. The Respiratory Therapy- Continuous Ventilator Flow Sheet indicated before the tracheostomy tube change Resident 1 had a HR of 80 beats per minute (bmp), respiratory rate was 20 breaths per minute, 97% oxygen saturation with rhonchi (low-pitched, rattling, or snoring-like lung sounds heard through a stethoscope [a medical instrument used for listening to internal sounds of the body, particularly the heart, lungs, and intestines], typically caused by mucus or obstruction in the large airways) breath sounds on bilateral lungs. The Respiratory Therapy- Continuous Ventilator Flow Sheet indicated that post (after) tracheostomy tube change Resident 1 had no HR, no respiration and no oxygen saturation with absent bilateral lung sounds with large amount of blood noted.During a review of Resident 1's Change of Condition (COC- a document used to record and report any significant changes in a resident's physical, mental, or psychosocial status), dated [DATE], timed at 10:02 a.m., the COC indicated Resident 1 had full arrest (often called cardiac arrest [is a life-threatening emergency where the heart unexpectedly stops beating or beats too ineffectively to pump blood to the body. The person becomes immediately unconscious, stops breathing normally or stops completely], and loses their pulse) while on tracheostomy reinsertion. The COC indicated the following incidents:8:02 a.m.- Acetaminophen (medication used to treat pain) 30 milliliter (ml one-thousandth of a liter) given via gastrostomy tube (g tube-a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) tube to premedicate (to administer medication to a patient before a medical procedure, surgery, or treatment to prepare them for it) resident for monthly routine tracheostomy tube change.8:10 a.m.- Initial vital signs taken and recorded as follows: blood pressure (BP)-116/51milimeters of mercury (mmHg-standard unit of pressure), temperature- 97.2 degrees Fahrenheit, respiratory rate-22 breaths per minute, oxygen saturation 96%.8:42 a.m.- Monthly routine trach change done by two skilled RT (RT 1 and RT 2) at the bedside. During the procedure RT 2 , decannulated (removed) tracheostomy size six extended length (XL) tracheostomy tube cuffed distal extension (TCD), and RT 1 reinserted new tracheostomy tube size six XL TCD using obturator (a curved, stiff plastic or metal guide with a rounded tip that is inserted inside the outer tube during insertion) to prevent trauma, aseptic technique (a set of strict medical practices designed to prevent the transfer of germs during medical procedures) observed, tracheostomy tube 100% inserted with no resistance noted, however upon suctioning (a medical procedure that uses a vacuum device to remove accumulated mucus, saliva, or fluids from the mouth, throat, nose, or trachea), resistance noted indicating blockage on the airways, on ventilator monitor, seen drop of volume to 150-180 ml, and increase of pressure to 70 peak noted, a sign that tracheostomy is not patent. Procedure repeated three times and unsuccessful, on the third time downsized (smaller size) tracheostomy tube size five used, still unsuccessful. Difficulty with bagging (the manual process of providing breathing support to a patient who is not breathing adequately or at all) noted on the tracheostomy tube. Switch bagging to upper airway, tracheostomy tube covered to give full oxygenation to the resident. RN 2 immediately called 911, report provided over the phone. Physician notified. Responsible Party (RP) notified. 8:52 a.m. -noted patient with large amount of blood when suctioned. Trauma is undeniable on the tracheostomy stoma. Continued with upper airway manual breath. with 100% oxygen supplement.8:53 a.m.- vital signs checked, noted deteriorating BP, systolic blood pressure (sbp- the top [first] number in a reading that measures the maximum pressure in your arteries when your heart beats and contracts) at 50 mmHg and the diastolic blood pressure (dbp- the bottom [second] number in a reading, measuring the pressure in your arteries when your heart muscle rests between beats) was unappreciated, HR-20 bpm, oxygen saturation at 50%. Continue to bag resident with 100% oxygen supplement on upper airways.8:54 a.m. HR and BP at this time was unappreciated, chest compression (a lifesaving, emergency technique used to manually pump a person's heart, keeping blood flowing to vital organs when the person stopped breathing or is in cardiac arrest) initiated.8:57 a.m. Paramedics arrived, report provided, took over care, electrocardiogram (EKG- a quick, painless, and noninvasive test that records the electrical signals of the heart to check for heart disease, arrhythmias, and damage) was done upon arrival, with cardiac rhythm reading showing asystole (flatline- is the complete cessation of electrical and mechanical activity in the heart, resulting in no cardiac output and no pulse). Paramedics applied LUCAS mechanical chest compression device (a portable, battery-operated device that provides automatic, consistent high-quality chest compressions). 911 (number to call for emergency response services) instructed RTs to continue with tracheostomy reinsertion.9:02 a.m.-first epinephrine (medication used to increase heart rate, blood flow to muscles, and blood sugar levels) dose given while facility RT attempt to re-insert tracheostomy tube and was unsuccessful.9:04 a.m., another attempt to reinsert tracheostomy tube, but unsuccessful, large amount of blood noted from the tracheostomy.9:07 a.m., second dose of epinephrine given, attempted to reinsert tracheostomy still unsuccessful. Paramedics called General Acute Care Hospital (GACH), consulted emergency room physicians to seek further direction.9:12 a.m., third dose of epinephrine given. 9:17 a.m. Resident 1's pupil (the black hole in the center of the colored part of the eye) was non reactive (a serious sign indicating that the eye's pathway to the brain, or the brain itself, is damaged, compressed, or not functioning properly).9:18 a.m. Paramedics declare time of death. Pulmonologist (a physician who specializes in diagnosing and treating diseases of the respiratory system, which includes the lungs, airways, and breathing muscles) and Primary Physician (PP) notified. Called RP and made aware.During a review of Resident 1's License Nurses Note, dated [DATE], timed at 2:43 p.m., the License Nurses Note indicated at 8:50 a.m. called 911, and at 9:18 a.m., paramedics declared time of death.During an interview on [DATE], at 11:06 a.m., with RT 1, RT 1 stated on [DATE], just after 8:30 a.m., he (RT 1) went inside Resident 1's room with RT 2 to assist RT 2 with Resident 1's tracheostomy tube change. RT 1 stated he (RT 1) donned (put on) personal protective equipment (PPE-clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) before entering the room, checked Resident 1's oxygen saturation, suctioned the airway, hyperoxygenate (it involves administering higher-than-usual oxygen concentrations of oxygen to elevate oxygen levels in tissues and blood, usually before procedure) and noted airway was patent. RT 1 stated observed blood from the tracheostomy when air was removed from the cuff (the inflatable balloon around the lower end, which seals the trachea when inflated) of the tracheostomy tube. RT 1 stated when RT 2 removed the tracheostomy tube, more blood came out and he (RT 1) had inserted the first attempt using the tracheostomy tube size six. RT 1 stated tracheostomy was inserted with no resistance. RT 1 stated after reinsertion, Resident 1's tracheostomy was connected to in line suction, but the suction tubing would not go through. RT 1 stated there was an occlusion (the state of being closed or blocked). RT 1 stated they connected Resident 1's tracheostomy to the ventilator but the ventilator had a spike in pressure and showed low tidal volume (TV-the amount of air that moves into or out of the lungs during a single, normal, resting breath) between 110-131 ml. RT 1 stated Resident 1's TV was set at 500 ml. RT 1 stated he (RT1) auscultated (to examine a resident by listening to internal body sounds typically using a stethoscope [a medical device for auscultation]) Resident 1's bilateral lungs and no lung sounds heard. RT 1 stated they called Registered Nurse 1 (RN 1) for assistance while RT 2 reinserted the second tracheostomy tube and still with no patency noted. RT 1 stated at this time Resident 1 started to have respiratory distress. and RT 3 came into the room and attempted the third tracheostomy tube insertion. RT 1 stated RT 3 made the third attempt and still not successful in establishing patent airway. RT 1 stated during the third attempt Resident 1 had increased breathing, respiratory distress, started to get cyanotic (a bluish-purple discoloration of the skin, lips, or fingernails caused by a lack of oxygen in the blood), HR dropped until pulse oximeter (non-invasive, clip-on device used to estimate blood oxygen saturation and pulse rate by shining light through the skin) not reading the oxygen saturation and HR, and he (RT 1) could not palpate (feel) a pulse. RT 1 stated RT 2 started the cardiac compression, and he (RT 1) did the second cardiac compression. RT 1 stated it was his (RT 1) first tracheostomy changes with Resident 1.During an interview on [DATE], at 12:13 p.m., with RT 2, RT 2 stated he (RT 2) was the one assigned to do the tracheostomy tube change and he (RT 2) had gathered all the supplies at bedside. RT 2 stated RT 1 assisted him (RT 2) on [DATE], to change Resident 1's tracheostomy tube. RT 2 stated when he (RT 2) deflated (removed the air) the tracheostomy cuff there was a noticeable amount of blood approximately two ml. RT 2 stated RT 1 was able to successfully insert the tracheostomy tube, but they could not get a patent airway. RT 2 stated they had connected the tracheostomy tube to the ventilator but showed high pressure and low TV. RT 2 stated he (RT 2) attempted the second reinsertion and still with no patent airway. RT 1 stated RT 3 came in to do the third attempt and Registered Nurse 1 (RN 1) was already notified. RT 2 stated all three attempts had no patent airway. RT 2 stated after the third attempt RT 4 completely blocked the tracheostomy and used ambubag (a handheld, self-inflating device used to provide positive-pressure ventilation to patients who are not breathing or are breathing inadequately) Resident 1's upper airway when Resident 1 started to crash (a sudden, severe, and unexpected failure of the heart's function or the circulatory system). RT 2 stated when he (RT 2) heard the paramedic sounds, that's when Resident 1's HR stopped and he (RT 2) could not palpate a pulse on Resident 1's left wrist.During an interview on [DATE], at 12:35 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated on [DATE], Certified Nursing Assistant 1 (CNA 1) notified her (LVN 1) to check on Resident 1 and when she (LVN 1) went inside the room, saw Resident 1 responsive, blinking and opening his (Resident 1) eyes. LVN 1 stated the RTs were attempting to reinsert for the second time, so she (LVN 1) notified RN 1. LVN 1 stated she (LVN 1) and RN 1 went to Resident 1's room and Resident 1 was still awake, pulse oximeter on Resident 1's right index finger showed 80%. LVN 1 stated she (LVN 1) observed when Resident 1 was ambubagged, Resident 1 still awake and blinked his (Resident 1) eyes then became unresponsive.During an interview on [DATE], at 1:01 p.m., with RT 4, RT 4 stated on [DATE], she (RT 4) was near Resident 1 room when she (RT 4) heard the call, she (RT 4) walked in and saw RTs 1, 2 and 3, at Resident 1's bedside. Resident 1's eyes were open and appear to be stable. RT 4 stated she (RT 4) started bagging Resident 1 upper airway after the third attempt and Resident 1 still had a pulse.During an interview on [DATE], at 8:49 a.m., with RN 1, RN 1 stated on [DATE], around 8:46 a.m., LVN 1 notified her (RN 1) to go to Resident 1's room and when he (RN 1) responded, saw RT 1 standing on the left side of the bed, RT 2 on the right side inserting the second attempt for tracheostomy tube change and RT 4 on the left side head part of the bed, ambubagging Resident 1 at bedside. RN 1 stated when he (RN 1) responded the RT already failed the first attempt of tracheostomy tube change. RN 1 stated on the third attempt, RN 2 called 911 (emergency response system) at 8:50 a.m. RN 1 stated Resident 1 started declining at 8:53 a.m., with HR around 20, and had shallow breathing (breathing that takes in only a small amount of air). RN 1 stated at 8:54 a.m., Resident 1 had no pulse and no HR, RT 2 started the chest compression. RN 1 stated two paramedics arrived, one at 8:57 a.m. and another at 8:58 a.m. RN 1 stated paramedics applied the LUCAS machine and gave three doses of epinephrine. RN 1 stated paramedics pronounce Resident 1's death at 9:18 a.m. RN 1 stated the facility's policy was to change every 30 days unless there is an order not to change it. RN 1 stated tracheostomy tube had holes and if not changed for more than two months, tissue can grow and can stick on those holes and once removed can cause trauma. RN 1 stated he (RN 1) was not sure when was the last time Resident 1's tracheostomy tube was changed. RN 1 stated any person cannot survive without oxygen for more than five minutes.During an interview on [DATE], at 9:27 a.m., with LVN 2, LVN 2 stated on [DATE], RT 1 asked her (LVN 2) to call RT 3. LVN 2 stated she (LVN 2) was the one who brought the crash cart (a specialized mobile trolley containing emergency, life-saving equipment and medication, designed to be moved quickly to a resident's side during a medical crisis, such as cardiac arrest) by Resident 1's door in case it is needed.During an interview on [DATE], at 9:56 a.m., with the Lead RT, the Lead RT stated it was Resident 1's first tracheostomy change in the facility since his (Resident 1) admission on [DATE]. The Lead RT stated the facility's protocol was to do a monthly routine tracheostomy tube change. The Lead RT stated Resident 1 was transferred out to GACH 2 on [DATE], for Computed Tomography (CT- a non-invasive, painless medical imaging procedure that uses rotating X-rays and computer technology to create detailed, cross-sectional slices of bones, blood vessels, and soft tissues) of the abdomen and readmitted back to the facility on [DATE], and was transferred again on [DATE], for malfunctioning g tube and readmitted back on [DATE].During an interview on [DATE], at 12:30 p.m., with the Director of Nursing (DON), the DON stated Resident 1 was transferred twice to GACH 2 before he (Resident 1) reached the 30th day in the facility so we (DON) assumed his (Resident 1) tracheostomy tube was changed in GACH 2. The DON stated she (DON) was not sure when was the last time the tracheostomy was changed and there was no documented evidence in Resident 1's medical record of when it was changed.During a concurrent interview and record review on [DATE], at 8:42 a.m., with the DON, Resident 1's GACH 1's- Radiation (energy that moves from one place to another in a form that can be described as waves or particles) Oncology (the specialized branch of medicine dedicated to the diagnosis, treatment, and prevention of cancer) Head and Neck New Patient Visit Note (Radiation Notes), dated [DATE], was reviewed. The Radiation Notes indicated Resident 1 was initially diagnosed with squamous cell carcinoma (SCC-a type of cancer that starts as a growth of cells on the skin) of the hard palate (the bony, front portion of the roof of your mouth, located between your upper teeth and the soft palate) in 2015, and underwent radiation in 2016. The Radiation Notes indicated Resident 1 had chemotherapy (a systemic cancer treatment that uses powerful drugs to destroy rapidly dividing cancer cells throughout the body) on 6/2017, to 7/2017, and had bilateral maxillectomy (a surgical procedure to remove all or part of the maxilla [upper jawbone]), excision (surgical removal) of right cheek skin, right mandible coronoidectomy (surgical removal of the mandibular coronoid process, a part of the lower jaw), right suprahyoid (a group of four small muscles located above the hyoid bone in the neck, connecting it to the jaw and skull base) neck dissection (the act of cutting apart or separating tissues), and tracheostomy.During a concurrent interview and record review on [DATE], at 9:27 a.m. with the Lead RT, Tracheostomy Tube Manufacturers Guidelines, dated 6/2013, was reviewed. The Tracheostomy Tube Manufacturers Guidelines indicated the tracheostomy tube and obturator are single patients use medical devices and usage should not exceed 29 days. Frequent and routine changes of the tracheostomy tube and accessory are recommended and should be evaluated by the qualified physician. The Lead RT stated tracheostomy tubes should be changed before the 29th day.During a concurrent an interview and record review on [DATE], at 9:28 a.m., with the DON, facility's policy and procedure (P&P), titled, Tracheostomy Tube Change, last reviewed on [DATE], and the Tracheostomy Tube Manufacturers Guidelines was reviewed. The DON stated the facility is aware that Resident 1's tracheostomy tube was not changed since admission on [DATE], until [DATE], and it was the facility's first attempt to change monthly, and the manufacturers guideline indicated to change before the 29th day. The DON stated the purpose of tracheostomy tube change monthly was for infection control. The DON stated that not changing tracheostomy tube could result in mucus build up.During an interview on [DATE], at 10:23 a.m., with the Lead RT, the Lead RT stated there is a possibility of tissue growth around the tracheostomy tube if tracheostomy was not changed close to 3 months. The Lead RT stated if there was tissue growth, massive bleeding could occur when tracheostomy was removed. The Lead RT also stated it could also cause infection like pneumonia (lung infection) since Resident 1 was on ventilator and could also cause tracheal malasia (a condition characterized by weak cartilage in the windpipe, causing it to collapse or narrow during breathing, coughing, or crying).During an interview on [DATE], at 11:02 p.m. with RT 3, RT 3 stated he (RT 3) attempted the third tracheostomy tube insertion and notice a lot of resistance when connected to ambubag. RT 3 stated if there was resistance it means the tracheostomy tube was not in place. RT 3 stated airway could have shifted reason for the resistance. RT 3 stated on the third attempt they still could not establish the airway.During an interview on [DATE], at 2:12 p.m., with RT 2, RT 2 stated before Resident 1's tracheostomy tube change, Resident 1 was awake, no bleeding from the tracheostomy site and vital signs were normal. RT 2 stated after the three attempts of tracheotomy tube change Resident 1 coded meaning Resident 1 had no pulse and no respiration and was pronounced dead. RT 2 stated the cause of Resident 1's death was that he (Resident 1) deteriorated (worsen) when airway could not be established.During an interview on [DATE], at 3:16 p.m., with RN 2, RN 2 stated she (RN 2) called 911 on [DATE], at 8:50 a.m., as per RN 1 instruction using the facility phone that Resident 1's tracheostomy tube was inserted but not patent. RN 2 stated the paramedics pronounced Resident 1's death at 9:18 a.m.During a concurrent interview and record review on [DATE], at 4:21 a.m., with the DON, the DON provided a Printout from a website on what are the risks of not changing the tracheostomy tube every 29 days. The Printout indicated, The risk of not changing a tracheostomy tube every 29 days includes:1. Infection-accumulation of secretions and mucus can lead to bacterial colonization and infection at the tracheostomy site.2. Airway obstruction-secretions can obstruct airflow, potentially leading to respiratory distress 3. Injury- the inner cannula can become damaged, causing air leakage and discomfort.4. Complications like tracheal stenosis (abnormal narrowing of the windpipe [trachea] due to scar tissue or inflammation, causing breathing difficulties), granulation tissues (the process of building new, temporary connective tissue and tiny blood vessels to fill in a wound from the base upward) and air embolism (a blockage in a blood vessel).The DON stated if tracheostomy tube was not change for more than 29 days, it could cause a block in the airway.During an interview on [DATE], at 11:17 a.m., with the DON, the DON stated the facility failed to change Resident 1's tracheostomy tube as indicated in the manufacturers guidelines and failed to follow the physician order to change monthly. The DON stated Resident 1's tracheostomy tube should have been changed within 29 days and on [DATE], should have been Resident 1's third tracheostomy tube changed. The DON stated the facility should have checked when the last time Resident 1's tracheostomy tube was changed to keep track on when the next change will be. The DON stated since Resident 1's tracheostomy tube was not changed close to 3 months (75 days) Resident 1 could have developed respiratory infection and buildup of secretions. The DON stated it could also result in possible granulation tissue formation causing blockage of the airway. The DON stated on [DATE], the RTs were able to insert the tracheostomy tube but could not establish a patent airway and if there were no patent airway, Resident 1 could get into cardiac pulmonary arrest and eventually die without oxygen.During an interview on [DATE], at 1:06 p.m., with the Pulmonologist, the Pulmonologist stated the standard for tracheostomy tube change was every month. The Pulmonologist stated he (Pulmonologist) ordered tracheostomy tube change every month. The Pulmonologist stated sick person like Resident 1 had less reserve of oxygen in their body. The Pulmonologist stated Resident 1 had a tracheostomy for open airway and was on ventilator to assists him (Resident 1) with breathing.During a review of facility's P&P, titled, Tracheostomy Tube Change, undated and last reviewed on [DATE], the P&P indicated, All residents tracheostomy tube will be routinely changed monthly, unless ordered otherwise by the physician.During a review of an online course titled, Tracheostomy Tube Changes, dated [DATE], the online course indicated, Indications for tracheostomy tube change:There are a variety of reasons for a tracheostomy tube change including: .routine changes as part of the ongoing airway management.Second and subsequent routine tracheostomy changes:There is variability between institutions on when to change a long-term tracheostomy tube. Recommendations are generally inconsistent and unsupported by evidence. Manufacturers typically recommend 30 days as the maximum amount of time for a double lumen tracheostomy tube to be left in place. Single cannula tracheostomy tubes are recommended to be changed every 7-10 days. The tracheostomy tube should be routinely changed based on the manufacturer's recommendations, because tube materials perish (to be destroyed) and can result in device failure or infection. Another reason to support tracheostomy tube change is the prevention of granulation tissue formation. An observational study has shown that regular tracheostomy tube changes every two weeks can often result in a statistically significant decrease in the number of patients who require surgical intervention for removal of granulation tissue (Yaremchuk, 2003) .Complications of Tracheostomy Tube Change.If there is resistance while passing the suction catheter, this may represent an improperly placed tube.During a review of an online Article titled, Tracheostomy Tube Change, dated [DATE], the article indicated, Tracheostomy tube changes are warranted for a variety of reasons, including confirming the maturation of the transcutaneous tract (especially during the first change), maintaining hygiene and managing the stoma (approximately every 30 days) .Potential contraindications include: . The tube change has a high probability of causing further tissue trauma or bleeding.Clinical significance: Regular tracheostomy tube changes are crucial for patient care. This practice can decrease the risk of complications such as granulation tissue formation, bleeding, and infection.

Based on observation, interview, and record review, the facility failed to implement its infection control measures for one of three sampled residents (Resident 2) by failing to ensure Registered Nurse 3 (RN 3) wore gown when suctioning Resident 2 who had a tracheostomy tube and on Enhance Barrier Precaution (EBP- infection control measures for high-risk residents, to reduce the spread of multidrug-resistant organism [MDRO- Bacteria that resist treatment with more than one antibiotic]).This failure had the potential for cross contamination (unintentional transfer of bacteria or germs or other contaminant from one surface to another) and spread infections and illnesses to residents, and staff.Findings:During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 4/7/2012, with diagnoses that included chronic respiratory failure (a long-term condition where the lungs cannot properly move oxygen into the blood or remove carbon dioxide, often lasting over a month) with tracheostomy (a surgically created hole [stoma] in the neck leading directly into the windpipe [trachea] to provide an airway, often using a tube to help with breathing) and gastrostomy tube.During a review of Resident 2's Physician Order, dated 7/22/2025, the Physician Order indicated EBP manifested by resident with ventilator, tracheostomy and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) tube feeding.During a review of Resident 2's Care Plan, dated 7/22/2025, the Care Plan regarding EBP indicated provide EBP gloves, gown and mask.During a review of Resident 2's Minimum Data Set (MDS-a resident assessment tool), dated 3/26/2026, the MDS indicated Resident 2's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 2 had a feeding tube and tracheostomy tube.During a review of Resident 2's Subacute Pulmonary Progress Notes, dated 4/22/2026, the Subacute Pulmonary Progress Notes indicated Resident 2 did not have the capacity to understand and make decisions.During an observation on 4/29/2026, at Resident 2's bedside. Observed an EBP signage posted outside of Resident 2's door that indicated, Everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also wear gloves and a gown for the following high-contact resident care activities. Device care or use. tracheostomy. Observed RN 3 don (put on) gloves and went inside Resident 2's room and pulled the curtain close.During a concurrent observation and interview on 4/29/2026, at 9:04 a.m., with RN 3 at Resident 2's bedside. Observed RN 3 wearing gloves and mask, no gown, suctioned Resident 2's tracheostomy tube. RN 3 stated he (RN 3) suctioned Resident 2's secretion from the tracheostomy tube.During an interview on 4/29/2026, at 11:47 a.m., with the Infection Preventionist (IP), the IP stated residents with open areas like wound, urinary catheter (a hollow tube inserted into the bladder to drain or collect urine), ventilator (a medical device to help support or replace breathing), tracheostomy and gastrostomy tube were on EBP. The IP stated all residents on Subacute were on EBP. The IP stated any direct contact with residents on EBP should wear gloves and gown. The IP stated suctioning Resident 2 is a direct contact and RN 3 should have worn a gown when suctioning Resident 2. The IP stated wearing gown minimize the spread of infection to residents. The IP stated the care plan was not followed.During an interview on 4/29/2026, at 12:47 p.m., with the Director of Nursing (DON), the DON stated residents in Subacute were all placed on EBP because they are all high-risk residents for infection.During an interview on 5/1/2026, at 9:28 a.m., with the DON, the DON stated the facility failed to ensure RN 3 wore a gown when suctioning Resident 2 who was on EBP. The DON stated there is a possible spread of infection because gown was not used.During a concurrent interview and record review on 5/5/2026, at 11:17 a.m., with the DON, facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions, dated 8/2022, and last reviewed on 4/15/2026, indicated, Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents.2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gowns are applied prior to performing the high contact resident care activity (as opposed to before entering the room).3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: . g. device care or use (central line [a long, flexible, soft tube inserted into a large vein-usually in the neck, chest, or arm that extends down to a major vein near the heart], urinary catheter, feeding tube, tracheostomy/ventilator); .10. Signs are posted in the door or wall outside the resident room indicating the type of precautions and personal protective equipment (PPE- clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) required. The DON stated RN 3 should have worn the gown while suctioning Resident 2 who was on EBP.

Based on interview and record review, the facility failed to ensure the medical records of one of three sampled residents (Resident 1) was maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to ensure licensed nurses documented the level of care provided to Resident 1 while the resident was in the facility. Resident 1's vital signs (essential, objective measurements of basic body functions, used to evaluate physical health, indicate disease, and monitor recovery) were not documented in the resident's medical records during a change of condition (COC) on 2/26/2026. This deficient practice resulted in incomplete information on Resident 1's medical records and had the potential for delayed medical interventions.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 2/7/2026 with diagnoses including metabolic encephalopathy (a temporary or permanent brain dysfunction caused by chemical imbalances in the body rather than a direct physical injury), cerebral infarction (a blockage in the blood vessel that stops oxygen and blood from reaching part of the brain), and unspecified dementia (a mental decline such as memory loss or confusion, that interfere with daily life, but the exact cause cannot be determined). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 2/14/2026, the MDS indicated Resident 1's cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making were severely impaired. During a review of Resident 1's COC Assessment Form, dated 2/26/2026, the COC Assessment Form indicated at 10:30 a.m., Resident 1 was observed confused, unable to make eye contact, and staring at the right side. Resident 1's vital signs values were documented in the Background section of the COC Assessment Form. At 12 p.m., Resident 1 was observed with increased weakness on the left side of the body and facial twitching. The COC Assessment Form indicated Resident 1's vital signs were within normal range. There were no documented vital signs values that indicated Resident 1's vital signs were normal. During a telephone interview on 3/9/2026 at 1:56 p.m. with Registered Nurse (RN) 1, RN 1 stated the licensed nurses were monitoring Resident 1 every 15 minutes that included the resident's vital signs. RN 1 stated she did not document the monitoring performed every 15 minutes on Resident 1. RN 1 stated she should document Resident 1's COC progress or decline in the resident's medical record to ensure complete documentation. During an interview on 3/9/2026 at 2:35 p.m. and concurrent record review of Resident 1's medical record, reviewed with the Director of Nursing (DON), the DON stated there was no confirmed documented evidence of Resident 1's vital signs after the resident's second COC at 12 p.m. on 2/26/2026. The DON stated failure to document the resident's vital signs after a COC could result in miscommunication amongst the healthcare team. The DON acknowledged and stated the facility failed to accurately and completely document Resident 1's vital signs following the resident's COC. During a review of the facility's policy and procedure (PnP) titled, Charting and Documentation, last reviewed on 4/16/2025, the PnP indicated all services provided to the resident. or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The PnP indicated documentation in the medical record will be objective, complete, and accurate.

Based on interview and record review, the facility failed to maintain medical records in accordance with acceptable professional standards and practices for one of three sampled residents (Resident 1) when the facility failed to accurately document in the Resident 1's medication administration records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident).This deficient practice resulted in inaccurate documentation of Resident 3's records.Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 1/15/2026 with diagnoses including urinary tract infection (UTI- an infection in the bladder/urinary tract), vascular dementia (a decline in thinking, memory, and behavior caused by reduced blood flow to the brain, which damages or kills brain cells), protein-calorie malnutrition (a serious condition caused by not eating enough calories and protein to meet the body's needs), pneumonia (a lung infection that inflames the air sacs [alveoli], causing them to fill with fluid or pus, which makes it hard to breathe and leads to symptoms like cough, fever, chills, and fatigue) and anxiety disorder (a mental health condition characterized by intense, excessive, and persistent fear or worry that does not go away and often worsens over time). During a review of Resident 1's Physician History and Physical (H&P- a doctor's foundational, comprehensive, two-part assessment of a resident), dated 1/15/2026, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's Order Summary Report (OSR), dated 1/15/2026, the OSR indicated:- sertraline HCI tablet 25 milligrams (mg-unit of measurement) give one tablet by mouth one time a day for depression mood behavior verbalization of sadness. - Colace give 100 mg by mouth one time a day for stool softener, hold for loose bowel movement.- Cranberry tablet 450 mg give one tablet by mouth one time a days for UTI prophylaxis- memantine HCI tablet 5 mg give one tablet by mouth two times a day for dementiaDuring a review of Resident 1's Order Summary Report (OSR), dated 1/17/2026, the OSR indicated liquacel oral liquid (amino acid) give 30 ml by mouth two times a day for supplement.During a review of Resident 1's Order Summary Report (OSR), dated 1/18/2026, the OSR indicated:- Acetaminophen oral tablet 325 mg give two tablets my mouth for pain management, give 30 minutes prior to treatment.- STAT (immediately) chest x-ray (a quick, painless, non-invasive imaging test that uses a low dose of radiation to create pictures of the structures inside your chest, including the heart, lungs, airways, blood vessels, and chest bones [ribs/spine]), Complete Blood Count (CBC-a common blood test that measures the overall health of your blood by counting the three main types of cells: red cells [carry oxygen], white cells [fight infection], and platelets [help clotting]), Comprehensive Metabolic Panel (CMP-test that acts as a broad screening tool to evaluate your overall health), due to acute cough and congestion.During a review of Resident 1's Change of Condition (COC), dated 1/18/2026 at 9:09p.m., the COC indicated Resident 1 had congestion, productive cough and was lethargic. Nursing note indicated Nurse Practitioner (NP) was notified and ordered chest x-ray but told NP the nurse ordered a chest x-ray yesterday and pending results.During a review of Resident 1's Radiology Result Report date 1/19/2026, the Radiology Result Report indicated Resident 1 had pneumonia and should be considered in the appropriate clinical setting.During a review of Resident 1's Order Summary Report (OSR), dated 1/19/2026, the OSR indicated the physician ordered amoxicillin-potassium clavulanate tablet 875 mg-125 mg give one tablet by mouth every twelve (12) hours for bacterial infection for seven days. During a review of Resident 1's Care plan (CP), initiated on 1/19/2026, the CP indicated Resident 1 was on amoxicillin-potassium clavulanate tablet 875 mg-125 mg for the treatment of pneumonia. The CP interventions included to administer medication as ordered and assess for signs and symptoms complications and notify the Medical Doctor (MD) and Responsible Party (RP). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 1/20/2026, the MDS indicated Resident 1 had the ability to understand and be understood. During a review of Resident 1's MAR for 1/2026, the MAR indicated on 1/20/2026 Resident 1 was administered the following medications:- Acetaminophen oral tablet 325 mg give two tablets my mouth for pain management, give 30 minutes prior to treatment on 1/20/2026 at 10 a.m. - Colace give 100 mg by mouth one time a day for stool softener, hold for loose bowel movement on 1/20/2026 at 9 a.m. - Cranberry tablet 450 mg give one tablet by mouth one time a days for UTI prophylaxis on 1/20/2026 at 9 a.m. - sertraline HCI tablet 25 milligrams (mg-unit of measurement) give one tablet by mouth one time a day for depression mood behavior verbalization of sadness on 1/20/2026 at 9 a.m.- amoxicillin-potassium clavulanate tablet 875 mg-125 mg give one tablet by mouth every twelve (12) hours for bacterial infection for seven days on 1/20/2026 at 9 a.m.- liquacel oral liquid (amino acid) give 30 ml by mouth two times a day for supplement on 1/20/2026 at 9 a.m.- Memantine HCI tablet 5 mg give one tablet by mouth two times a day for dementia on 1/20/2026 at 9 a.m.During a concurrent interview and record review on 1/26/2026 at 12:57 p.m. of Resident 1's MAR for 1/2026 with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 1/20/2026 was Resident 1's assigned nurse. LVN 1 stated was made aware that Resident 1 was not eating his breakfast. LVN 1 stated Resident 1's morning medications were not given because Resident 1 would not open his mouth. LVN 1 reviewed Resident 1's MAR for 1/20/2026 and LVN 1 stated she signed off medications as given but that was an accident. LVN 1 stated she did not make a note indicating the medications were signed off by error. LVN 1 stated if we accidentally sign off the medications, we are supposed to do a correction of each medication and indicate wrong documentation. LVN 1 stated she signed off seven medications as given but they were not given. LVN 1 stated she should have notified her supervisor and doctor when Resident 1 refused his antibiotics because that is an important medication. LVN 1 stated there could have been a potential for a delay in care because the doctor was unaware Resident 1 refused his antibiotic. LVN 1 stated she did not tell her supervisor until lunch time when Resident 1 refused lunch as well as his breakfast, a delay of about three hours. LVN1 stated if the doctor had been made aware sooner could have possibly changed the oral antibiotic to an intravenous (IV -fluids given directly into the blood stream) medication. During a concurrent interview and record review on 1/26/2026 at 3:34 p.m. with the Director of Nursing (DON), the DON stated if a resident refuses and or unable to take their medications there is a specific documentation that will indicate that. The DON stated LVN 1 should have not signed off medication as given and should have documented that the resident did not take the medications and the reason why the medication was not given. The DON stated the MD must be notified within the shift of the missed antibiotic or refused antibiotics. The DON stated the nurses should have notified the MD and the supervisor. The DON stated this is inaccurate documentation the medications were not given. The DON stated if the antibiotics are not given as prescribed, they can be a risk for the infection not to be addressed. The DON stated per policy it is not specified when MD needs to be notified of refusal of antibiotics but should be within the nurse's shift. The DON stated believes the nurse still notified the MD of the significant COC of lethargic but not of the missed antibiotics.During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, last reviewed on 4/16/2025, the P&P indicated documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.During a review of the facility's P&P titled, Medical Refusal, last reviewed on 4/16/2025, the P&P indicated medication refusal will be documented and attending physician will be notified. In the case of anticoagulant, insulin or antibiotics, the physician will be notified in the same day as refusal.

Based on interview and record review, the facility failed to ensure a resident was free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which are not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for one of three sampled residents (Resident 1) when the facility failed to administer amoxicillin-potassium clavulanate (a prescription combination antibiotic used to treat various bacterial infections, such as sinusitis, pneumonia, ear infections, and urinary tract infections).This deficient practice had the potential to negatively affect Resident 1.Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 1/15/2026 with diagnoses including urinary tract infection (UTI- an infection in the bladder/urinary tract), vascular dementia (a decline in thinking, memory, and behavior caused by reduced blood flow to the brain, which damages or kills brain cells), protein-calorie malnutrition (a serious condition caused by not eating enough calories and protein to meet the body's needs), pneumonia (a lung infection that inflames the air sacs [alveoli], causing them to fill with fluid or pus, which makes it hard to breathe and leads to symptoms like cough, fever, chills, and fatigue) and anxiety disorder (a mental health condition characterized by intense, excessive, and persistent fear or worry that does not go away and often worsens over time). During a review of Resident 1's Physician History and Physical (H&P- a doctor's foundational, comprehensive, two-part assessment of a resident), dated 1/15/2026, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's Order Summary Report (OSR), dated 1/18/2026, the OSR indicated the physician's order included STAT (immediately) chest x-ray (a quick, painless, non-invasive imaging test that uses a low dose of radiation to create pictures of the structures inside your chest, including the heart, lungs, airways, blood vessels, and chest bones [ribs/spine]), complete blood count (CBC-a common blood test that measures the overall health of your blood by counting the three main types of cells: red cells [carry oxygen], white cells [fight infection], and platelets [help clotting]), comprehensive metabolic panel (CMP-test that acts as a broad screening tool to evaluate your overall health), due to acute cough and congestion.During a review of Resident 1's Change of Condition (COC), dated 1/18/2026 at 9:09 p.m., the COC indicated Resident 1 had congestion, productive cough and was lethargic. Nursing note indicated Nurse Practitioner (NP) was notified and ordered chest x-ray but told NP the nurse ordered a chest x-ray yesterday and pending results.During a review of Resident 1's Radiology Result Report date 1/19/2026, the Radiology Result Report indicated Resident 1 had pneumonia which should be considered in the appropriate clinical setting.During a review of Resident 1's Order Summary Report (OSR), dated 1/19/2026, the OSR indicated the physician ordered amoxicillin-potassium clavulanate tablet 875 mg-125 mg give one tablet by mouth every twelve (12) hours for bacterial infection for seven days. During a review of Resident 1's Care plan (CP), initiated on 1/19/2026, the CP indicated Resident 1 was on amoxicillin-potassium clavulanate tablet 875 mg-125 mg for the treatment of pneumonia. The CP interventions included to administer medication as ordered and assess for signs and symptoms complications and notify the Medical Doctor (MD) and Responsible Party (RP).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 1/20/2026, the MDS indicated Resident 1 had the ability to understand and be understood. During a review of Resident 1's MAR for 1/2026, the MAR indicated on 1/20/2026 Resident 1 was administered amoxicillin-potassium clavulanate tablet 875 mg-125 mg give one tablet by mouth every twelve (12) hours for bacterial infection for seven days on 1/20/2026 at 9 a.m.During a concurrent interview and record review on 1/26/2026 at 12:57 p.m. of Resident 1's MAR for 1/2026 with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 1/20/2026 was Resident 1's assigned nurse. LVN 1 stated was made aware that Resident 1 was not eating his breakfast, LVN 1 stated Resident 1's morning medications were not given because Resident 1 would not open his mouth. LVN 1 reviewed Resident 1's MAR for 1/20/2026 and LVN 1 stated she signed off medications as given but that was an accident. LVN 1 stated she did not make a note indicating the medications were signed off by error. LVN 1 stated if we accidentally sign off the medications, we are supposed to do a correction of each medication and indicate wrong documentation. LVN 1 stated she signed off seven medications as given but they were not given. LVN 1 stated she should have notified her supervisor and doctor when Resident 1 refused his antibiotics because that is an important medication. LVN 1 stated there could have been a potential for a delay in care because the doctor was unaware Resident 1 refused his antibiotic. LVN 1 stated she did not tell her supervisor until lunch time when Resident 1 refused lunch as well as his breakfast, a delay of about three hours. LVN 1 stated if the doctor had been made aware sooner could have possibly changed the oral antibiotic to an intravenous (IV -fluids given directly into the blood stream) medication. During a concurrent interview and record review on 1/26/2026 at 3:34 p.m. with the Director of Nursing (DON), the DON stated if a resident refuses and or unable to take their medications there is a specific documentation that will indicate that. The DON stated LVN 1 should have not signed off medication as given rather LVN 1 should have documented that the resident did not take the medications and the reason why the medication was not given. The DON stated the MD must be notified within the shift of the missed antibiotic or refused antibiotics. The DON stated the nurses should have notified the MD and the supervisor. The DON stated this is inaccurate documentation because the medications were not given. The DON stated if the antibiotics are not given as prescribed it can be a risk for the infection not to be addressed. The DON stated per policy it is not specified when MD needs to be notified of refusal of antibiotics but should be within the nurse's shift. The DON stated believes the nurse still notified the MD of the significant COC of lethargic but not of the missed antibiotics.During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, last reviewed on 4/16/2025, the P&P indicated documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.During a review of the facility's P&P titled, Medical Refusal, last reviewed on 4/16/2025, the P&P indicated medication refusal will be documented and attending physician will be notified. In the case of anticoagulant, insulin or antibiotics, the physician will be notified in the same day as refusal.

Based on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices for one of four sampled residents (Resident 3) when the facility failed to accurately document Resident 3's diagnosis. This deficient practice resulted in inaccurate documentation in Resident 3's records.Findings: During a review of Resident 3's admission Record (AR), the AR indicated the facility admitted Resident 3 on 9/11/2024 and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and chronic kidney disease (CKD- condition where the kidneys are damaged and cannot function properly over an extended period). During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool) dated 6/17/2025, the MDS indicated Resident 3 sometimes understood and was sometimes understood. The MDS indicated Resident 3 was dependent (helper does all of the effort) with eating, oral hygiene, toileting, showering, upper and lower body dressing, putting on and taking off footwear, and personal hygiene. During a review of Resident 3's General Acute Care Hospital (GACH) 1 Discharge summary dated [DATE], the GACH 1 Discharge Summary indicated Resident 3's discharge diagnosis as scabies (a highly contagious skin condition caused by the infestation of the skin by the human itch mite, a tiny parasite that burrows into the skin to live and lay eggs). The GACH 1 Discharge Summary indicated discharge instructions to repeat ivermectin (a medication used to kill or paralyze parasites like worms, mites, and lice in both humans and animals) and continue isolation. During a review of Resident 3's Surveillance Data Collection Form Scabies dated 8/7/2025, the Data Collection form Scabies indicated Resident 3 was admitted from hospital, resident with diagnosis of scabies from GACH 1. Per doctor continue ivermectin oral tablet give 12 milligrams (mg- a unit of measurement) via gastrostomy tube (g-tube: a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) one time only for scabies until 8/11/25, 8/18/25, and 8/25/25 with ongoing treatment. Resident 3 still noted with generalized flaky skin and dry with no itchiness and no redness noted at this time. During an interview on 9/22/2025 at 4:30 p.m. with the Director of Nursing (DON), the DON stated Resident 3 does have a history of scabies. During a concurrent interview and record review of Resident 3's diagnosis on 9/22/2025 at 4:50 p.m. with the DON, the DON reviewed Resident 3's diagnosis and stated diagnosis does not indicate Resident 3 has a history of scabies. The DON stated for Resident 3 must indicate Resident 3's history of scabies even if it was resolved, because it is an overall synopsis of the resident's condition. The DON stated not including Resident 3's history of scabies in his diagnosis can result in inaccurate records. During a review of the facility's Policy and Procedures (P&P) titled, Charting and Documentation, last reviewed on 4/16/2025, the P&P indicated documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

Based on observation, interview, and record review the facility failed to: A. Ensure one of four sampled residents (Resident 10) who had intact skin upon admission on [DATE], was assessed as at risk for developing pressure ulcers (localized damage to the skin and/or underlying tissue usually over a bony prominence), required assistance with turning while in bed and in a chair, and was incontinent of bowel and bladder (having no or insufficient voluntary control over urination or defecation) did not develop pressure ulcers while in the facility and received appropriate treatment and services to maintain skin integrity (the condition of the skin being intact, healthy and free from damage) by failing to: 1.Ensure Licensed Vocational Nurse 2 (LVN 2) and Treatment Nurse 1 (TN 1) assessed and reported to the Director of Nursing (DON) that Resident 10 developed skin peeling and redness between the buttocks on 7/24/2025. 2. Assess Resident 10 promptly upon Certified Nurse Assistant 2's (CNA 2) identification of an open sacrococcyx (tailbone) wound as indicated in the Daily Body Check Report, dated 7/28/2025. 3.Ensure Vitamin A and Vitamin D (A&D - a skin protectant used to treat and prevent diaper rash and minor skin irritations) was applied to the left and right foot callus (hard, thick patches of skin) as ordered on 7/28/2025 for Resident 10. 4. Conduct a timely Wound Risk Assessment (also known as Braden Scale - an assessment tool used to predict the risk of a resident developing pressure ulcers) for Resident 10 upon the development of Moisture Associated Skin Damage (MASD - inflammation [becomes reddened, swollen or hot] or skin erosion [breakdown of outer layers of skin] caused by prolonged exposure to moisture like urine, stool, sweat) on 7/31/2025 and the subsequent identification of wounds to the sacrococcyx and left buttock on 8/12/2025. 5.Ensure Certified Nurse Assistant 9 (CNA 9) completed body checks for Resident 10 on 8/8/2025, 8/9/2025 and 8/10/2025. 6. Ensure TN 1 removed Resident 10's incontinence brief on 8/11/2025 to assess the skin underneath during the administration of MASD treatment to the right and left buttocks. 7. Ensure TN 1 reported and obtained a physician's order prior to providing wound treatment to Resident 10 on 8/12/2025, when TN 1 applied a bordered gauze dressing (a wound care product designed to absorb wound drainage and protect the wound) to Resident 10's left buttock and sacrococcyx. 8. Administer Acetaminophen (also known as Tylenol, a medication used to relieve pain) as ordered to Resident 10 on 8/13/2025 prior to the administration of wound treatment. 9. Implement the facility's policy and procedure (P&P) titled Care and Prevention of Pressure Sores (also known as Pressure Ulcers), last reviewed on 4/16/2025 that indicated to provide appropriate facility interventions to manage and prevent pressure sores. These deficient practices resulted in the development of two facility-acquired pressure ulcers for Resident 10, as identified by Physician Assistant 1 (PA 1) on 8/13/2025. On 8/13/2025, PA 1 identified a Stage two pressure ulcer (partial thickness loss of skin, presenting as a shallow open sore or wound) on the left buttock and a Stage three pressure ulcer (full-thickness skin loss that extends through the skin into deeper tissue and fat but do not reach muscle, tendon or bone) on the sacrococcyx. B. Provide care consistent with professional standards of practice to prevent pressure ulcers for two of four sampled residents (Resident 16 and 33), who were at risk for pressure ulcer/injury, required assistance with turning while in bed and chair, incontinent of bowel and bladder, by failing to: 1. Provide heel protectors (devices designed to reduce pressure and friction on the heels, primarily to prevent or treat pressure ulcers) to Resident 16. This deficient practice had the potential to result in the development or worsening of pressure ulcers. 2. Ensure Resident 33 had their low air loss mattress (LALM - a special mattress designed to distribute the resident's body weight over a broad surface area and help prevent skin breakdown) at the correct setting. This deficient practice had the potential to increase Resident 33's risk of skin breakdown and develop pressure ulcers. Findings: A. During a review of Resident 10's admission Record (AR), the AR indicated that the facility admitted the resident on 6/2/2025 with diagnoses including unspecified sequelae (the long-term conditions that happen because of an illness or injury) cerebral infarction (stroke - loss of blood flow to a part of the brain ), chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), myocardial infarction type two (heart attack- occurs when the heart muscle doesn't get enough oxygen due to an imbalance between oxygen supply and demand, not caused by a blockage in the coronary arteries {blood vessel supplying blood to the heart}), generalized muscle weakness, and abnormalities of gait (manner of walking) and mobility (movement). During a review of Resident 10's History and Physical (H&P - comprehensive assessment conducted by a healthcare provider that includes gathering a thorough medical history from the resident and performing a physical examination to assess their overall health and identify any potential medical concern), dated 6/2/2025, the H&P indicated Resident 10 did not have the capacity to understand and make decisions. The H&P indicated that Resident 10's integumentary (skin) was intact. During a review of Resident 10's admission Re-assessment, dated 6/3/2025, the admission Re-assessment indicated Resident 10 had left axilla (armpit) mass, and calluses on the right and left feet. During a review of Resident 10's Minimum Data Set (MDS - a resident assessment tool), dated 6/9/2025, the MDS indicated that Resident 10 has the ability to make self understood and has the ability to understand others. The MDS indicated Resident 10 required partial/moderate assistance from staff for bed mobility including rolling to the left and right. The MDS indicated Resident 10 was always incontinent of bowel and bladder. The MDS indicated Resident 10 had no unhealed pressure ulcer but was identified as being at risk for developing pressure ulcers. During a review of Resident 10's Braden Scale (a scoring tool used to predict resident's risk of developing a pressure ulcer, total score ranges from zero {0} to 18. A lower score indicating a higher risk of developing a pressure ulcer.) dated 6/3/2025, timed at 2:18 p.m., the Braden Scale assessment indicated a score of 17, which signifies that Resident 10 is at risk for developing pressure ulcer. During a review of Resident 10's Physician Orders dated 7/31/2025, the Physician Order indicated treatment for Resident 10's MASD to the right and left buttocks extending to the perianal (around the anal {near the anus – opening at the end of the digestive tract, through which solid waste – stool, is expelled from the body} area). The Physician Order indicated to cleanse with normal saline (a mixture of water and salt), pat dry, apply a skin barrier cream, leave open to air every day shift for 30 days. During a review of Resident 10's Physician Orders dated 8/12/2025, the Physician Orders indicated to administer Acetaminophen tablet 325 milligrams (mg - a unit of measurement), give two tablets by mouth every day shift prior to wound care and treatment. During an interview on 8/12/2025 at 2:26 p.m., with Resident 10, Resident 10 stated having a wound on her (Resident 10) back. Resident 10 stated that she (Resident 10) did not have this wound upon admission to the facility. Resident 10 stated that the wound on her (Resident 10) back is starting to hurt, and that she (Resident 10) is in pain. Resident 10 further stated that a staff member (name unknown) applied something to the wound the previous day, but she (Resident 10) was unsure of what was applied. During an interview on 8/12/2025 at 2:30 p.m., with TN 1, TN 1 stated that Resident 10 does not have a wound treatment in place, because Resident 10 only has MASD. TN 1 stated that she (TN 1) has not yet performed the MASD treatment ordered for Resident 10. During a concurrent observation and interview on 8/12/2025 at 2:32 p.m., with TN 1, Certified Nurse Assistant 1 (CNA 1), and Certified Nurse Assistant 2 (CNA 2), at Resident 10's bedside (the place next to a resident's bed), CNA 1 and CNA 2 repositioned Resident 10 onto her (Resident 10) right side to change her (Resident 10) incontinence briefs. Two bordered gauze dressings were observed, one on Resident 10's left buttock and one on Resident 10's sacrococcyx area both without dates and staff initial. TN 1 removed the two bordered gauze dressings and stated Resident 10 has two open wounds. TN 1 stated that she (TN 1) does not know who applied the dressings on Resident 10. TN 1 then exited Resident 10's room. During a concurrent observation and interview on 8/12/2025 at 2:41 p.m., with CNA 1 and CNA 2, at Resident 10's bedside, CNA 1 stated that she (CNA 1) provided care for Resident 10 yesterday (8/11/2025), during the 3 p.m. to 11 p.m. shift, and observed bordered gauze dressings already in place on Resident 10's left buttock and sacrococcyx. CNA 1 stated that she (CNA 1) did not touch or remove the dressings. CNA 2 stated that she (CNA 2) cared for Resident 10 yesterday (8/11/2025), during the 7 a.m. to 3 p.m. shift, and observed a large open wound on Resident 10's sacrococcyx. CNA 2 stated that she (CNA 2) then documented the wound on Resident 10's Daily Body Check Report and notified the charge nurse (Licensed Vocational Nurse 1 {LVN 1). During a concurrent observation and interview on 8/12/2025 at 2:43 p.m., with TN 1, at Resident 10's bedside, TN 1 measured Resident 10's wounds and stated that Resident 10's sacrococcyx wound measured 4.5 centimeters (cm- a unit of measurement) in length by (x) three (3) cm in width, 80% wound bed granulation (the formation of new connective tissue and blood vessels that fill in a wound bed during the proliferative phase of healing), and 20% slough (dead tissue that is usually yellow, tan, gray, or green in color, usually moist and stringy in texture, that may be found in wounds). TN 1 stated that the wound edges were attached, with no signs of undermining (the destruction of tissue or ulcer extending under the skin edges so that the pressure ulcer is larger at its base than at the skin surface). TN 1 stated that the wound on Resident 10's left buttock measured two (2) cm in length x 0.4 cm in width and depth would be considered unstageable (a type of wound that occurs when pressure on the skin causes tissue damage that cannot be accurately assessed or staged due to the presence of necrotic {dead or dying} tissue) because the depth could not be determined. During an observation on 8/13/2025 at 8 a.m., Physician Assistant 1 (PA 1) and TN 1 were at Resident 10's bedside. During an interview on 8/13/2025 at 8:15 a.m., with TN 1, TN 1 stated that PA 1 evaluated Resident 10's wounds and performed excisional debridement (a surgical procedure involving the sharp removal of dead, damaged, or infected tissue from a wound to promote healing) on Resident 10's sacrococcyx wound. TN 1 stated that she (TN 1) then applied Santyl (also known as collagenase, a topical ointment that removes dead tissue from wounds so they can start to heal) to Resident 10's sacrococcyx wound as ordered. TN 1 further stated that she (TN 1) was the staff member who applied the bordered gauze dressings to Resident 10's left buttock and sacrococcyx area yesterday (8/12/2025). During a review of Resident 10's Wound Care Consultation Notes (WCCN) dated 8/13/2025, the WCCN indicated Resident 10 had the following wounds: 1. Sacral, Stage three pressure ulcer, size 4 cm x 2.7 cm x 0.2 cm, wound base granular (a wound in the process of healing) with exposed subcutaneous (under or beneath the skin), 40% slough, 60% granular, and excisional debridement. 2. Left buttock, Stage two pressure ulcer, size 1 cm x 0.4 cm x 0.1 cm, wound base granular with exposed dermis (middle layer of skin in your body). The WCCN indicated the following recommendations: 1. Wound #1, Sacral: to monitor/offload (removing or minimizing the pressure, weight, and force from a specific area of the body, such as a wound or a body part at risk of injury), foam, and Santyl. 2. Wound #2, Left Buttock: to monitor/offload and foam; Zinc cream (medication used to treat and prevent skin irritation) for moisture control, A&D ointment for skin maintenance, every two hours turning at all times while in bed; and apply heel protectors (device used to protect the heel of a resident's foot from pressure ulcers or pain caused by impact and friction) or keep heels floating or with pillows under legs at all times while in bed. During an interview on 8/13/2025 at 8:17 a.m., with LVN 2, LVN 2 stated that she (LVN 2) has not yet started medication administration. LVN 2 stated that she (LVN 2) has not given any medications to Resident 10. LVN 2 further stated that she (LVN 2) plans to administer Resident 10's medications after Resident 10 has eaten and been changed. During an interview on 8/13/2025 at 9:15 a.m., with Resident 10, at Resident 10's bedside, Resident 10 stated that she (Resident 10) is able to move her (Resident 10) legs but is unable to roll her (Resident 10) body to the right or left on her (Resident 10) own. Resident 10 stated that she (Resident 10) requires staff assistance to turn while in bed. Resident 10 further stated that she (Resident 10) can assist slightly but not significantly. During an interview on 8/13/2025 at 9:18 a.m., with Resident 10 and LVN 2, at Resident 10's bedside, Resident 10 stated that she (Resident 10) has pain rated eight out of 10 pain on the pain scale (a tool used to measure and describe the intensity of pain, ranging from 0 [no pain] to 10 [worst possible pain]) in both hands. During a concurrent interview and record review on 8/13/2025 at 9:18 a.m., with LVN 2, Resident 10's Medication Administration Record (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for 8/2025 was reviewed. LVN 2 stated that tramadol (a pain medication used to treat moderate to severe pain) was administered to Resident 10 on 8/13/2025 at 3:08 a.m., and the last dose of Acetaminophen was given to Resident 10 in 6/2025. LVN 2 stated that she (LVN 2) has not administered any pain medication to Resident 10 during her shift. During a concurrent interview and record review on 8/13/2025 at 11:30 a.m., with Restorative Nursing Assistant 1 (RNA 1), Resident 10's Daily Body Check Report dated 8/4/2025 was reviewed. RNA 1 stated that on 8/4/2025 he (RNA 1) was working in the role of a CNA and was assigned to Resident 10. RNA 1 stated that on 8/4/2025 he (RNA 1) marked an X on the Daily Body Check Report to indicate that Resident 10 had a small, open, reddish pressure ulcer. RNA 1 stated that he (RNA 1) reported this finding to LVN 2 on the same day, and she (LVN 2) informed him (RNA 1) that she (LVN 2) would report it to TN 1. During an interview on 8/13/2025 at 2:47 p.m., with LVN 2, LVN 2 stated that the purpose of administering Acetaminophen to Resident 10 prior to wound treatment is for pain management. LVN 2 stated that TN 1 did not inform her (LVN 2) this morning (8/13/2025) that the wound treatment would be performed so she (LVN 2) did not administer the Acetaminophen. LVN 2 stated that Acetaminophen is given before wound treatment to help prevent Resident 10 from experiencing pain during the wound treatment. During a concurrent interview and record review on 8/13/2025 at 3:31 p.m., with LVN 1, Resident 10's Change of Condition (COC – when there is a sudden change in a resident's condition) Assessment form, Nursing Progress Notes (from 6/2/2025 to 8/13/2025), and Daily Body Check Report (from 6/2/2025 to 8/13/2025) were reviewed. LVN 1 stated that she (LVN 1) signed the Daily Body Check Reports on 7/28/2025 and 8/11/2025. LVN 1 stated that she (LVN 1) did not perform body checks on those dates (7/28/2025 and 8/11/2025) and does not have any documentation to support that the Daily Body Check Reports were completed. LVN 1 stated that the body checks are performed by the treatment nurse, and she (LVN 1) assumed the treatment nurse (TN 1) would complete them since Resident 10 has a treatment order for MASD. LVN 1 stated that the MASD began on 7/31/2025 and that she (LVN 1) should have checked Resident 10 on 7/28/2025. LVN 1 stated that if a new skin issue or wound is identified, she (LVN 1) would document the location, and if the wound was present, LVN 1 would complete a COC Assessment form. LVN 1 stated that she (LVN 1) does not recall whether she (LVN 1) reported Resident 10's new skin issue or wound to TN 1 on 7/28/2025. LVN 1 further stated that she (LVN 1) assumed TN 1 would inform her (LVN 1) of any changes in Resident 10's skin condition such as the development of a new wound or pressure ulcer, however no such information was relayed to her by TN 1. LVN 1 stated that the standard of practice requires documentation of any care or treatment provided. LVN 1 stated that if care or treatment is not documented, it is considered not to have been done. LVN 1 further stated that failure to document can result in a decline in the resident's condition. During a concurrent interview and record review on 8/14/2025 at 8:16 a.m., with CNA 2, the Daily Body Check Reports dated 7/28/2025, 7/31/2025, and 8/11/2025, were reviewed. CNA 2 stated that she (CNA 2) completed the documentation for the Daily Body Check Report. CNA 2 stated that the large, open wound on Resident 10's tailbone was the same wound site she (CNA 2) observed on 7/28/2025 and 7/31/2025. CNA 2 further stated that the wound on Resident 10's tailbone was the same size on both dates 7/28/2025 and 7/31/2025. CNA 2 stated that the smaller wound on Resident 10's left buttock, as observed on 8/12/2025 was open, red and had darkened edges. During a concurrent interview and record review on 8/14/2025 at 10 a.m., with TN 1, Resident 10's Braden Scale, dated 6/3/2025, 6/10/2025, 6/17/2025, and 6/24/2025, were reviewed. TN 1 stated that the Braden Scale determines how the facility would take care of residents and predict residents' risk of pressure ulcers. TN 1 stated Resident 10's Braden Scale indicated the following: -On 6/3/2025, Resident 10 had a score of 17 (at risk). -On 6/10/2025, Resident 10 had a score of 19 (no risk). -On 6/17/2025, Resident 10 had a score of 19. -On 6/24/2025, Resident 10 had a score of 19. TN 1 stated that Resident 10's Braden Scale assessments would no longer be accurate now. TN 1 stated that Resident 10 is at risk for developing pressure ulcers. TN 1 further stated that a Braden Scale should have been completed when Resident 10 was identified with MASD on 7/31/2025, but she was unsure who was responsible for completing the assessment. During a concurrent interview and record review on 8/14/2025 at 10:06 a.m., with TN 1, Resident 10's Treatment Administration Record (TAR – a document used to record and track treatments and procedures administered to a resident) from 6/2025 to 8/2025, were reviewed. TN 1 stated that Resident 10 did not refuse wound treatments. During a follow-up interview on 8/14/2025 at 10:08 a.m., with TN 1, TN 1 stated that on 8/12/2025 at 2:32 p.m., when TN 1 was asked whether she (TN 1) had performed the MASD treatment for Resident 10 as there were two bordered gauze dressings observed (one on Resident 10's left buttock and one on Resident 10's sacrococcyx area), and TN 1 responded that she (TN 1) did not know who applied the dressings, TN 1 stated she (TN 1) had misunderstood what was said and that she (TN 1) did not hear the State Agency (SA) correctly. TN 1 stated that she (TN 1) already did the MASD treatment to Resident 10 and that she (TN 1) was the facility staff who applied the two bordered gauze dressings on Resident 10. TN 1 stated that when she (TN 1) saw the two open wounds she (TN 1) panicked and left the room. TN 1 stated that she (TN 1) observed Resident 10's pressure ulcers on the left buttocks and sacrococcyx area on 8/14/2025 before 12 p.m. TN 1 stated that she (TN 1) did not know how Resident 10's wound occurred and that she intended to speak with the DON. TN 1 stated that she (TN 1) provided MASD treatment to Resident 10 on 8/11/2025. TN 1 further stated that she (TN 1) treated Resident 10's wound on the left and right buttocks extending into the perianal area really fast because Resident 10's family was there. TN 1 stated Resident 10 wore adult briefs. TN 1 stated that during the treatment on 8/11/2025 she (TN 1) did not remove Resident 10's brief and did not check Resident 10's skin to determine whether a wound was present or not. TN 1 stated that she did not assess Resident 10's left and right buttocks during the treatment. TN 1 stated that she (TN 1) only applied the barrier cream (A&D) to the resident's perianal area. TN1 further stated that she (TN 1) would not perform treatment if there was bowel movement or urine. TN 1 stated that she (TN 1) is supposed to remove the briefs and assess Resident 10's skin but did not do so. During an interview on 8/14/2025 at 2 p.m., with PA 1, PA 1 stated that she (PA 1) was notified of Resident 10's wounds on 8/12/2025 and examined Resident 10 on 8/13/2025. PA 1 stated that the progression for a Stage Three pressure ulcer depends on the overall status of the resident. PA 1 stated that for a resident who is bedridden (a resident confined to their bed due to illness, requiring assistance and unable to move around independently), a pressure ulcer can possibly progress over a few days to overnight sometimes due to pressure, nutrition, and moisture. PA 1 stated that Resident 10 has MASD, which contributed to the progression and development of Resident 10's pressure ulcer. PA 1 further stated that for a resident such as Resident 10, who initially had intact skin, the presence of MASD can significantly increase the risk of skin breakdown and the subsequent development of pressure ulcer. During a concurrent interview and record review on 8/14/2025 at 2:50 p.m., with CNA 9, Resident 10's Daily Body Check Report was reviewed. CNA 9 stated that she (CNA 9) works 7 a.m. to 3 p.m. shift and was assigned to Resident 10 on 8/8/2025, 8/9/2025, and 8/10/2025. CNA 9 stated she (CNA 9) did not complete the Daily Body Check Report for Resident 10 on 8/8/2025, 8/9/2025, and 8/10/2025. CNA 9 stated that she (CNA 9) is responsible for completing the Daily Body Check Report daily. CNA 9 stated that she (CNA 9) sometimes completes the Daily Body Check Report, but at times does not complete it as required. CNA 9 stated that when she (CNA 9) identifies a skin issue on a resident, she (CNA 9) verbally reports the skin problem or concern to her (CNA 9) charge nurse. During a concurrent interview and record review on 8/14/2025 at 4:45 p.m., with TN 1, Resident 10's Care Plan (CP) titled, Risk for Developing Pressure Sore, dated 6/9/2025, was reviewed. TN 1 stated that the CP indicated goals for minimizing the risk of skin breakdown or pressure sore daily. The CP indicated interventions including assessing Resident 10's skin integrity during care, turning and repositioning as needed when in bed or wheelchair, administer/provide treatments as ordered, and assessing risk using Wound Risk Assessment on admission, quarterly, and as needed. During a concurrent interview and record review on 8/15/2025 at 9:52 a.m., with LVN 2, Resident 10's COC Assessment form, Nursing Progress Notes (from 6/2/2025 to 8/13/2025), and Daily Body Check Report (from 6/2/2025 to 8/13/2025) were reviewed. LVN 2 stated that she (LVN 2) signed the Daily Body Check Report for Resident 10 on 7/24/2025 and that she (LVN 2) was notified regarding Resident 10's skin peeling and redness between the buttocks on 7/24/2025. LVN 2 stated that she (LVN 2) verbally informed TN 1 to check on Resident 10. LVN 2 stated that she (LVN 2) did a body check on Resident 10 on 7/24/2025, but she (LVN 2) did not document the findings from the body check. LVN 2 stated that if residents had a COC related to skin condition, the treatment nurse is supposed to complete the COC form. During an interview on 8/15/2025 at 9:58 a.m., with TN 1, TN 1 stated that on 8/12/2025 she (TN 1) applied the bordered gauze dressing on Resident 10 without a physician's order. TN 1 stated that the facility's protocol requires staff to report any new skin issues to the physician, obtain a treatment order, and then initiate the prescribed treatment. TN 1 stated that obtaining an order prior to administering wound care is important to ensure that the appropriate treatment is provided to promote healing. TN 1 further stated that it is not acceptable to administer wound treatment without a physician's order, as doing so could potentially worsen the wound. During an interview on 8/15/2025 at 11:05 a.m., with TN 1, TN 1 stated that on 8/13/2025 prior to performing wound treatment, she (TN 1) has to verify with the charge nurse whether pain medication had been administered to Resident 10. TN 1 stated she (TN 1) does not recall if she (TN 1) confirmed Resident 10 received pain medication. TN 1 further stated that she (TN 1) proceeded with the wound treatment alongside PA 1 without verifying whether Resident 10 had received pain medication. During an interview on 8/15/2025 at 12:16 p.m., with the Director of Staff Development (DSD), the DSD stated that CNAs are expected to complete the Daily Body Check Report during the 7 a.m. to 3 p.m. shift. The DSD stated that she (DSD) does not have the Daily Body Check Report documentation for Resident 10 on 7/26/2025, 7/27/2025, 8/1/2025, 8/2/2025, 8/3/2025, 8/5/2025, 8/6/2025, 8/7/2025, 8/8/2025, and 8/10/2025. During an interview on 8/15/2025 at 12:48 p.m., with the DON, the DON stated that the Daily Body Check Report is completed during the morning shift (7 a.m. to 3 p.m.) by the CNAs, who are responsible for documenting any observed skin issues and reporting the skin issues to the charge nurse. The DON stated the charge nurse then co-signs the document. The DON stated that if a skin concern is identified during the morning shift and a treatment nurse is available, the charge nurse is expected to notify the TN to assess the area. The DON stated that the charge nurse is responsible for verifying whether the identified skin issue is new. The DON stated the verification process would include reviewing current physician orders, previous COC documentation and the resident's care plan. The DON stated that if the charge nurse reported a new skin issue to the treatment nurse, the treatment nurse would not acknowledge it unless there is a current physician order for treatment. The DON stated it is important for the Daily Body Checks Report to be completed to ensure timely identification of any skin issues or conditions of concern. The DON stated that when the body checks are not performed, there is a risk that wounds or skin breakdowns may not be identified promptly, potentially delaying necessary care. During an interview on 8/15/2025 at 1:00 p.m., with the DON, the DON stated that there must always be a physician's order in place to ensure correct and appropriate wound treatment is being provided. The DON stated that before initiating any wound care, the licensed nurse should notify the physician, obtain a treatment order, and complete a COC Assessment form. The DON also stated that Resident 10's most recent wound risk assessment (6/24/2025), as indicated in the Braden Scale was not accurate and did not reflect Resident 10's condition placing Resident 10 at risk for developing pressure ulcers. The DON stated that the Braden Scale assessment for Resident 10 was last completed on 6/24/2025 and was outdated, failing to account for Resident 10's present clinical status. During an interview on 8/15/2025 at 1:13 p.m., with the DON, the DON stated that pain medication should be provided to residents after residents' pain has been assessed and before wound treatment as ordered. The DON stated that pain medication is administered to residents to help minimize discomfort and manage pain during treatment procedures. During an interview on 8/15/2025 at 2:48 p.m., with the DON, the DON stated that all wound treatments for Resident 10 should be documented in the electronic health record (EHR – a comprehensive, digital collection of a resident's health information). The DON stated that the EHR is designed to alert the licensed nurse if a treatment was not done to ensure treatments are not missed. The DON stated that each treatment provided must be signed off and accurately recorded in the treatment record. The DON further stated that missed treatments can lead to a decline in the resident's wound condition. During an interview on 8/15/2025 at 2:53 p.m., with the DON, the DON stated that TN 1 should have assessed and visually examined Resident 10's wound while performing wound treatment. The DON stated that she (DON) could not verify the progression of the wound because wound conditions can change or regress within two hours. The DON stated that it is not possible to appropriately administer treatment without first assessing the area where the treatment is to be applied. The DON stated that TN 1 failed to assess and verify Resident 10's wound prior to treatment which resulted in the wound being missed. During an interview on 8/15/2025 at 2:58 p.m., with the DON, the DON stated that TN 1 demonstrated a lack of competency by failing to identify, report, and implement preventive measures for pressure ulcers. The DON stated that she (DON) discovered TN 1 had been dishonest in her (TN 1) documentation and communications. The DON also stated that TN 1 administered wound treatments without obtaining proper physician orders and failed to complete the COC Assessment form for Resident 10 on Monday (8/11/2025). The DON further stated that several required interventions were not carried out as expected. The DON stated that given Resident 10's comorbidities, lack of appropriate care contributed to the development and possible worsening of Resident 10's pressure ulcers (Stage Three on the sacrococcyx area and Stage Two on the left buttock area). During a review of the facility's P&P titled, Body Checks, last reviewed on 4/16/2025, the P&P indicated the objective is

Based on observation, interview, and record review, the facility failed to ensure the facility's policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption was followed for one of one sampled resident refrigerator by failing to: 1. Ensure Certified Nursing Assistant (CNA) 4 informed Resident 82 that the facility had refrigerator designated for residents' food brought from home. 2. Ensure the facility's resident refrigerator was within acceptable temperature range per facility's policy and procedure for refrigerator at 40 degrees Fahrenheit (F, a scale for measuring temperature) or below and freezer at 0 degrees F or below. 3. Ensure expired whole milk yoghurt (6 packs), with expiration date of 7/23/2025 was discarded. These deficient practices had the potential to result in food-borne illnesses (food poisoning) of residents and can lead to other serious medical complications and hospitalization. Findings: 1.During a review of Resident 82's admission Record, the admission Record indicated the facility admitted the resident on 9/11/2023, with diagnoses including but not limited to Parkinson's disease (a progressive brain disorder that affects movement, balance, and coordination), hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone and hyperlipidemia (a condition where there are abnormally high levels of lipids in the blood). During a review of Resident 82's History and Physical (H&P), dated 9/11/24, the H&P indicated the resident has the capacity to understand and make decisions. During a review of Resident 82's Minimum Data Set (MDS, a resident assessment tool), dated 6/18/2025, the MDS indicated Resident 82 had the ability to make self understood and understand others. The MDS indicated Resident 82's cognition was intact (mental processes that enable people to think, understand, make decisions, and complete tasks) and participated in the assessment and goal setting of healthcare management. During an interview on 8/13/2025, at 2:40 p.m., with Resident 82, Resident 82 stated nobody has told her that there is a refrigerator for residents' food from home. Resident 82 stated her family brought food from home but discarded leftovers as it would be spoiled the next day. Resident 82 stated that no one has explained to her about food storage for foods brought by her family. During an interview on 8/13/2025, at 3:02 p.m., with CNA 4, CNA 4 stated Resident 82 was informed that leftovers are discarded beyond 2 hours because there is no refrigerator for storage. CNA 4 stated she was not aware of a refrigerator available for residents outside food. During an interview on 8/13/2025, at 3:35 p.m., with the Director of Staff Development (DSD), the DSD stated food from home should be stored at the resident's refrigerator located at the dining area. The DSD stated the policy on residents outside food storage is communicated through in-service to staff and stated the signature is the confirmation. During a review of the facility's recent policy and procedure (P&P) titled Outside Food Resident/Freezer Storage, last review date on 4/16/2025, the P&P indicated: POLICY This policy was created to increase compliance with diet orders, promote food intake, and promote safe and sanitary storage, handling, and consumption of outside foods. PROCEDURE The facility will maintain one refrigerator and freezer for resident use. 2.During a concurrent observation and interview on 8/13/2025, at 3:57 p.m., with the Activities Director (AD), in the dining area, observed the resident' refrigerator for food brought from home with the temperature of 46 degrees F and six pack of unopened box of milk yoghurt. The AD stated that she is responsible for checking the temperature and food contents of the residents' refrigerator food brought from home. The AD stated that the temperature should be 40 degrees F and below and if it is above 40 degrees, they are supposed to report it to the maintenance supervisor. The AD also stated the food brought from home should be labeled with name, room number and the date it was received. The AD stated the six packs of milk yoghurt is expired, the expiry date was 7/23/2025. The AD stated that she should have reported to the maintenance supervisor that the temperature of the residents' refrigerator was not within normal range, and she should have discarded the expired six packs of milk yoghurt. The AD stated her failure to report the abnormal temperature of the residents' refrigerator and failure to discard the expired six packs of milk yoghurt can cause food borne illness to residents. During an interview on 8/14/2025, at 3 p.m., with the Maintenance Supervisor (MS), The MS stated he is responsible for the weekly temperature check of the resident's refrigerator at the dining area the refrigerator at the dining area and the daily check are performed by the AD. The MS stated he did not get a report from the AD that the residents' refrigerator temperature was 46 degrees F. The MS stated if AD reported the abnormal temperature to him, he could have fixed it right away to prevent the food inside the residents' refrigerator from spoiling. The MS stated, there is a potential for residents to consume the expired food that can cause diarrhea. During an interview and record review on 8/14/2025, at 3:35 p.m., with the Director of Nursing (DON), reviewed the policy and procedure (P&P) for storing resident's food brought from home and photos of resident's refrigerator temperature and contents taken on 8/13/2025, at 4:03 p.m. The DON stated the temperature of the residents' refrigerator is 46 degrees F and there is expired six packs of milk yoghurt. The DON stated the AD is responsible for monitoring the temperature of the residents' refrigerator in the dining room daily and to report to the MS if there is an abnormal temperature. The DON also stated the AD should have discarded the expired six packs of milk yoghurt in the refrigerator with expiry date of 7/23/2025. The DON stated the failure of the AD to report the resident's abnormal refrigerator temperature to the MS and failure to discard the expired six packs of milk yoghurt could cause residents to have food borne illnesses. During a review of the facility's recent P&P titled Outside Food Resident/Freezer Storage, last reviewed on 4/16/2025, the P&P indicated: POLICY This policy was created to increase compliance with diet orders, promote food intake, and promote safe and sanitary storage, handling, and consumption of outside foods. PROCEDURE Activity staff/ designee will check the inside temperature of the Refrigerator and Freezer daily and will initial and record the temperature. If the temperatures are not within appropriate range activity staff/ designee will notify the Maintenance Supervisor and Administrator If the temperatures are not within appropriate range, food may be discarded. Recommended Refrigerator Temperature: 40 degrees F or lower /Freezer Temperature: 0 degrees F or lower. Food items that are expired or beyond the best buy date are discarded.

Based on interview and record review, the facility failed to ensure the resident's right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition for three of three sampled residents (Residents 67, 96, and 13) reviewed for informed consents (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) by failing to ensure: 1.Resident 67's Lorazepam (slowing activity in the brain to allow for relaxation) and Quetiapine (used to treat certain mental health conditions) informed consents indicated the name of the medication, dosage, and frequency of intake. 2.Resident 96's had an informed consent for Remeron (is a type of antidepressant medication used primarily to treat major depressive disorder in adults). 3.Resident 96's Depakote (mood stabilizer) informed consents indicated how the informed consent was verified, indicated the licensed nurses' signature and the date it was verified. 4.Resident 13's use of restraint left-hand mitten (is a soft, padded glove that covers the hands of a patient, particularly those who may be confused or prone to agitation) informed consent indicated the signature of the physician and the date the physician explained the risk and benefits of the use of restraint (devices that limit a patient's movement) left-hand mitten, and how the informed consent was verified by the licensed nurse. These deficient practices had violated the residents` right to be informed of the risk and benefits of the treatments provided to the residents. Findings: 1.During a review of Resident 67's admission Record, the admission Record indicated the facility admitted the resident on 3/8/2025, and readmitted the resident on 7/26/2025, with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), anxiety disorder (a mental health condition characterized by excessive and persistent worry, fear, and nervousness that interferes with daily life), and dementia (a progressive state of decline in mental abilities). During a review of Resident 67's History and Physical (H&P), dated 7/26/2025, the H&P indicated the resident did not have the capacity to make complex healthcare decisions; however, the resident was able to decide for activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) and can make needs known. During a review of Resident 67's Minimum Data Set (MDS, a resident assessment tool), dated 8/2/2025, the MDS indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident was on a high-risk drug class antipsychotic (medications used to treat psychosis, a condition where a person experiences a disconnect from reality) and antianxiety (a type of prescription drug that helps to reduce the symptoms of anxiety and fear, such as intense worry, nervousness, panic, and physical tension) medications. During a review of Resident 67's Order Summary Report, the order Summary Report indicated an order for: 8/10/2025 Lorazepam Tablet 0.5 milligrams (mg, a unit of weight). Give one (1) tablet by mouth every six (6) hours as needed for anxiety for 30 days monitor for behavior (m/b) recurrent outburst of anger, informed consent obtained by MD from RP after explanation of risks and benefits. 7/27/2025 Quetiapine Fumarate Oral Tablet (Quetiapine Fumarate). Give 12.5 mg by mouth two times a day for psychosis (a mental state where there's a disconnect from reality) m/b inability to cope with internal stimuli leading to episodes of stress and frustration. Informed consent obtained by MD from RP after explanation of risks and benefits. During a review of Resident 67's Care Plan (CP) Reports titled Seroquel (Atypical Anti-psychotic, have fewer and less severe side effects). Resident has episodes of psychosis, and Antipsychotic drug/dementia. At risk for complications, last revised on 3/31/2025, the CPs indicated interventions to involve the family in care if possible/available and encourage resident to discuss interest/concerns and notification of physician/responsible party of change of condition (COC). During a review of Resident 67's Informed Consents, dated 7/26/2025, the Informed Consents did not indicate the name of the medication, the dosage, and the frequency of medication intake the staff obtaining consents for. During a concurrent interview and record review on 8/13/2025, at 10:47 a.m., with Registered Nurse (RN) 4, reviewed Resident 67's Order Summary Report, Care Plan, and Informed Consents. RN 4 stated there were two informed consents for psychotropic medications in the resident's chart, but it did not indicate the name of the drug, the dosage, and the frequency of medication intake. RN 4 stated it was important to indicate the name of the drug, the dosage, and the frequency of intake of the medication to know what treatment is being provided for the resident. During an interview on 8/15/2025, at 11:37 a.m., with the Director of Nursing (DON), the DON stated Resident 67's Informed Consents should have the important information written on the consent for psychotropic medications. The DON stated they should include the name of the drug, dose, and frequency of intake of the medication to ensure the resident is well informed of their medication regimen. During a review of the facility's recent policy and procedure (P&P) titled Informed Consent, last reviewed on 4/16/2025, the P&P indicated before initiating the administration of psychotherapeutic drugs or physical restraints, facility staff shall verify that the patient's health record contains documentation that the patient has been given informed consent to the proposed treatment or procedure. 2.During a review of Resident 96's admission Record, the admission Record indicated the facility admitted the resident on 5/9/2011, and readmitted the resident on 6/7/2017, with diagnoses including anxiety disorder, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and mood disorder (a mental health condition characterized by significant and persistent disruptions in a person's emotional state, impacting their ability to function normally in daily life). During a review of Resident 96's H&P, dated 10/18/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 96's MDS, dated [DATE], the MDS indicated the resident rarely to never had the ability to make self-understood and understand others and had severely impaired cognition (refers to a significant decline in a person's mental abilities, affecting their memory, thinking, reasoning, and judgment to the extent that it seriously interferes with daily life and independence). The MDS indicated the resident was on a high-risk drug class antidepressant medication. During a review of Resident 96's Order Summary Report, the Order Summary Report indicated an order for: 8/22/2022 Depakote Sprinkles (Divalproex Sodium). Give 125 mg via gastrostomy tube (g-tube, is a medical device that provides a way to get nourishment and/or medication directly into the stomach, bypassing the mouth and esophagus) in the evening for mood disorder m/b recurrent behavior fluctuations from calm & smiling to irritable & agitated and vice versa. 5/30/2025 Remeron tablet (Mirtazapine). Give 15 mg via g-tube at bedtime for depression m/b persistent weight loss/ loss of appetite. During a review of Resident 96's Informed Consent for Depakote, dated 5/27/2025, the Informed Consent did not indicate the verification of informed consent information (mode of verification, signature of the nurse verifying the consent, title, and the date of verification). There was no Informed Consent for Remeron on the medical chart of Resident 96. During a concurrent interview and record review on 8/12/2025, at 9:30 a.m., with RN 5, reviewed Resident 96's Order Summary Report and Informed Consents. RN 5 stated there was an informed consent for Depakote however, the mode of verification of the informed consent was not signed and dated by licensed staff. RN 5 also stated there was no informed consent for Remeron in Resident 96`s medical chart. RN 5 stated it was important to ensure the informed consents are obtained and complete to ensure the resident is well informed of what treatment they are getting, and they are aware of the risk and benefits of the proposed treatment. During an interview on 8/15/2025, at 11:37 a.m., with the DON, the DON stated Resident 96's Informed Consents should have the important information written on the consent for psychotropic medications. The DON stated they should include the mode of how the licensed nurse verified if the physician explained the risk and benefits of taking the drug regimen. The DON also stated psychotropic medication should have informed consent prior to administering the medication to honor their right to agree or disagree to the proposed treatment. During a review of the facility's recent P&P titled Informed Consent, last reviewed on 4/16/2025, the P&P indicated before initiating the administration of psychotherapeutic drugs or physical restraints, facility staff shall verify that the patient's health record contains documentation that the patient has been given informed consent to the proposed treatment or procedure. 3.During a review of Resident 13's admission Record, the admission Record indicated the facility admitted the resident on 3/1/2019, and readmitted the resident on 5/29/2025, with diagnoses including Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), dementia, and history of falling. During a review of Resident 13's H&P, dated 5/29/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 13's MDS, dated [DATE], the MDS indicated the resident rarely to never had the ability to make self-understood and understand others and had severely impaired cognition. The MDS indicated that the resident had upper extremity impairment and was dependent on mobility and activities of daily living (ADLs). The MDS indicated the resident had limb restraints in bed and on chair. During a review of Resident 13's Order Summary Report, dated 5/30/2025, the Order Summary Report indicated an order to monitor behavior episodes of attempting to pull on life sustaining equipment every (q) shift and tally by hashmark. Left hand mitten use every shift. During a review of Resident 13's Informed Consent for left hand mitten, dated 5/29/2025, the Informed Consent did not indicate the physician's signature and date the physician spoke to the resident regarding the risk and benefit of applying the restraint and the verification of how the licensed nurse verified the informed consent with the resident or representative. During a concurrent interview and record review on 8/13/2025, at 1:31 p.m., with Licensed Vocational Nurse (LVN) 5, reviewed Resident 13's Order Summary Report and Consent. LVN 5 stated the informed consent did not indicate the physician's signature and date the physician spoke to the resident regarding the risk and benefit of applying the restraint and the verification of how the licensed nurse verified the informed consent with the resident or representative. LVN 5 stated it was important to ensure the doctor signed and dated the consent to ensure the risk and benefits of applying the restraint was explained to the resident or representative. LVN 5 stated it is important to indicate how the licensed nurse verified the consent with the resident or representative to ensure the resident consented to the treatment plan. During an interview on 8/15/2025, at 11:37 a.m., with the DON, the DON stated Resident 13's informed consent should have the important information written on the consent for the use of restraint left hand mitten. The DON stated they should include the mode of how the licensed nurse verified if the physician explained the risk and benefits of taking the drug regimen. The DON also stated the physician should sign and date the informed consent to attest that the physician obtained a consent on the use of the restraint left hand mitten by explaining the risk and benefit of the proposed treatment. During a review of the facility's recent P&P titled Informed Consent, last reviewed on 4/16/2025, the P&P indicated before initiating the administration of psychotherapeutic drugs or physical restraints, facility staff shall verify that the patient's health record contains documentation that the patient has been given informed consent to the proposed treatment or procedure.

Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs and preferences by failing to ensure the pad call light (a specialty alerting device that have ultra-sensitive touch surface for patients with limited mobility for nurses or other nursing personnel to assist a patient when in need) was within reach for three (3) of six (6) sampled residents (Residents 41, 148, and 158) reviewed under the environment task. This deficient practice had the potential to result in a delay of care and services and possible injury to residents when they are unable to call for assistance. Findings: a. During a review of Resident 158's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility originally admitted the resident on 6/6/2024, and readmitted in the facility on 4/7/2025, with diagnoses including dependence on respirator (also known as ventilator - a machine used to help a person breath when they are unable to do so on their own) status , contracture of muscle multiple sites, and type two (2) diabetes mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 158's History and Physical (H&P) dated 4/8/2025, the H&P indicated Resident 158 was incapacitated (refers to a person's inability to manage their own affairs due to physical or mental limitations). During a review of Resident 158's Minimum Data Set (MDS, a resident assessment tool), dated 6/13/2025, the MDS indicated Resident 158 had an intact cognition (mental action or process of acquiring knowledge and understanding) and was able to understand and make his needs known. The MDS further indicated Resident 158 required supervision or touching assistance with eating and total assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 158's fall risk assessments dated 12/9/2024, 3/18/2025, and 4/7/2025, the fall risk assessments indicated Resident 158 was at a high risk for falls. During a review of Resident 158's care plan (CP) on risk for falls or injury initiated on 7/17/2024, the CP indicated to keep call light within easy reach and encourage resident to use it to get assistance as one of the interventions to reduce the risk of falls and injury daily. During a concurrent observation and interview on 8/11/2025 at 9:47 a.m. inside Resident 158's room, observed Resident 158 lying in bed, awake, alert, responding by mouthing words. Resident 158 stated he was unable to find his call light, and he did not know where it was placed. During a concurrent observation and interview on 8/11/2025 at 9:49 a.m. inside Resident 158's room with Licensed Vocational Nurse (LVN) 9, LVN 9 stated Resident 158's call light was placed under the draw sheet, and the resident was unable to reach for the call light. LVN 9 stated after providing care to the residents, the staff have to ensure the residents' call light, and all frequently used items are within the residents' reach at all times prior to leaving the room. LVN 9 stated Resident 158's call light should have been placed within reach so Resident 158 would be able to call for assistance when needed as it placed Resident 158 at risk for his needs not being attended and met timely. During an interview on 8/15/2025 at 9:50 a.m. with Registered Nurse (RN) 2, RN 2 stated staff are supposed to ensure that the call lights are placed within the residents' reach after providing care and prior to leaving the room. RN 2 stated Resident 158's call light should have been placed within reach and not under the draw sheet as the resident was unable to see where the call light was. RN 2 stated if the call light was not within Resident 158's reach, the resident would not be able to call for assistance when needed and there could be a delay in providing assistance and meeting Resident 158's needs. During a review of the facility's policy and procedure (P&P) titled, Call Lights, last reviewed on 4/16/2025, the P&P indicated a purpose to assure resident received prompt assistance. The P&P further indicated that all staff shall ensure that the call light is within the resident's reach when in his/her room or when in the toilet and monitoring the lights and making sure that lights are answered promptly, regardless of who is assigned to each resident. b. During a review of Resident 148's admission Record, the admission Record indicated Resident 148 was originally admitted in the facility on 12/13/2024, and readmitted in the facility on 2/15/2025, with diagnoses including psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), tracheostomy (a surgical opening in the neck into the windpipe when a person is unable to breathe thru the nose or mouth), and anxiety disorder (a mental health condition where excessive fear and worry interfere with daily life, causing significant distress). During a review of Resident 148's History and Physical (H&P) dated 2/16/2025, the H&P indicated Resident 148 was incapacitated (refers to a person's inability to manage their own affairs due to physical or mental limitations). During a review of Resident 148's MDS assessment dated [DATE], the MDS assessment indicated Resident 148 was unable to understand others and make her needs known and had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 148 required total assistance from staff with all activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 148's fall risk assessments dated 3/5/2025 and 6/3/2025, the fall risk assessments indicated Resident 148 was at a high risk for falls. During a review of Resident 148's care plan (CP) on risk for falls or injury initiated on 3/24/2025, the CP indicated to attach call light to bed within access of resident as one of the interventions to reduce the risk of falls and injury daily. During an observation on 8/11/2025 at 10:56 a.m. inside Resident 148's room, observed Resident 148 lying in bed, asleep. Observed Resident 148's call light was placed on top of the overhead light. During a concurrent observation and interview on 8/11/2025 at 11:46 a.m. inside Resident 148's room, with Certified Nursing Assistant (CNA) 5, CNA 5 stated Resident 148's call light was placed on top of the overhead light away from Resident 148 and was unable to reach for the call light. CNA 5 stated after providing care to the residents, the staff have to ensure the residents' call light, and all frequently used items are within the residents' reach at all times prior to leaving the room. CNA 5 stated Resident 148's call light should have been placed within reach so Resident 148 can call for assistance when needed as it placed Resident 148 at risk for her needs not being attended to and met timely. During an interview on 8/15/2025 at 9:50 a.m. with Registered Nurse (RN) 2, RN 2 stated staff are supposed to ensure that the call lights are placed within the residents' reach after providing care and prior to leaving the room. RN 2 stated Resident 148's call light should have been placed within reach and not on top of the overhead light as the resident. RN 2 stated if the call light was not within Resident 148's reach, the resident would not be able to call for assistance when needed and there could be a delay in providing assistance and meeting Resident 148's needs. During a review of the facility's policy and procedure (P&P) titled, Call Lights, last reviewed on 4/16/2025, the P&P indicated a purpose to assure resident received prompt assistance. The P&P further indicated that all staff shall ensure that the call light is within the resident's reach when in his/her room or when in the toilet and monitoring the lights and making sure that lights are answered promptly, regardless of who is assigned to each resident. c. During a review of Resident 41's admission Record, the admission Record indicated the facility originally admitted the resident on 1/24/2023, and readmitted in the facility on 5/22/2025, with diagnoses including respiratory failure (a condition that occurs when the lungs cannot remove all of the carbon dioxide [a colorless, odorless gas that the body breathes out] the body produces), tracheostomy (a surgical opening in the neck into the windpipe when a person is unable to breathe thru the nose or mouth), and neurogenic bladder (lack bladder control due to a brain, spinal cord or nerve problem). During a review of Resident 41's History and Physical (H&P) dated 7/9/2025, the H&P indicated Resident 41 did not have the capacity to understand and make decisions. During a review of Resident 41's Minimum Data Set, dated [DATE], the MDS indicated Resident 41 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and was unable to understand others and make her needs known. The MDS further indicated Resident 41 required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 41's fall risk assessments dated 10/23/2024, 1/22/2025, 4/22/205, 7/8/2025, 7/22/2025, the fall risk assessments indicated Resident 41 was at a high risk for falls. During a review of Resident 41's care plan (CP) on risk for falls or injury initiated on 7/10/2024, the CP indicated to keep call light within easy reach and encourage resident to use it to get assistance as one of the interventions to reduce the risk of falls and injury daily. During a concurrent observation and interview on 8/11/2025 at 12:51 p.m., inside Resident 41's room with LVN 8, observed Resident 41 lying in bed and turned to the right side. LVN 8 stated Resident 41's call light was hanging over the left side rail and was not within the resident's reach as Resident 41 was facing away from the call light. LVN 8 stated after providing care to the residents, the staff have to ensure the residents' call light, and all frequently used items are within the residents' reach at all times prior to leaving the room. LVN 8 stated Resident 41's call light should have been placed within reach so Resident 41 can call for assistance when needed as it placed Resident 41 at risk for her needs not being attended to and met timely. During an interview on 8/15/2025 at 9:50 a.m. with Registered Nurse (RN) 2, RN 2 stated staff are supposed to ensure that the call lights are placed within the residents' reach after providing care and prior to leaving the room. RN 2 stated Resident 41's call light should have been placed within reach and not over the left side rail. RN 2 stated if the call light was not within Resident 41's reach, the resident would not be able to call for assistance when needed and there could be a delay in providing assistance and meeting Resident 41's needs. During a review of the facility's policy and procedure (P&P) titled, Call Lights, last reviewed on 4/16/2025, the P&P indicated a purpose to assure resident received prompt assistance. The P&P further indicated that all staff shall ensure that the call light is within the resident's reach when in his/her room or when in the toilet and monitoring the lights and making sure that lights are answered promptly, regardless of who is assigned to each resident.

Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for five of seven sampled residents (Residents 76, 6, 148, 51, and 79) reviewed for physical restraints care area by failing to: 1.Ensure Resident 76's use of tab alarm (a simple device designed to alert staff when a resident attempts to get out of bed or a chair without assistance) was assessed quarterly for appropriateness of use per facility policy and procedure. 2.Ensure Resident 6 did not have rolled pillows tucked under the resident's fitted sheet on both sides. 3.Ensure Resident 148 had a physician's order, informed consent, complete a restraint assessment, and develop and implement a care plan for the use of left-hand mitten (a large, soft glove that covers a patient's hand to prevent from inadvertently dislodging medical equipment). 4.Ensure Resident 51 did not have a pillow under the fitted sheet to his right side and a wedge pillow (a triangular-shaped pillow that elevates one side of the body) under the fitted sheet to his left side while in bed. 5.Conduct a Physical Restraint Assessment for Resident 79, obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered), and a physician's order prior to the use of a Geri chair (a type of adjustable, reclining wheelchair that may prevent a resident from rising independently) then, develop and implement a Geri chair care plan (CP, a written course of action that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs). The deficient practices had the potential to result in the restriction of residents' freedom of movement, a decline in physical functioning and psychosocial harm of the residents. Findings: 1.During a review of Resident 76's admission Record, the admission Record indicated the facility admitted the resident on 12/19/2024, with diagnoses including presence of cardiac pacemaker (used to control or increase the heartbeat), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), and dementia (a progressive state of decline in mental abilities). During a review of Resident 76's History and Physical (H&P), dated 12/21/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 76's Minimum Data Set (MDS, a resident assessment tool), dated 6/8/2025, the MDS indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident was dependent to needing partial assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). The MDS indicated that the resident had a bed and chair alarm (alert caregivers when someone at risk of falling tries to get out of bed or a chair without help). During a review of Resident 76's Order Summary Report, the Order Summary Report indicated an order for: -12/19/2024 Tab alarm when in bed and wheelchair to alert staff/remind resident to ask for assistance when transferring or ambulating. Ensure equipment is in place and functioning properly. Every shift. -7/24/2025 Support & Safety Device- low bed (a bed frame or mattress set that is closer to the floor compared to standard bed frames) to decrease potential injury. Ensure equipment is in place and functioning properly. During a review of Resident 76's Fall Risk Evaluation, dated 7/24/2025, the Fall Risk Evaluation indicated the resident was at moderate risk for falls. During a review of Resident 76's Care Plan (CP) Report titled Tab Alarm, last revised on 1/9/2025, the CP indicated an intervention to assess need to use device quarterly or as needed. During a concurrent observation and interview on 8/11/2025, at 9:33 a.m., with Certified Nursing Assistant (CNA) 8, inside Resident 76's room, observed Resident 76's bed in the lowest position and had a tab alarm on. CNA 8 stated the resident`s bed had a tab alarm to prevent the resident from getting out of bed without assistance and to prevent falls. During a concurrent interview and record review on 8/13/2025, at 11:33 a.m., with Licensed Vocational Nurse (LVN) 5, reviewed Resident 76's Medical Diagnosis, Order Summary Report, Fall Risk Evaluation, Restraint-Physical (Quarterly/Annual Evaluation), and Care Plan. LVN 5 stated the resident had an order for Tab Alarm. LVN 5 stated that the Tab Alarm was used to prevent the resident from getting out of bed without assistance. LVN 5 stated the use of Tab Alarm is a physical restraint. LVN 5 stated the Restraint-Physical (Quarterly/Annual Evaluation) was last done on 3/26/2025. LVN 5 stated the Restraint-Physical (Quarterly/Annual Evaluation) should have been done quarterly to ensure the Tab Alarm is still indicated for the resident as it keeps the resident in bed and had the potential for residents to physical deconditioning (the decline in physical fitness and function that occurs due to prolonged inactivity). LVN 5 also stated the CP indicated to evaluate the use of the restraint Tab Alarm quarterly. During an interview on 8/15/2025, at 11:37 a.m., with the Director of Nursing (DON), the DON stated Resident 76's use of Tab Alarm should have been reassessed quarterly to ensure its appropriate use. The DON stated the Tab Alarm is the least restrictive form of restraint as it lets the resident move around in bed. However, it limits their movements in bed and not letting them get out in bed and walk as it will trigger an alarm when the resident pulls the cord attached to his gown. The DON stated the use of Tab Alarm should be assessed quarterly and as needed by licensed staff. The DON stated the facility missed one quarter of Restraint-Physical Evaluation. The DON stated the missed Restraint-Physical Evaluation could potentially result to resident physical deconditioning due to confining the resident in bed with minimal range of motion (ROM, how far you can move a joint or a body part, like an arm or leg, without pain or discomfort) and activity. During a review of the facility's recent policy and procedure (P&P) titled Resident Assessment, last reviewed on 4/16/2025, the P&P indicated the Minimum Data Set shall be completed for each resident regardless of payer status in facilities certified by the Medicare/Medicaid programs. Guidelines 3. Schedule and Completion of the MDS: Assessment (admission, quarterly, annual, significant change) will be completed as per RAI instructions/guidelines. During a review of the facility-provided Information on Tab Alarm (TA) 1 copyright 2018, indicated TA 1 improves patient safety by alerting caregivers when a patient attempts to get out of a wheelchair or bed without assistance. WARNING: 1.Long pull cord can entangle the patient and be potentially dangerous. Use with care and supervision. 2.This product is not intended as a substitute for appropriate periodic visual patient/resident monitoring techniques. This product is only intended to supplement standard patient/resident monitoring techniques currently in use. 2.During a review of Resident 6's admission Record, the admission Record indicated the facility originally admitted Resident 6 on 3/11/2025 and readmitted on [DATE], with diagnoses including respiratory failure (a condition that occurs when the lungs cannot remove all of the carbon dioxide [a colorless, odorless gas that the body breathes out] the body produces), tracheostomy (a surgical opening in the neck into the windpipe when a person is unable to breathe thru the nose or mouth), and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 6's History and Physical (H&P) dated 6/5/2025, the H&P indicated Resident 6 did not have the capacity to understand and make decisions. During a review of Resident 6's MDS assessment dated [DATE], the MDS assessment indicated Resident 6 had severely impaired cognition (mental action or process of acquiring knowledge and understanding), required total assistance from staff with all activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves), and had impairment on BUE and BLE. During a review of Resident 6's Order Summary Report dated 7/31/2025, the Order Summary Report did not indicate a physician's order for the use of pillows tucked under the fitted sheet. During a review of Resident 6's fall risk evaluation dated 3/1/2025, the fall risk evaluation indicated Resident 6 was at a high risk for falls. During a review of Resident 6's care plan (CP) on risk for falls initiated on 3/24/2025, the CP indicated frequent visual monitoring as one of the interventions to reduce risk of falls and/or injury. During an observation on 8/11/2025 at 9:17 a.m., inside Resident 6's room, observed Resident 6 lying in bed with rolled pillows tucked under the fitted sheet. During a concurrent observation and interview on 8/11/2025 at 9:31 a.m. inside Resident 6's room with Licensed Vocational Nurse (LVN) 11, LVN 11 stated Resident 6 had rolled pillows tucked under the fitted sheet. LVN 11 stated rolled pillows are utilized for repositioning the residents and are supposed to be placed on top of the fitted sheet. LVN 11 stated the rolled pillows should not have been tucked under Resident 6's fitted sheet as the resident was unable to remove the pillows by himself and is considered a restraint. LVN 11 stated use of pillows tucked under the fitted sheet is not acceptable practice in the facility. During a concurrent observation and interview on 8/1/2025 at 9:35 a.m. inside Resident 6's room with Certified Nursing Assistant (CNA) 11, CNA 11 stated Resident 6 had rolled pillows tucked under the fitted sheet. CNA 11 stated rolled pillows are used to reposition the residents and are supposed to be placed on top of the fitted sheet. CNA 11 stated the rolled pillows should not have been tucked under Resident 6's fitted sheet as the resident was unable to remove the pillows by himself and is considered a restraint. CNA 11 stated use of pillows tucked under the fitted sheet is not acceptable practice in the facility. During an interview on 8/14/2025 at 11:16 a.m. with Registered Nurse (RN) 3, RN 3 stated pillows are used for the residents for turning and repositioning. RN 3 stated staff are supposed to place the pillows on top of the fitted sheet and not tucked under the fitted sheet. RN 3 stated placing the pillows under the fitted sheet is considered a restraint as the residents are unable to remove it by themselves. RN 3 stated the rolled pillows should not have been placed under Resident 6' s fitted sheet as the resident was unable to remove the pillows and is considered a restraint. RN 3 stated Resident 6's freedom of movement is restricted when pillows are placed under the fitted sheet on both sides. During an interview on 8/15/2025 at 11:45 a.m. with the Director of Nursing (DON), the DON stated that pillows are supposed to be placed on top of the fitted sheet for turning and repositioning of residents. The DON stated it is considered a restraint if the pillows are placed under the fitted sheet as the resident is unable to remove the pillows and is restricting the resident's freedom of movement. The DON stated the pillows should not have been placed under Resident 6's fitted sheet on both sides as the resident was unable to remove the pillows by himself and restricting Resident 6's freedom of movement. During a review of the facility's policy and procedure (P&P) titled, Physical Restraints, last reviewed on 4/16/2025, the P&P indicated: -Physical Restraints are any manual method, or physical or mechanical device, material or equipment attached to or adjacent to the resident's body that the individual cannot remove easily, and which restrict freedom of movement or normal access to the use of one's body. -The licensed nurse shall be responsible for obtaining an order from the attending physician, which is to include: 1.Specific type of restraint 2.Purpose of the restraint 3.Time and pace of application 4.Approaches to prevent decrease functioning when applicable 5.Informed consent obtained from resident or from surrogate decision-maker. -The plan of care shall specify the reason for the use of the restraint, the type, when and where it is to be used. -A restraint shall be applied on such a manner that speedy removal is possible in the event of a fire of another emergency. 3.During a review of Resident 148's admission Record, the admission Record indicated the facility originally admitted Resident 148 on 12/13/2024 and readmitted on [DATE], with diagnoses including psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), tracheostomy (a surgical opening in the neck into the windpipe when a person is unable to breathe thru the nose or mouth), and anxiety disorder (a mental health condition where excessive fear and worry interfere with daily life, causing significant distress). During a review of Resident 148's H&P dated 2/16/2025, the H&P indicated Resident 148 was incapacitated (refers to a person's inability to manage their own affairs due to physical or mental limitations). During a review of Resident 148's MDS assessment dated [DATE], the MDS assessment indicated Resident 148 was unable to understand others and make her needs known and had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 148 required total assistance from staff with all activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS further indicated that Resident 148 received antianxiety medications. During a review of Resident 148's Order Summary Report dated 7/31/2025, the Order Summary Report did not indicate a physician's order for the use of left-hand mitten. The Order Summary Report further indicated a physician's order dated 2/14/2025 for left freedom splint (soft splints that help restrict elbow and knee movement keep patients from accidentally pulling out important medical tubes) to prevent resident from attempting to pull on life sustaining tubes. During a review of Resident 148's fall risk evaluation dated 3/5/2025 and 6/3/2025, the fall risk evaluations indicated Resident 148 was at a risk for falls. During a review of Resident 148's care plan (CP) titled, Physical restraint in use, initiated on 12/14/2024, the CP did not indicate the use of left-hand splint. During an observation on 8/11/2025 at 10:56 a.m., 8/12/2025 at 7:40 a.m., and 8/13/2025 at 7:45 a.m., inside Resident 148's room, observed Resident 148 lying in bed with left-hand mitten on. During a concurrent observation and interview on 8/13/2025 at 7:45 a.m. with Registered Nurse (RN) 2, RN 2 stated Resident 148 had left-hand mitten on as the resident had multiple episodes of attempting to pull on life sustaining tubes. RN 2 stated the family was aware and the mitten was a family preference for Resident 148's safety. During a concurrent interview and record review on 8/13/2025 at 1:39 p.m. reviewed Resident 148's physician's order, informed consents, restraint assessments, and care plan with RN 3. RN stated Resident 148 did not have a physician's order for the use of left-hand mitten, there was no informed consent, care plan, and restraint assessment completed prior to application of the left-hand mitten. RN 3 stated Resident 148's daughter previously preferred left-hand mitten and now had changed preference to left freedom splint. RN 3 stated prior to the application of any restraint, the licensed nurse (LN) is supposed to obtain a physician's order, informed consent, complete a restraint assessment, and develop and implement a care plan. RN 3 stated the LN should have obtained a physician's order, informed consent from Resident 148's family, complete a restraint assessment, and develop a care plan prior to the application of left-hand mitten on Resident 148 for safety. During an interview on 8/15/2025 at 11:45 a.m. with the DON, the DON stated prior to application of restraints, the staff are supposed to try the least restrictive measures first. The DON stated if the least restrictive measures did not work, the LN is supposed to obtain an order from the physician for the type of restraint needed and the reason for the restraint, confirm informed consent from the family with explanation of risks and benefits to give them a chance to decline or agree with the plan, complete a restraint assessment to ensure the appropriate type of restraint is used, and develop a care plan to ensure all the staff involved in the resident care is aware of the type of restraint to be used. During a review of the facility's policy and procedure (P&P) titled, Physical Restraints, last reviewed on 4/16/2025, the P&P indicated: -Physical Restraints are any manual method, or physical or mechanical device, material or equipment attached to or adjacent to the resident's body that the individual cannot remove easily, and which restrict freedom of movement or normal access to the use of one's body. -The licensed nurse shall be responsible for obtaining an order from the attending physician, which is to include: 1.Specific type of restraint 2.Purpose of the restraint 3.Time and pace of application 4.Approaches to prevent decrease functioning when applicable 5.Informed consent obtained from resident or from surrogate decision-maker. -The plan of care shall specify the reason for the use of the restraint, the type, when and where it is to be used. -A restraint shall be applied on such a manner that speedy removal is possible in the event of a fire of another emergency. During a review of the facility's P&P titled, Informed Consent, last reviewed 4/16/2025, the P&P indicated the facility will verify that the patient's health record contains documentation that the patient has given informed consent before initiating a physical restraint. The P&P further indicated: -Before initiating the administration of physical restraints, facility staff shall verify that the patient's health record contains documentation that the patient has given informed consent to the proposed treatment or procedure. -The attending physician is responsible for determining what information is necessary to obtain informed consent when a physician restraint is ordered. And disclosing the risks of the proposed treatment or procedure. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, last reviewed on 4/16/2025, the P&P indicated a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The P&P further indicated: -The comprehensive person-centered care plan: 1.Includes measurable objectives and timeframes 2.Describes the services that are to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being including: (3) which professional services are responsible for each element of care -Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision-making. -Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. 4.During a review of Resident 51's admission Record, the admission Record indicated the facility originally admitted the resident on 9/7/2024 and readmitted the resident on 5/3/2025, with diagnoses including but not limited to, acute respiratory failure (a condition where the lungs cannot release enough oxygen into the blood) and nontraumatic intracerebral hemorrhage (bleeding inside the brain tissue) in the brain stem (posterior stalk-like part of the brain that connects the cerebrum with the spinal cord). During a review of Resident 51's History and Physical, dated 5/4/2025, the History and Physical indicated the resident was bedbound with limited function. During a review of Resident 51's MDS dated [DATE], the MDS indicated Resident 51 had severely impaired cognitive (relating to or involving the processes of thinking and reasoning) skills for daily decision making and was dependent on staff for all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a concurrent observation and interview on 8/11/2025 at 9:31 a.m. with Licensed Vocational Nurse (LVN) 11 at Resident 51's bedside, Resident 51 had a pillow under the fitted sheet to his right side and a wedge pillow under the fitted sheet to his left side while in bed. LVN 11 stated pillows should not be tucked under the fitted sheet, they should be placed on top of the fitted sheet. LVN 11 stated the pillows under the fitted sheet could be considered a restraint as the resident is unable to remove them by himself. LVN 11 stated they just had an in-service where they reviewed restraints and not to put pillows under fitted sheets. During a concurrent observation and interview on 8/11/2025 at 9:35 a.m. with Certified Nursing Assistant (CNA) 11, CNA 11 stated the pillows should not be under the fitted sheet. CNA 11 stated they just had an in-service about not putting pillows or wedge pillows under the fitted sheet. CNA 11 stated they are considered a restraint as the resident cannot remove the pillow if it is under the fitted sheet. During a review of the Resident 51's medical record on 8/11/2025, the medical record did not indicate an order, assessment, or care plan for the use of pillows under the fitted sheet. During an interview on 8/15/2025 at 10:50 a.m. with the Director of Nursing (DON), the DON stated if a wedge pillow or bolsters (a supportive or cushioning device used for positioning patients) are used they should not be under the resident's fitted sheet. The DON stated if these pillows are under the resident's sheet, they are harder to remove and could restrict the resident's movement. The DON stated if they wanted to use pillows in that way, they would need a proper assessment and physicians order to use them. During a review of the facility's policy and procedure (P&P) titled, Policy: Physical Restraint, last reviewed 4/16/2025, the P&P indicated physical restraints include any material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, and which restrict freedom of movement or normal access to the use of one's body. The P&P indicated a physical restraint assessment should be completed by a licensed nurse with input from the interdisciplinary team. The P&P indicated a licensed nurse should obtain an order from the attending physician for the specific restraint and informed consent from the resident or their representative. 5.During a review of Resident 79's admission Record (AR), the AR indicated the facility admitted the resident on 11/30/2021 and most recently readmitted the resident on 6/20/2025 with diagnoses that included cerebral infarction (CVA-stroke, loss of blood flow to a part of the brain), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) affecting the left nondominant side, lack of coordination, muscle weakness, and history of falls. During a review of Resident 79's MDS dated [DATE], the MDS indicated the resident sometimes was able to understand others and sometimes was able to make themself understood. The MDS further indicated the resident was dependent on staff for toileting, bathing, dressing, personal hygiene, and mobility; and required substantial/maximal assistance for eating. The MDS indicated no chairs preventing rising were used as a physical restraint. During a review of Resident 79's History and Physical (H&P), dated 6/24/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 79's Restraint Physical Evaluation form regarding a low bed with floor mats, dated 6/20/2025, the Restraint Physical Evaluation form indicated the resident had an unsteady gait and attempts to self-transfer. During a review of Resident 79's Fall Risk Evaluation form, dated 7/24/2025, the Fall Risk Evaluation form indicated the resident had a history of 1 to 2 falls in the past three months and was a high risk for falls. During a concurrent observation and interview on 8/11/2025 at 11:45 a.m., observed Resident 79 in the dining room in a Geri chair. Observed the resident's feet and legs elevated to hip height with the back of the chair fully reclined placing the resident in a laying position. Resident 79 stated that he (Resident 79) was not comfortable. During a concurrent observation and interview on 8/13/2025 at 11:14 a.m., observed Resident 79 in the dining room in a Geri chair. Observed the resident's feet and legs elevated to hip height with the back of the chair fully reclined placing the resident in a laying position. Resident 79 stated he (Resident 79) did not like being in the Geri chair in the reclining position with the feet up. Resident 79 stated Resident 79 wanted to sit up, but Resident 79 could not sit up. Observed Resident 79 was able to move the right leg and right arm. During an interview on 8/13/2025 at 11:21 a.m. with Restorative Nursing Assistant (RNA) 1, RNA 1 stated Resident 79 was placed in the Geri chair in the reclined position with the legs up on 8/11/2025 and 8/13/2025 because the resident had left sided weakness and RNA 1 did not want the resident to fall. RNA 1 stated Resident 79 slides in the Geri chair and tries to put the right leg down. RNA 1 stated Resident 79 forgets that Resident 79 cannot stand up and Resident 79 tries to stand with the right leg. During a concurrent interview and record review on 8/13/2025 at 11:59 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 reviewed Resident 79's physician orders, informed consents, and Physical Restraint Evaluation forms. LVN 2 stated when a resident is physically restrained it can affect the resident by making the resident feel trapped resulting in psychosocial issues. LVN 2 stated the facility process[TRUNCATED]

Based on interview and record review, the facility failed to ensure the resident's drug regimen was free from unnecessary drugs for three of five sampled residents (Resident 125, 148, and 15) reviewed for unnecessary medications by failing to ensure: 1.Resident 125's Xanax 0.25 milligram (mg, a unit of weight) tablet every six (6) hours as needed for anxiety (a feeling of worry, nervousness, or unease, typically about an event or something with an uncertain outcome) had a 14-day stop date. This deficient practice had the potential to result in use of unnecessary psychotropic drugs (medications that affect your brain and change how you think, feel, and behave) for Resident 125, and can lead to side effect and adverse consequence (refers to the negative or harmful results that follow from a particular action or event) such as a decline in quality of life and functional capacity. 2.Resident 148's Ativan (an antianxiety [a type of psychotropic medications that help reduce feelings of anxiety, fear, and worry] medication) had a physician's order for monitoring for adverse side effects (unwanted or dangerous medication-related side effects). As a result, Resident 148 could have experienced adverse effects related to psychotropic medication (medications that affect brain activities associated with mental processes and behavior) therapy, such as drowsiness, dizziness, constipation, or increased risk of fall, possibly leading to impairment or decline in their mental or physical condition or functional or psychosocial status. 3.Resident 15's antipsychotic medications Seroquel and Risperdal (medications used to treat mental illness) were used for a clear indication as diagnosed and documented in the resident's clinical record. 4.Resident 15's antipsychotic medications Seroquel and Risperdal were not used simultaneously without a clearly documented rationale. The deficient practices of failing to ensure antipsychotic medications were used to treat a resident's specific, diagnosed medical condition and that two antipsychotic medications of the same class were used concurrently without documented clinical rationale increased the risk that Resident 15 could have experienced adverse effects (unwanted or dangerous medication-related side effects) related to psychotropic medication (medications that affect brain activities associated with mental processes and behavior) therapy, such as drowsiness, dizziness, constipation, or increased risk of fall, possibly leading to impairment or decline in their mental or physical condition or functional or psychosocial status. Findings: 1.During a review of Resident 125's admission Record, the admission Record indicated the facility admitted the resident on 8/1/2025, with diagnoses including anxiety disorder (a mental health condition characterized by excessive and persistent worry, fear, and nervousness that interferes with daily life), ataxia (a neurological condition that affects a person's coordination and balance, making it difficult to perform everyday movements like walking, speaking, or writing), and history of falling. During a review of Resident 125's History and Physical (H&P), dated 8/1/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 125's Minimum Data Set (MDS, a resident assessment tool), dated 8/8/2025, the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (normal mental abilities that allow someone to effectively handle the day-to-day demands of life). The MDS indicated the resident was taking a high-risk drug class antianxiety medication (a drug used to treat symptoms of anxiety, such as feelings of fear, dread, uneasiness, and muscle tightness, that may occur as a reaction to stress). During a review of Resident 125's Physician's Order Sheet, dated 8/5/2025, the Physician's Order Sheet indicated an order for Xanax oral tablet 0.25 mg (Alprazolam), give 0.25 mg by mouth every six (6) hours as needed for anxiety monitor for behavior (m/b) recurrent feelings of worrying regarding health. The Physician's Order Sheet indicated that informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) obtained by the physician from Responsible Party (RP) after explanation of risk and benefit. During a review of Resident 125's Care Plan (CP) Report titled Alprazolam (Xanax). At risk for adverse effect from black box med (are prescription drugs that carry the strongest safety warnings the Food and Drug Administration [FDA] can issue), initiated on 8/6/2025, the CP indicated an intervention of before prescribing alprazolam and throughout treatment, assess each patient's risk for abuse, misuse, and addiction; and to reduce the risk of withdrawal reactions, use a gradual taper to discontinue alprazolam or reduce the dosage. During a concurrent interview and record review on 8/13/2025, at 1:36 p.m., with Licensed Vocational Nurse (LVN) 5, reviewed Resident 125's Medical Diagnosis, Order Summary Report, Physician's Order Sheet, Care Plan, and Consents. LVN 5 stated there was an order for Xanax oral tablet 0.25 mg (Alprazolam) every six hours as needed for anxiety, however there was no 14-day stop date on its use, and the physician did not create a progress note on why it did not have an end date. LVN 5 stated it was important to have a 14 day stop date on as needed (PRN) psychotropic medications to evaluate its effectiveness and to ensure the resident is not getting addicted to its use. During an interview on 8/15/2025, at 11:37 a.m., with the Director of Nursing (DON), the DON stated Resident 125's Xanax oral tablet 0.25 mg (Alprazolam) every six hours for anxiety should have a 14 day stop date to force evaluation of the effectiveness of the medication and to prevent prolonged use. The DON stated the failure of the facility to indicate a stop date in the use of Xanax 0.25 mg PRN predisposed the resident to its adverse effects from a black box medication. During a review of the facility's recent policy and procedure (P&P) titled Psychotropic Medication Use, last reviewed on 4/16/2025, the P&P indicated under Policy Interpretation and Implementation 2. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: a. Anti-psychotics; b. Anti-depressants; c. Anti-anxiety medications; and d. Hypnotics. 11. Psychotropic medications are not prescribed on a PRN basis unless that medication is necessary to treat a diagnoses specific condition that is documented in the clinical record. a. PRN orders for psychotropic medications are limited to 14 days. (2) For psychotropic medications that are antipsychotics: PRN orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. 2. During a review of Resident 148's admission Record, the admission Record indicated the facility originally admitted Resident 148 on 12/13/2024, and readmitted in the facility on 2/15/2025, with diagnoses including psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), tracheostomy (a surgical opening in the neck into the windpipe when a person is unable to breathe thru the nose or mouth), and anxiety disorder (a mental health condition where excessive fear and worry interfere with daily life, causing significant distress). During a review of Resident 148's History and Physical (H&P) dated 2/16/2025, the H&P indicated Resident 148 was incapacitated (refers to a person's inability to manage their own affairs due to physical or mental limitations). During a review of Resident 148's MDS assessment dated [DATE], the MDS assessment indicated Resident 148 was unable to understand others and make her needs known and had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 148 required total assistance from staff with all activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS further indicated that Resident 148 received antianxiety medications. During a review of Resident 148's Order Summary Report dated 7/31/2025, the Order Summary Report indicated the following physician's order: -8/1/2025: Ativan oral tablet 0.5 milligrams (mg – a unit of measurement) give one tablet via gastrostomy (GT - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) every six (6) hours as needed for anxiety for 14 days manifested by restlessness leading to shortness of breath. -4/30/2025: Monitor episodes of anxiety manifested by recurrent restlessness leading to shortness of breath and tally by hashmark for Ativan use every shift. During a review of Resident 148's care plan (CP) on periods of anxiety manifested by restlessness leading to shortness of breath at risk for side effects of medication usage initiated on 2/27/2025, the CP indicated to summarize effectiveness and side effects of drug monthly for the physician per psychotropic policy and observe for side effects and document occurrence of side effects per psychotropic policy as a few of the interventions to minimize the risk of adverse side effects of medication use. During a concurrent interview and record review on 8/13/2025 at 10:00 a.m., reviewed Resident 148's physician's order, informed consents, summary of episodes of anxiety, and care plans with Registered Nurse (RN) 3. RN 3 stated Resident 148 had a physician's order for Ativan and behavior monitoring for episodes of anxiety but there was no physician's order for monitoring of the adverse side effects. RN 3 stated if a resident had a physician's order for antianxiety medications, there should also be behavior episodes and side effects monitoring. RN 3 stated there should have been a physician's order for side effects monitoring for Resident 148's use of Ativan. RN 3 stated it was important that residents are monitored for side effects every shift for antianxiety medications to ensure Resident 148 did not experience adverse effects related to the use of Ativan which may lead to a decline in Resident 148's mental or physical condition. During an interview on 8/15/2025 at 11:45 a.m. with the Director of Nursing (DON), the DON stated if the licensed nurse received a physician's order for Ativan, a physician's order should have been obtained as well for monitoring behavior episodes and monitoring adverse side effects every shift. The DON stated she was made aware that there was no physician's order for adverse side effects monitoring for the use of Ativan on Resident 148. The DON stated there should have been a physician's order for monitoring adverse side effects for Resident 148's use of Ativan for the resident's safety that Resident 148 did not experience adverse side effects that were unmonitored which could lead to a decline in resident's physical, mental, or psychological functioning. During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Use, last reviewed on 4/16/2025, the P&P indicated: -Psychotropic medication management includes indications for use, dose, duration, adequate monitoring for efficacy and adverse consequences, and preventing, identifying and responding to adverse consequences. -Residents receiving psychotropic medications are monitored for adverse consequences. 3. During a review of Resident 15's admission Record (a record containing diagnostic and demographic resident information), dated 8/13/2025, the admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including unspecified psychosis (a collection of symptoms indicating a disconnect with reality including auditory or visual hallucinations or delusions.) During a review of Resident 15's History and Physical (H&P- a record of a physician's comprehensive medical examination), dated 7/23/2025, the H&P indicated the resident did not have capacity to understand and make medical decisions. During a review of Resident 15's Order Summary Report (a summary of all active physician's orders), dated 7/31/2025, indicated he was receiving the following antipsychotic medications: 1.Risperdal one milligrams (mg – a unit of measure for mass) via gastrostomy tube (g-tube – a tube surgically implanted into the stomach for the administration of medication and nutrition) two times a day for psychosis manifested by inability to cope with daily living activities causing anger. 2.Seroquel 100 mg via g-tube at bedtime for psychosis manifested by inability to cope with internal stimuli leading to episodes of stress and frustration. During a review of Resident 15's clinical record, it did not contain any record or documentation of Resident 15 displaying symptoms of psychosis such as auditory or visual hallucinations, delusional beliefs, disorganized behavior, thinking, or speech, or lack of emotional expression. Further review of the clinical record indicated there was no documented rationale or clinical justification for the use of Seroquel and Risperdal simultaneously. During an interview on 8/13/2025 at 8:03 a.m. with the Licensed Vocational Nurse (LVN) 4 , LVN 4 stated she is one of the nurses, along with the Certified Nursing Assistants (CNA), who provide direct care to Resident 15 daily. LVN 4 stated common behaviors for this resident are yelling that he doesn't want to be here and resisting care like changing or blood sugar checks. LVN 4 stated sometimes she or the CNAs must come back multiple times before Resident 15 will allow care to be provided. LVN 4 stated Resident 15 is relatively new to this facility and was admitted near the end of July. LVN 4 stated these kinds of behaviors may be a result of him being in a new, unfamiliar setting. LVN 4 stated she has not ever heard this resident talking to people who aren't there, claiming he could see people who weren't there, or verbalizing paranoid beliefs such as people being after him. During an interview on 8/13/2025 at 10:58 a.m. with the Director of Nursing (DON), the DON stated psychosis itself is not a diagnosis, but a collection of symptoms that could stem from a diagnosis of mental illness such as schizophrenia or bipolar disorder, dementia, substance abuse, or possibly other medical issues. The DON stated symptoms of psychosis typically include auditory and/or visual hallucinations, paranoid delusions or delusions of grandeur, disorganized speech or behavior, or having little to no emotional expression or response. The DON stated Resident 15's use of Seroquel and Risperdal for unspecified psychosis is not a sufficient indication for the use of antipsychotic medication as the behaviors assigned to these medications, such as expressions of anger or frustration making his daily care difficult, do not align with symptoms of psychosis. The DON stated behaviors such as expressions of stress, frustration, or anger during the delivery of direct care could be explained by an environmental change, unfamiliar care givers, or simply lacking the capacity to understand his current situation. The DON stated it is inappropriate to use antipsychotic medications simply to make the delivery of direct care easier or more convenient for staff. The DON stated Seroquel and Risperdal are both antipsychotics in the same class. The DON stated it was not clear from Resident 15's clinical record why he needed to use both medications simultaneously. The DON indicated the clinical record did not contain any documentation or a clinical rationale which would explain the therapeutic duplication. The DON stated antipsychotics have a black box warning for use in the elderly to control behaviors because their use for that reason has resulted in residents' deaths. The DON stated the use of antipsychotic medications without an adequate indication or in therapeutic duplication could also cause Resident 15 to experience unnecessary adverse effects such as drowsiness, dizziness, dry mouth, constipation, urinary retention, or movement disorders possibly resulting in a decline in his quality of life. During a review of the facility's undated policy and procedure Psychotherapeutic Medications, the Policy and procedure indicated The use of psychotherapeutic medications shall be kept to a minimum in this facility. These medications are to be used only for specific behaviors by a resident, quantitatively and qualitatively documented by the facility, that cause: a. Danger to Self, b. Danger to other residents or staff, c. Psychotic symptoms (hallucinations, paranoia, delusion) that create frightful distress in the resident. A specific diagnosis, and a specific behavior or thought process justifying the need of psychotherapeutic medications are to be identified in the resident's health record.

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive care plan (CP, a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs) by failing to: 1.Develop and implement a CP for the use of a Geri chair (a type of adjustable, reclining wheelchair that may prevent a resident from rising independently) for one of six sampled residents (Resident 79) reviewed during the Physical Restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) care area. 2. Develop and implement a CP for a resident wearing bilateral hand mitts (soft, padded mittens used in healthcare settings to prevent patients from interfering with medical devices, dressings, or treatment) for one of six sampled residents (Resident 66) reviewed under the Physical Restraints care area. 3. Develop and implement a CP for the use of an antianxiety medication (a type of psychotropic medications that help reduce feelings of anxiety, fear, and worry) for one (1) of the five (5) sampled residents (Resident 148) reviewed for psychotropic medications (a class of medications used to treat mental health conditions by aiming to alter mood, behavior, perception, and thought processes). 4. Develop and implement a CP for the resident's use of restraint bed placed against the wall for one of six sampled residents (Resident 96) reviewed for physical restraints. 5. Implement a CP for a resident who was identified at risk for pressure ulcer/injuries (a skin and tissue injury caused by prolonged pressure on the skin, often over bony areas) for one of four sampled residents (Resident 10) reviewed for pressure ulcer. These deficient practices had the potential to result in miscommunication among interdisciplinary staff, residents, and resident representatives resulting in a delay of necessary care and services. Findings: a. During a review of Resident 79's admission Record (AR), the AR indicated the facility admitted the resident on 11/30/2021, and most recently readmitted the resident on 6/20/2025, with diagnoses that included cerebral infarction (CVA-stroke, loss of blood flow to a part of the brain), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) affecting the left nondominant side, lack of coordination, muscle weakness, and history of falls. During a review of Resident 79's Minimum Data Set (MDS – resident assessment tool) dated 6/27/2025, the MDS indicated the resident sometimes was able to understand others and sometimes was able to make themself understood. The MDS further indicated the resident was dependent on staff for toileting, bathing, dressing, personal hygiene, and mobility; and required substantial/maximal assistance for eating. The MDS indicated no chairs preventing rising were used as a physical restraint. During a review of Resident 79's History and Physical (H&P), dated 6/24/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a concurrent observation and interview on 8/11/2025 at 11:45 a.m., observed Resident 79 in the dining room in a Geri chair. Observed the resident's feet and legs elevated to hip height with the back of the chair fully reclined placing the resident in a laying position. Resident 79 stated Resident 79 was not comfortable. During a concurrent observation and interview on 8/13/2025 at 11:14 a.m., observed Resident 79 in the dining room in a Geri chair. Observed the resident's feet and legs elevated to hip height with the back of the chair fully reclined placing the resident in a laying position. Resident 79 stated Resident 79 did not like being in the Geri chair in the reclining position with the feet up. Resident 79 stated Resident 79 wanted to sit up, but Resident 79 could not sit up. During an interview on 8/13/2025 at 11:21 a.m. with Restorative Nursing Assistant (RNA) 1, RNA 1 stated Resident 79 was placed in the Geri chair in the reclined position with the legs up on 8/11/2025 and 8/13/2025 because the resident had left side weakness and RNA 1 did not want the resident to fall. During an interview on 8/13/2025 at 11:59 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 79 had a stroke and has been in a Geri chair ever since returning from the hospital on 6/20/2025. During an interview and record review on 8/13/2025 at 4:01 p.m. with the Director of Nursing (DON), the DON reviewed Resident 79's CPs and the facility policy and procedures (P&P) regarding Geri chairs and care plans. The DON stated Geri chairs may be used in the facility, but there was a process to follow to ensure the correct use of the device and the safety of the residents. The DON stated a CP is developed and implemented for the Geri chair. The DON stated CPs are resident centered plans of care developed by the interdisciplinary team and family that include interventions that are reviewed quarterly and as needed. The DON stated without a CP for the use of the Geri chair, staff may not be able to execute interventions for the use of the Geri chair affecting the resident's safety and mobility. The DON stated, for example, a resident may need a Geri chair for safety due to a lack of trunk control, but without a Geri chair CP, staff may put the resident in a regular wheelchair, resulting in a fall. The DON stated Resident 79 did not have a CP for the use of the Geri chair but should have. The DON stated that the facility P&P was not followed for Resident 79's use of the Geri chair potentially leading to a physical decline in the resident. During a review of the facility P&P titled, Geri Chair Use When Not a Restraint, last reviewed 4/16/2025, the P&P indicated geriatric chairs are not considered a restraint when resident has no voluntary or involuntary movement and cannot transfer independently. Complete CP entry for the use of Geri chair. During a review of the facility P&P titled, Care Plans, last reviewed 4/16/2025, the P&P indicated a comprehensive, person-centered CP that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The CP interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The CP includes: - measurable objectives and timeframes -describes services that are to be furnished -includes the resident's stated goals -builds on the residents' strengths -reflects currently recognized standards of practice for problem areas and conditions. CP interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. Assessments of residents is ongoing, and CPs are revised as information about the resident and the resident's condition change. b. During a review of Resident 66's admission Record, the admission Record indicated the facility originally admitted the resident on 5/22/2024, and readmitted the resident on 8/8/2024, with diagnoses including but not limited to, adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity) and early onset Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities). During a review of Resident 66's H&P, dated 8/8/2025, the H&P indicated the resident had cognitive (relating to or involving the processes of thinking and reasoning) impairment, The H&P indicated to monitor Resident 66 for safety. During a review of Resident 66's MDS, dated [DATE], the MDS indicated Resident 66 had severely impaired cognitive skills for daily decision making and was dependent on staff for all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 66's Order Summary Report, the Order Summary Report indicated the following orders dated 6/30/2025: 1. Left hand mitten to decrease potential injury due to resident behavior of attempting to pull on life sustaining equipment. 2. Right hand mitten to decrease potential injury due to resident behavior of attempting to pull on life sustaining equipment. During a concurrent interview and record review on 8/13/2025 at 2:56 p.m. with Minimum Data Set Nurse (MDSN) 2, Resident 66's care plan titled, Physical restraint in use.LEFT AND RIGHT HAND MITTENS, dated 8/13/2025, was reviewed. MDSN 2 stated she renewed this resident's care plan recently and the resident should have a care plan addressing the bilateral hand mitts. MDSN 2 stated the care plan needs to be there for the safety of the resident, because for example the staff would need to know to check how tight the mitts are and if there is too much pressure on the resident's skin. During an interview on 8/15/2025 at 10:50 a.m. with the DON, the DON stated the care plan should be initiated at the time the hand mitts are ordered. The DON stated the care plan is the overall picture of care and gives the interventions needed for the hand mitts so it should be there when the mitts are applied to the resident. The DON stated the care plan is needed to communicate what the interventions for the hand mitts should be to staff. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, last reviewed 4/16/2025, the policy and procedure indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy and procedure further indicated, Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. c. During a review of Resident 148's admission Record, the admission Record indicated the facility originally admitted Resident 148 on 12/13/2024, and readmitted in the facility on 2/15/2025, with diagnoses including psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), tracheostomy (a surgical opening in the neck into the windpipe when a person is unable to breathe thru the nose or mouth), and anxiety disorder (a mental health condition where excessive fear and worry interfere with daily life, causing significant distress). During a review of Resident 148's H&P dated 2/16/2025, the H&P indicated Resident 148 was incapacitated (refers to a person's inability to manage their own affairs due to physical or mental limitations). During a review of Resident 148's MDS assessment dated [DATE], the MDS assessment indicated Resident 148 was unable to understand others and make her needs known and had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 148 required total assistance from staff with all activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS further indicated that Resident 148 received antianxiety medications. During a review of Resident 148's Order Summary Report dated 7/31/2025, the Order Summary Report indicated the following physician's order: -5/6/2025: buspirone hydrochloride (also known as Buspar, a type of antianxiety medication) tablet five (5) milligrams (mg – a unit of measurement) two (2) times a day for anxiety manifested by pulling on life sustaining tubes. Informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) obtained by the physician from the responsible party after explanation of risks and benefits. -8/8/2025: buspirone hydrochloride tablet 5 mg three (3) times a day for anxiety manifested by pulling on life sustaining tubes. Informed consent obtained by the physician from the responsible party after explanation of risks and benefits. During a concurrent interview and record review on 8/13/2025 at 10 a.m., reviewed Resident 148's physician's order, informed consents, summary of episodes of anxiety, and care plans with Registered Nurse (RN) 3. RN 3 stated Resident 148 had a physician's order for Buspar but there was no care plan developed and implemented when the order was first initiated. RN 3 stated any services the facility was providing for the resident should have a care plan, especially high-risk medications such as psychotropic medications. RN 3 stated Resident 148's care plan addressing the Buspar use should have been developed and implemented as it is the plan of care on how to properly address resident's behavior, so the staff would be aware of the appropriate interventions necessary to prevent delay in meeting Resident 148's needs. During an interview on 8/15/2025 at 3 p.m. with the DON, the DON stated there should be a care plan for each resident to reflect the care the resident is receiving in the facility. The DON stated a care plan is a summary of the interventions, goals, timelines and that care plan is used to communicate interventions, goals to other healthcare providers to ensure residents are provided consistent and high-quality care. The DON stated Resident 148's care plan on the use of Buspar should have been developed and implemented as it placed Resident 148 at risk for a delay in the delivery of the necessary care and services the resident needs. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, last reviewed on 4/16/2025, the P&P indicated a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The P&P further indicated: -The comprehensive person-centered care plan: 1.Includes measurable objectives and timeframes 2. Describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being including: 3. Which professional services are responsible for each element of care -Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision-making. -Assessments of residents are ongoing, and care plans are revised as information about the residents and the resident's conditions change. d. During a review of Resident 96's admission Record, the admission Record indicated the facility admitted the resident on 5/9/2011, and readmitted the resident on 6/7/2017, with diagnoses including epilepsy (a brain disorder that causes recurring seizures), hemiplegia and hemiparesis (is weakness or a decrease in movement on one side of the body), and cerebral infarction. During a review of Resident 96's H&P, dated 10/18/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 96's MDS, dated [DATE], the MDS indicated the resident rarely to never had the ability to make self-understood and understand others and had severely impaired cognition (refers to a significant decline in a person's mental abilities, making it challenging or impossible to carry out everyday tasks independently). The MDS indicated the resident was dependent to needing supervision on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 96's Order Summary Report, the Order Summary Report indicated an order for: 8/28/2024 Bed against the wall secondary to RP preference. Informed consent obtained by MD from RP after explanation of risks and benefits. Every shift. 10/20/2023 [Falling Star Program] Frequent visual monitoring due to high risk for fall and injury. Document every (q) shift. Every shift. During a review of Resident 96's Restraint-Physical (Quarterly/Annual Evaluation), dated 5/20/2025, the Restraint-Physical (Quarterly/Annual Evaluation) indicated the reason for the restraint was for unsteady gait, agitated, aggressive behavior, with hemiplegia and hemiparesis. The Restraint-Physical (Quarterly/Annual Evaluation) also indicated bed against the wall per family preference. During a review of Resident 96's Fall Risk Evaluation, dated 5/20/2025, the Fall Risk Evaluation indicated the resident was at moderate risk for falls. During a concurrent observation and interview on 8/12/2025, at 10:42 a.m., with Certified Nursing Assistant (CNA) 6, inside Resident 96's room, observed Resident 96's bed was placed against the wall at the left side of the resident. CNA 6 stated the bed was placed against the wall per family request and the resident was at risk for falls. During a concurrent interview and record review on 8/13/2025, at 1:45 p.m., with LVN 5, reviewed Resident 96's Medical Diagnosis, Order Summary Report, Restraint-Physical (Quarterly/Annual Evaluation), Fall Risk Evaluation, and Care Plan. LVN 5 stated there was no comprehensive care plan developed and implemented on the use of restraint bed placed against the wall on Resident 96. LVN 5 stated the failure of the facility to develop a comprehensive, person-centered care plan on the use of restraint bed placed against the wall on the resident had the potential for delay in the necessary care and services to the resident. During an interview on 8/15/2025, at 11:37 a.m., with the DON, the DON stated there should be a comprehensive, person-centered care plan on the use of restraint bed placed against the wall on Resident 96 to ensure its safe use. The DON stated the care plan contains the goals, timelines, and the agreed upon interventions the resident needs to safely care for a resident on a restraint. The care plan helps the healthcare team members to provide consistent, high-quality care to residents. During a review of the facility's recent P&P titled Care Plans, Comprehensive Person-Centered, last reviewed on 4/16/2025, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. e. During a review of Resident 10's admission Record (AR), the AR indicated that the facility admitted the resident on 6/2/2025 with diagnoses including unspecified sequelae (the long-term conditions that happen because of an illness or injury) cerebral infarction (stroke - loss of blood flow to a part of the brain ), chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), myocardial infarction type two (heart attack- occurs when the heart muscle doesn't get enough oxygen due to an imbalance between oxygen supply and demand, not caused by a blockage in the coronary arteries {blood vessel supplying blood to the heart}), generalized muscle weakness, and abnormalities of gait (manner of walking) and mobility (movement). During a review of Resident 10's History and Physical (H&P – comprehensive assessment conducted by a healthcare provider that includes gathering a thorough medical history from the resident and performing a physical examination to assess their overall health and identify any potential medical concern), dated 6/2/2025, the H&P indicated Resident 10 did not have the capacity to understand and make decisions. The H&P indicated that Resident 10's integumentary (skin) was intact. During a review of Resident 10's admission Re-assessment, dated 6/3/2025, the admission Re-assessment indicated Resident 10 had left axilla (armpit) mass, and calluses on the right and left feet. During a review of Resident 10's Minimum Data Set (MDS - a resident assessment tool), dated 6/9/2025, the MDS indicated that Resident 10 has the ability to make self understood and has the ability to understand others. The MDS indicated Resident 10 required partial/moderate assistance from staff for bed mobility including rolling to the left and right. The MDS indicated Resident 10 was always incontinent of bowel and bladder. The MDS indicated Resident 10 had no unhealed pressure ulcer but was identified as being at risk for developing pressure ulcers. During a review of Resident 10's Braden Scale (a scoring tool used to predict resident's risk of developing a pressure ulcer, total score ranges from zero {0} to 18. A lower score indicating a higher risk of developing a pressure ulcer.) dated 6/3/2025, timed at 2:18 p.m., the Braden Scale assessment indicated a score of 17, which signifies that Resident 10 is at risk for developing pressure ulcer. During a review of Resident 10's Physician Orders dated 7/31/2025, the Physician Order indicated treatment for Resident 10's MASD to the right and left buttocks extending to the perianal (around the anal {near the anus – opening at the end of the digestive tract, through which solid waste – stool, is expelled from the body} area). The Physician Order indicated to cleanse with normal saline (a mixture of water and salt), pat dry, apply a skin barrier cream, leave open to air every day shift for 30 days. During a review of Resident 10's Physician Orders dated 8/12/2025, the Physician Orders indicated to administer Acetaminophen tablet 325 milligrams (mg - a unit of measurement), give two tablets by mouth every day shift prior to wound care and treatment. During an interview on 8/12/2025 at 2:26 p.m., with Resident 10, Resident 10 stated having a wound on her (Resident 10) back. Resident 10 stated that she (Resident 10) did not have this wound upon admission to the facility. Resident 10 stated that the wound on her (Resident 10) back is starting to hurt, and that she (Resident 10) is in pain. Resident 10 further stated that a staff member (name unknown) applied something to the wound the previous day, but she (Resident 10) was unsure of what was applied. During an interview on 8/12/2025 at 2:30 p.m., with TN 1, TN 1 stated that Resident 10 does not have a wound treatment in place, because Resident 10 only has MASD. TN 1 stated that she (TN 1) has not yet performed the MASD treatment ordered for Resident 10. During a concurrent observation and interview on 8/12/2025 at 2:32 p.m., with TN 1, Certified Nurse Assistant 1 (CNA 1), and Certified Nurse Assistant 2 (CNA 2), at Resident 10's bedside (the place next to a resident's bed), CNA 1 and CNA 2 repositioned Resident 10 onto her (Resident 10) right side to change her (Resident 10) incontinence briefs. Two bordered gauze dressings were observed, one on Resident 10's left buttock and one on Resident 10's sacrococcyx area both without dates and staff initial. TN 1 removed the two bordered gauze dressings and stated Resident 10 has two open wounds. TN 1 stated that she (TN 1) does not know who applied the dressings on Resident 10. TN 1 then exited Resident 10's room. During a concurrent observation and interview on 8/12/2025 at 2:41 p.m., with CNA 1 and CNA 2, at Resident 10's bedside, CNA 1 stated that she (CNA 1) provided care for Resident 10 yesterday (8/11/2025), during the 3 p.m. to 11 p.m. shift, and observed bordered gauze dressings already in place on Resident 10's left buttock and sacrococcyx. CNA 1 stated that she (CNA 1) did not touch or remove the dressings. CNA 2 stated that she (CNA 2) cared for Resident 10 yesterday (8/11/2025), during the 7 a.m. to 3 p.m. shift, and observed a large open wound on Resident 10's sacrococcyx. CNA 2 stated that she (CNA 2) then documented the wound on Resident 10's Daily Body Check Report and notified the charge nurse (Licensed Vocational Nurse 1 {LVN 1). During a concurrent observation and interview on 8/12/2025 at 2:43 p.m., with TN 1, at Resident 10's bedside, TN 1 measured Resident 10's wounds and stated that Resident 10's sacrococcyx wound measured 4.5 centimeters (cm- a unit of measurement) in length by (x) three (3) cm in width, 80% wound bed granulation (the formation of new connective tissue and blood vessels that fill in a wound bed during the proliferative phase of healing), and 20% slough (dead tissue that is usually yellow, tan, gray, or green in color, usually moist and stringy in texture, that may be found in wounds). TN 1 stated that the wound edges were attached, with no signs of undermining (the destruction of tissue or ulcer extending under the skin edges so that the pressure ulcer is larger at its base than at the skin surface). TN 1 stated that the wound on Resident 10's left buttock measured two (2) cm in length x 0.4 cm in width and depth would be considered unstageable (a type of wound that occurs when pressure on the skin causes tissue damage that cannot be accurately assessed or staged due to the presence of necrotic {dead or dying} tissue) because the depth could not be determined. During an observation on 8/13/2025 at 8 a.m., Physician Assistant 1 (PA 1) and TN 1 were at Resident 10's bedside. During an interview on 8/13/2025 at 8:15 a.m., with TN 1, TN 1 stated that PA 1 evaluated Resident 10's wounds and performed excisional debridement (a surgical procedure involving the sharp removal of dead, damaged, or infected tissue from a wound to promote healing) on Resident 10's sacrococcyx wound. TN 1 stated that she (TN 1) then applied Santyl (also known as collagenase, a topical ointment that removes dead tissue from wounds so they can start to heal) to Resident 10's sacrococcyx wound as ordered. TN 1 further stated that she (TN 1) was the staff member who applied the bordered gauze dressings to Resident 10's left buttock and sacrococcyx area yesterday (8/12/2025). During a review of Resident 10's Wound Care Consultation Notes (WCCN) dated 8/13/2025, the WCCN indicated Resident 10 had the following wounds: Sacral, Stage three pressure ulcer, size 4 cm x 2.7 cm x 0.2 cm, wound base granular (a wound in the process of healing) with exposed subcutaneous (under or beneath the skin), 40% slough, 60% granular, and excisional debridement. Left buttock, Stage two pressure ulcer, size 1 cm x 0.4 cm x 0.1 cm, wound base granular with exposed dermis (middle layer of skin in your body). The WCCN indicated the following recommendations: Wound #1, Sacral: to monitor/offload (removing or minimizing the pressure, weight, and force from a specific area of the body, such as a wound or a body part at risk of injury), foam, and Santyl. Wound #2, Left Buttock: to monitor/offload and foam; Zinc cream (medication used to treat and prevent skin irritation) for moisture control, A&D ointment for skin maintenance, every two hours turning at all times while in bed; and apply heel protectors (device used to protect the heel of a resident's foot from pressure ulcers or pain caused by impact and friction) or keep heels floating or with pillows under legs at all times while in bed. During an interview on 8/13/2025 at 8:17 a.m., with LVN 2, LVN 2 stated that she (LVN 2) has not yet started medication administration. LVN 2 stated that she (LVN 2) has not given any medications to Resident 10. LVN 2 further stated that she (LVN 2) plans to administer Resident 10's medications after Resident 10 has eaten and been changed. During an interview on 8/13/2025 at 9:15 a.m., with Resident 10, at Resident 10's bedside, Resident 10 stated that she (Resident 10) is able to move her (Resident 10) legs but is unable to roll her (Resident 10) body to the r[TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure licensed nurses provided care in accordance with professional standards to three of three sampled residents (Residents 4, 13, and 35) reviewed for insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq, beneath the skin) insulin administration sites for Residents 4, 13, and 35. The deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Cross-reference F760 Findings: 1. During a review of Resident 4's AR, the AR indicated the facility admitted the resident on 9/4/2024, and readmitted the resident on 10/27/2024, with diagnoses including type two diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), respiratory failure (a condition where the lungs cannot adequately exchange oxygen and carbon dioxide, leading to dangerously low oxygen levels and/or dangerously high carbon dioxide levels in the blood), and dependence on respirator (means a person needs a machine to help them breathe). During a review of Resident 4's H&P, dated 10/27/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 4's MDS, dated [DATE], the MDS indicated the resident rarely to never had the ability to make self-understood and understand others and had severely impaired cognition (a person with severely impaired cognition has very serious difficulties with memory, attention, thinking, learning, or making decisions). The MDS indicated the resident was on a high-risk drug class hypoglycemic medication (re essentially sugar-lowering drugs for individuals with diabetes). During a review of Resident 4's Order Summary Report, indicated an order for: 6/16/2025 Insulin Glargine-yfgn Subcutaneous Solution 100 unit per milliliters (unit/ml, describes the amount of a substance present in each milliliter of a liquid) (Insulin Glargine-yfgn). Inject 16 unit subcutaneously at bedtime for DM. Rotate site (hold if blood sugar (bs) less than [<] 100). 6/24/2025 Insulin Aspart Injection Solution 100 unit/ml (Insulin Aspart). Inject as per sliding scale (increasing administration of the pre meal insulin dose based on the blood sugar level before the meal): if 0 - 150 = 0 <70 may give 8 ounces (oz, a unit of volume) orange juice (OJ) and notify MD; 151 - 200 = 2 unit; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units >350 give 10 units and notify MD, subcutaneously every 6 hours for DM. Rotate Sites. During a review of Resident 4's Location of Administration Report of Insulin from 6/2025 to 8/2025, the Location of Administration indicated: -Insulin Aspart Injection Solution 100 unit/ml was administered on, 7/27/2025 at 12:31 a.m. on the Abdomen – Left Lower Quadrant (LLQ) 7/28/2025 at 5:06 a.m. on the Abdomen – LLQ -Insulin Lispro Injection Solution 100 unit/ml was administered on, 6/14/2025 at 5:10 a.m. on the Abdomen - LLQ 6/15/2025 at 5:21 a.m. on the Abdomen – LLQ -Insulin Glargine-yfgn Subcutaneous Solution 100 unit/ml was administered on, 8/7/2025 at 9:08 p.m. on the Abdomen – Right Lower Quadrant (RLQ) 8/8/2025 at 8:14 p.m. on the Abdomen – RLQ During a review of Resident 4's Care Plan (CP) Report titled Resident is at risk for hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar), last revised on 9/10/2024, the CP indicated an intervention to administer medications as ordered. During a concurrent interview and record review on 8/13/2025, at 11:36 a.m., with Licensed Vocational Nurse (LVN) 5, reviewed Resident 4's Medical Diagnosis, Order Summary Report, Location of Administration Report for Insulin from 6/2025 to 8/2025, and Care Plan. LVN 5 stated there were multiple instances where the licensed staff did not rotate the sites of administration of insulin on Resident 4. LVN 5 stated the staff should rotate insulin administration sites on residents to prevent hematoma (collection of blood outside of a blood vessel, often appearing as a bruise), skin irritation, and lipodystrophy on residents. LVN 5 stated injecting insulin on the sites where lipodystrophy occurred can result to malabsorption of insulin that can cause hyper or hypoglycemia on residents. During an interview on 8/15/2025, at 11:37 a.m., with the DON, the DON stated the licensed staff should have rotated the insulin sites of administration for Resident 4 to prevent lipodystrophy on residents. The DON stated frequent repetition of insulin site administration could lead to lipodystrophy on residents which causes malabsorption of insulin producing hypo or hyperglycemia on residents. During a review of the facility-provided Highlights of Prescribing Information on the use of Insulin Aspart injection, for subcutaneous or intravenous use, with initial U.S. approval in 2000, the Highlights of Prescribing Information indicated to rotate injection sites within the same region from one injection to the next to reduce risk of lipodystrophy and localized cutaneous amyloidosis. During a review of the facility-provided Highlights of Prescribing Information on the use of Insulin Lispro injection, for subcutaneous or intravenous use, with initial U.S. approval in 1996, the Highlights of Prescribing Information indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis. During a review of the facility-provided Highlights of Prescribing Information on the use of Insulin Glargine, U-300, injection, for subcutaneous use, with initial U.S. approval in 2015, the Highlights of Prescribing Information indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis. 2. During a review of Resident 13's AR, the AR indicated the facility admitted the resident on 3/1/2019, and readmitted the resident on 5/29/2025, with diagnoses including chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), dependence on respirator, and type 2 diabetes mellitus. During a review of Resident 13's H&P, dated 5/29/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 13's MDS, dated [DATE], the MDS indicated the resident rarely to never had the ability to make self-understood and understand others and had severely impaired cognition. The MDS indicated the resident was on a high-risk drug class hypoglycemic medication. During a review of Resident 13's Order Summary Report, dated 5/29/2025, the Order Summary Report indicated an order for: - Insulin Regular Human Injection Solution 100 unit/ml (Insulin Regular (Human)). Inject as per sliding scale: if 60 - 130 = 0 may give 8 oz of OJ for BS< 60; 131 - 160 = 2U; 161 - 200 = 3U; 201 - 250 = 4U; 251 - 300 = 6U; 301 - 350 = 8U; 351 - 400 = 10U BS >400 give 12U and call MD, subcutaneously every 6 hours for DM 2. - Insulin Glargine Subcutaneous Solution (Insulin Glargine). Inject 20 unit subcutaneously at bedtime for DM 2 (rotate injection sites) Hold if bs<100. During a review of Resident 13's Location of Administration Report for Insulin from 6/2025 to 8/2025, the Location of Administration Report indicated: -Insulin Glargine Subcutaneous Solution was administered on, 6/12/2025 at 9:22 p.m. on the Abdomen – Left Upper Quadrant (LUQ) 6/14/2025 at 9:02 p.m. on the Abdomen – LUQ -Insulin Regular Human Injection Solution 100 unit/ml was administered on, 6/29/25 at 12:09 a.m. on the Abdomen – LLQ 6/30/2025 at 12:22 a.m. on the Abdomen – LLQ 8/2/2025 at 2:57 p.m. on the Arm-Upper arm (rear) (right) 8/2/2025 at 7:39 p.m. on the Arm-Upper arm (rear) (right) 8/6/2025 at 2:59 a.m. on the Arm - left 8/7/2025 at 11:54 p.m. on the Arm – left 8/8/2025 at 8:57 p.m. on the Abdomen-LUQ 8/10/2025 at 10 p.m. on the Abdomen-LUQ 8/10/2025 at 5:10 p.m. on the Abdomen-RLQ 8/11/2025 at 5:35 p.m. on the Abdomen-RLQ During a review of Resident 13's CP Report titled Resident is at risk for hypoglycemia and hyperglycemia, last revised on 4/25/2025, the CP indicated an intervention to administer medications as ordered. During a concurrent interview and record review on 8/13/2025, at 11:45 a.m., with LVN 5, reviewed Resident 13's Medical Diagnosis, Order Summary Report, Location of Administration Report for Insulin from 6/2025 to 8/2025, and Care Plan. LVN 5 stated there were multiple instances where the licensed staff did not rotate the sites of administration of insulin for Resident 13. LVN 5 stated the staff should rotate insulin administration sites on residents to prevent hematoma, skin irritation, and lipodystrophy on residents. LVN 5 stated injecting insulin on the sites where lipodystrophy occurred can result to malabsorption of insulin that can cause hyper or hypoglycemia on residents. During an interview on 8/15/2025, at 11:37 a.m., with the DON, the DON stated the licensed staff should have rotated the insulin sites of administration to Resident 13 to prevent lipodystrophy on residents. The DON stated frequent repetition of insulin site administration could lead to lipodystrophy on residents which causes malabsorption of insulin producing hypo or hyperglycemia on residents. During a review of the facility-provided Highlights of Prescribing Information on the use of Humulin R (insulin human) injection, for subcutaneous or intravenous use, with initial U.S. approval in 1982. the Highlights of Prescribing Information indicated to rotate injection sites to reduce the risk of lipodystrophy and localized cutaneous amyloidosis. During a review of the facility-provided Highlights of Prescribing Information on the use of Insulin Glargine, U-300, injection, for subcutaneous use, with initial U.S. approval in 2015, the Highlights of Prescribing Information indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis. 3. During a review of Resident 35's AR (AR), the AR indicated the facility admitted the resident on 3/7/2022 and most recently admitted the resident on 7/26/2025 with diagnoses that included severe acute bronchitis (inflammation of the airway that carries air to and from the lungs) from respiratory syncytial virus (RSV, a respiratory virus that infects the lungs and breathing passages), sepsis (a life-threatening blood infection), dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that interfere with daily life), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 35's MDS, dated [DATE], the MDS indicated the resident rarely/never was able to understand others and rarely/never was able to make themself understood. The MDS further indicated that the resident was dependent on staff for eating, bathing, dressing, oral and personal hygiene, toileting, and mobility. During a review of Resident 35's Care Plan (CP) titled, Resident is at risk for hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) related to diabetes mellitus, initiated 6/16/2022 and last revised on 10/31/2025, the CP indicated to administer medication as ordered. During a review of Resident 35's Order Summary Report, the Order Summary Report indicated the following order: -Insulin lispro (a fast acting insulin), inject per sliding scale (a method of managing blood sugar levels in people with diabetes where the amount of insulin given is adjusted based on the current blood sugar reading): if 150 - 199 = 1 unit (a measurement); 200- 249 = 2 units; 250 - 299 = 3 units; 300 - 349 = 4 units; 350 - 399 = 5 units; 400 and above = 6 units and call the physician, subcutaneously before meals and at bedtime for DM, rotate injection sites, dated 7/26/2025. During a concurrent interview and record review on 8/13/2025 at 12:47 p.m. with LVN 5, LVN 5 reviewed Resident 35's physician orders, care plans, and Location of Administration Report for insulin lispro for 8/2025. LVN 5 stated the process for insulin administration is to check the resident's blood sugar and administer insulin according to the sliding scale. LVN 5 stated the standard of practice and physician order is to rotate insulin administration sites. LVN 5 stated insulin can be administered in numerous sites on the body including the upper, middle, and lower area of the abdomen; and right and left arm. LVN 5 stated it is important to always administer insulin in a different site to ensure the insulin is absorbed properly by the body and there is no bruising at sites used repetitively. LVN 5 reviewed the Location of Administration form for insulin lispro and noted the following administration sites: - On 8/1/2025 at 11:30 a.m. administered on the Abdomen-Left Lower Quadrant (LLQ) - On 8/1/2025 at 4:40 p.m. administered on the Abdomen-LLQ, not rotated from previous site. - On 8/1/2025 at 9 p.m. administered on the Abdomen-LLQ, not rotated from previous site. - On 8/2/2025 at 11:30 a.m. administered on the Abdomen-LLQ, not rotated from previous site. - On 8/2/2025 at 4:30 p.m. administered on the Abdomen-LLQ, not rotated from previous site. - On 8/2/2025 at 9 p.m. administered on the Abdomen-LLQ, not rotated from previous site. - On 8/3/2025 at 9 p.m. administered on the Abdomen-Right Lower Quadrant (RLQ) - On 8/4/2025 at 6:30 a.m. administered on the Abdomen – RLQ, not rotated from previous site. - On 8/5/2025 at 4:30 p.m. administered on the Abdomen-LLQ - On 8/6/2025 at 6:30 a.m. administered on the Abdomen-LLQ, not rotated from previous site. - On 8/6/2025 at 4:30 p.m. administered on the Abdomen-LLQ - On 8/6/2025 at 9 p.m. administered on the Abdomen-LLQ, not rotated from previous site. - On 8/8/2025 at 11:30 a.m. administered on the Abdomen-LLQ - On 8/8/2025 at 4:30 p.m. administered on the Abdomen-LLQ, not rotated from previous site. - On 8/8/2025 at 9 p.m. administered on the Abdomen-LLQ, not rotated from previous site. - On 8/9/2025 at 11:30 a.m. administered on the Abdomen-LLQ, not rotated from previous site. - On 8/9/2025 at 4:30 p.m. administered on the Abdomen-LLQ, not rotated from previous site. - On 8/9/2025 at 9 p.m. administered on the Abdomen-LLQ, not rotated from previous site. - On 8/12/2025 at 11:30 a.m. administered on the Abdomen-LLQ - On 8/12/2025 at 4:30 p.m. administered on the Abdomen-LLQ, not rotated from previous site. - On 8/12/2025 at 9 p.m. administered on the Abdomen-LLQ, not rotated from previous site. LVN 5 further stated Resident 35 had a lot of sites that were used back-to-back and not rotated, but they should have been. LVN 5 stated the licensed nurses that administered Resident 35's insulin did not follow the physician's orders because the sites were not rotated. During an interview on 8/15/2025 at 11:37 a.m., with the DON, the DON stated the licensed staff should rotate the insulin sites of administration on residents. The DON stated frequent repetition of insulin site administration could lead to lipodystrophy causing malabsorption of insulin producing hypoglycemia or hyperglycemia in residents. During a review of the facility-provided Highlights of Prescribing Information on the use of Insulin Lispro injection, for subcutaneous or intravenous use, with initial U.S. approval in 1996, the Highlights of Prescribing Information indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis. During a review of the policy and procedure (P&P) titled, Subcutaneous Medication Administration, last reviewed 4/15/2025, the P&P indicated the purpose was to administer medication in the subcutaneous tissue in order to promote slow medication absorption and prolong medication action. Select an appropriate side for injection.

Based on observation, interview, and record review, the facility failed to ensure six of seven sampled residents (Residents 11, 51, 41, 168, 4, 125, and 155) reviewed under the urinary catheter (a tube that is inserted into the bladder, allowing urine to drain) and urinary tract infection (UTI, a common infection that occurs when bacteria enters and multiplies in the urinary system, which includes the kidneys, bladder, and urethra) care area received appropriate treatment and services to prevent UTIs by: 1.Failing to ensure Resident 11, 51, 41, 168, and 4's catheter tubing did not have dependent loops or kinks (incorrect positioning of the catheter tubing that forms a U-shaped loop or low point that traps urine and creates back pressure). These deficient practices increased the risk of urine to backflow into the bladder which may lead to the development of a UTI. 2.Failing to ensure Residents 125 and 155's urinal bottles (portable container for collecting urine) were labeled with the name and room number of the residents. These deficient practices had the potential to lead to switching urinal bottles with other residents and cross-contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another). Findings: 1. During a review of Resident 11's admission Record, the admission Record indicated the facility originally admitted the resident on 1/22/2024, and readmitted the resident on 6/5/2025, with diagnoses including but not limited to, respiratory failure (a condition where the lungs cannot release enough oxygen into the blood), obstructive and reflux uropathy (a urinary tract blockage that allows urine to flow backward into the kidneys), and type two diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 11's History and Physical, dated 6/6/2025, the History and Physical indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 11's Minimum Data Set (MDS – a resident assessment tool), dated 7/29/2025, the MDS indicated Resident 11 had severely impaired cognitive (relating to or involving the processes of thinking and reasoning) skills for daily decision making and was dependent on staff for all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 11's Order Summary Report, the Order Summary Report indicated the following order dated 6/5/2025: Foley (indwelling) catheter attached to bedside drainage bag for wound management. During a review of Resident 11's care plan (a document that outlines a patient's healthcare needs, goals, and the interventions and treatments planned to achieve those goals, serving as a roadmap for their care and facilitating communication among the healthcare team), titled, Alteration in elimination and at risk for UTI secondary to Foley Catheter., dated 3/26/2025, the care plan indicated to maintain proper alignment of the Foley catheter to promote proper drainage. During a concurrent observation and interview on 8/11/2025 at 10:56 a.m. with Registered Nurse (RN) 3, at Resident 11's bedside, Resident 11's Foley catheter tubing had a dependent loop below the drainage bag with urine pooling in the tubing. RN 3 stated the catheter tubing should be placed so the urine can freely drain by gravity. RN 3 stated it should drain by gravity, so the urine doesn't back up and cause an infection. 2. During a review of Resident 51's admission Record, the admission Record indicated the facility originally admitted the resident on 9/7/2024 and readmitted the resident on 5/3/2025 with diagnoses including but not limited to, acute respiratory failure (a condition where the lungs cannot release enough oxygen into the blood), nontraumatic intracerebral hemorrhage (bleeding inside the brain tissue) in the brain stem (posterior stalk-like part of the brain that connects the cerebrum with the spinal cord), and UTI. During a review of Resident 51's History and Physical, dated 5/4/2025, the History and Physical indicated the resident was bedbound with limited function. During a review of Resident 51's MDS dated [DATE], the MDS indicated Resident 51 had severely impaired cognitive (relating to or involving the processes of thinking and reasoning) skills for daily decision making and was dependent on staff for all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 51's Order Summary Report, the Order Summary Report indicated the following order dated 6/29/2025: Foley catheter attached to bedside drainage bag for neuromuscular dysfunction of bladder (when nerve damage prevents the bladder from working correctly). During a review of Resident 51's care plan, titled, Alteration in urinary elimination and at risk for UTI secondary to use of Foley Catheter., dated 9/16/2024, the care plan indicated to maintain proper alignment of the Foley catheter to promote proper drainage. During a concurrent observation and interview on 8/11/2025 at 9:31 a.m. with Licensed Vocational Nurse (LVN) 11 at Resident 51's bedside, Resident 51's Foley catheter tubing was looped. LVN 11 stated the urine cannot flow freely and may backflow and cause a UTI. LVN 11 stated the bag should hang towards the lower part of the bed so there would not be a dependent loop or kinks. During an interview on 8/15/2025 at 10:50 a.m. with the Director of Nursing (DON), the DON stated for residents with a Foley catheter, the tubing should not be looped, and the urine should be freely flowing down the tubing. The DON stated looped tubing can affect the flow of urine and the urine should not flow back towards the bladder because there is a risk of infection. During a review of the facility's policy and procedure (P&P) titled, Catheter Care, Urinary, last reviewed on 4/16/2025, the P&P indicated the purpose to prevent urinary catheter-associated complications including UTIs. The P&P indicated to check the resident frequently to be sure he or she is not lying on the catheter, and the tubing is free of kinks. The P&P indicated to always position the drainage bag lower than the bladder to prevent urine from flowing back into the bladder. 3. During a review of Resident 41's admission Record, the admission Record indicated the facility originally admitted the resident on 1/24/2023, and readmitted in the facility on 5/22/2025, with diagnoses including respiratory failure (a condition that occurs when the lungs cannot remove all of the carbon dioxide [a colorless, odorless gas that the body breathes out] the body produces), tracheostomy (a surgical opening in the neck into the windpipe when a person is unable to breathe thru the nose or mouth), and neurogenic bladder (lack bladder control due to a brain, spinal cord or nerve problem). During a review of Resident 41's History and Physical (H&P) dated 7/9/2025, the H&P indicated Resident 41 did not have the capacity to understand and make decisions. During a review of Resident 41's MDS dated [DATE], the MDS indicated Resident 41 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and was unable to understand others and make her needs known. The MDS further indicated Resident 41 required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 41 had an indwelling urinary catheter. During a review of Resident 41's Order Summary Report, the Order Summary Report indicated the following physician's order: -7/8/2025: Foley catheter (FC – also known as urinary catheter) French (Fr – a unit of measurement) 16 per ten (10) milliliters (ml – a unit of measurement) attached to bedside drainage bag due to neurogenic bladder every shift. -7/8/2025: FC care every day shift. -7/8/2025: Monitor FC urinary drainage bag and indicate if the following abnormal is present: dark color, cloudy consistency with sediments, foul odor, hematuria (blood in the urine), bladder distention, burning sensation every shift. -7/8/2025: Secure FC tubing with anchor every day shift to minimize dislodging of catheter. -Change bedside drainage bag every Sunday and as needed. During a concurrent observation and interview on 8/11/2025 at 12:51 p.m. inside Resident 41's room with Licensed Vocational Nurse (LVN) 8, LVN 8 stated Resident 41's urinary catheter tubing had a loop preventing the urine from flowing freely into the bag. LVN 8 stated the urinary catheter tubing had urine in the loop with some white sediments. LVN 8 stated staff responsibility when it comes to care of urinary catheter is to ensure the bag is below the bladder, the bag had privacy cover, and there must be no kink or loop in the tubing. LVN 8 stated if there is a kink or loop the urine cannot flow freely and cause development of urine infection. LVN 8 stated Resident 41's urinary catheter tubing should not have a loop so the urine can flow freely and prevent backing up to the bladder which can cause development of UTI. During an interview on 8/15/2025 at 11:37 a.m., with the Director of Nursing (DON), The DON stated for urinary catheter care, the staff are supposed to ensure the drainage bag is not touching floor to keep the bag clean, monitor for signs and symptoms of UTI, application of a leg strap to anchor the tubing and prevent accidental pulling, and the urine should be free flowing. The DON stated the coil should not be kinked or coiled because it prevents the urine flow and the urine can back flow. The DON stated Resident 41's urinary catheter tubing should not have been coiled or kinked as it had the potential for the urine not to flow freely and flow back into the bladder which could lead to development or UTI. During a review of the facility's policy and procedure (P&P) titled, Catheter Care, Urinary, last reviewed on 4/16/2025, the P&P indicated a purpose to prevent urinary catheter0associated complications, including UTI. The P&P further indicated that to maintain unobstructed urine flow, check the resident frequently to be sure he or she is not lying on the catheter and tubing free of kinks. 4. During a review of Resident 168's admission Record, the admission Record indicated the facility admitted the resident on 8/5/2016, and readmitted the resident on 8/5/2025, with diagnoses including benign prostatic hyperplasia (BPH, a health issue that becomes more common with age), obstructive and reflux uropathy (refer to conditions where urine flow is blocked or reversed, respectively, potentially causing kidney damage), and clostridium perfringens (a common bacteria that can cause food poisoning). During a review of Resident 168's History and Physical (H&P), dated 8/6/2025, the H&P indicated the resident was alert to person only and did not have the capacity to understand and make decisions. During a review of Resident 168's MDS dated [DATE], the MDS indicated the resident sometimes had the ability to make self-understood and understand others and had moderately impaired cognition (it refers to a stage where thinking and memory problems are clearly noticeable and impact daily life). The MDS indicated the resident was dependent on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). The MDS indicated the resident had an indwelling catheter (including suprapubic catheter and nephrostomy tube [is a small tube placed directly into the kidney through a small opening in the back]). During a review of Resident 168's Order Summary Report, dated 8/5/2025, the Order Summary Report indicated an order for: - Suprapubic Catheter French Size (Fr, refers to the diameter, or thickness, of the catheter tube itself) 18/10 milliliters (ml, a unit of volume) attached to bedside drainage bag due to: Obstructive uropathy with urinary retention. Every shift. -Monitor Suprapubic Catheter urinary drainage bag and indicate if the following abnormal if present: dark Color, cloudy consistency with sediments, foul odor, hematuria (blood in the urine), bladder distention, burning sensation (+) = presence of signs and symptoms (S/S) of UTI, (0) = absence of S/S of UTI If '+' is documented, complete a progress note and specify the s/s of UTI noted and Notify MD. Every shift. During a review of Resident 168's Care Plan (CP) Report titled Alteration in urinary elimination and at risk for UTI secondary to use of suprapubic catheter, last revised on 5/9/2025, the CP indicated an intervention to maintain proper alignment of Foley (a catheter brand) catheter to promote proper drainage. During a concurrent observation and interview on 8/11/2025, at 9:43 a.m., with Certified Nursing Assistant (CNA) 5, inside Resident 168's room, observed Resident 168's suprapubic catheter tubing with urine and sediments on the looped suprapubic catheter tubing. CNA 5 stated that the suprapubic catheter should have no loops on them because it will hinder the free flow of urine. CNA 5 stated the tubing should be free flowing to prevent backflow of urine causing infection to residents. During a concurrent interview and record review on 8/13/2025, at 1:54 p.m., with Licensed Vocational Nurse (LVN) 5, reviewed Resident 168's Medical Diagnosis, Order Summary Report and Care Plan. LVN 5 stated there is an order for suprapubic catheter placement on the resident and a care plan was developed on its use. LVN 5 stated there should be no kinks or loops on the resident's suprapubic catheter tubing to prevent backflow of urine to the bladder causing urinary tract infection to residents. During an interview on 8/15/2025, at 11:37 a.m., with the Director of Nursing (DON), the DON stated the staff should have kept the suprapubic catheter tubing of Resident 168 kink and loop free to prevent backflow of urine to the bladder causing UTI to residents. The DON stated it is the responsibility of licensed staff to ensure the catheter bag is not touching the floor, there are no kinked/looped catheter tubing, and had a leg strap or stat lock to anchor the tubing to prevent pulling and tugging of the catheter. During a review of the facility's recent policy and procedure (P&P) titled Urinary Tract Infections (Catheter-Associated), Guidelines for Preventing, last reviewed on 4/16/2025, the P&P indicated the purpose of this procedure is to provide guidelines for the prevention of catheter-associated urinary tract infections (CAUTIs). Steps in the Procedure 6. Maintain unobstructed urine flow. a. Keep the catheter and tubing free of kinks. During a review of the facility's recent P&P titled Catheter Care, Urinary, last reviewed on 4/16/2025, the P&P indicated the purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. Maintaining Unobstructed Urine Flow 1. Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks. 3. Position the drainage bag lower than the bladder at all times to prevent urine from flowing back into the urinary bladder. 5. During a review of Resident 4's admission Record, the admission Record indicated the facility admitted the resident on 9/4/2024, and readmitted the resident on 10/27/2024, with diagnoses including neuromuscular dysfunction of the bladder (means that the nerves controlling the bladder are not working properly), respiratory failure (a condition where the lungs cannot adequately exchange oxygen and carbon dioxide, leading to dangerously low oxygen levels and/or dangerously high carbon dioxide levels in the blood), and type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 4's H&P, dated 10/27/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 4's MDS, dated [DATE], the MDS indicated the resident rarely to never had the ability to make self-understood and understand others and had severely impaired cognition (means a person has very serious trouble with their thinking abilities – so serious that it significantly impacts their daily life and independence). The MDS indicated the resident was dependent on mobility and activities of daily living (ADLs). The MDS indicated the resident had an indwelling catheter (including suprapubic and nephrostomy tube). During a review of Resident 4's Order Summary Report, the Order Summary Report indicated an order for: 5/9/2025 Foley Catheter Fr (18) / (10) ml attached to bedside drainage bag due to: (Urinary Retention). Every Shift. 10/28/2024 Monitor Foley Catheter urinary drainage bag and document the following: Color, consistency, odor, hematuria, bladder distention, burning sensation (+) = presence of S/S of UTI, (0) = absence of S/S of UTI DOCUMENT: 'Y' if monitored and any of the above observed, Notify MD & document in nurses' progress notes. Every shift. 10/28/2024 Foley catheter care. Every day shift. During a review of Resident 4's CP Report titled Alteration in urinary elimination at risk for UTI secondary to use of Foley catheter, and Potential for unavoidable recurrent UTI, last revised on 9/10/2024, the CP's indicated an intervention to maintain proper alignment of foley catheter to promote proper drainage and catheter care as ordered. During a concurrent observation and interview on 8/11/2025, at 10:11 a.m., with Registered Nurse (RN) 2, inside Resident 4's room, observed Resident 4's indwelling catheter with a loop on the tubing with urine and sediments on them. RN 2 stated there should be no loop on the indwelling catheter tubing to prevent backflow of urine to the bladder causing UTI. During a concurrent interview and record review on 8/13/2025, at 1:57 p.m., with LVN 5, reviewed Resident 4's Medical Diagnosis, Order Summary Report, and Care Plan. LVN 5 stated there is an order for insertion of Foley/Indwelling catheter on the resident and had a care plan on its use. LVN 5 stated there should be no loops/kinks on Resident 4's indwelling catheter tubing to prevent backflow of the urine on the bladder causing UTI. During an interview on 8/15/2025, at 11:37 a.m., with the DON, the DON stated the staff should have kept the Foley/Indwelling catheter tubing of Resident 4 kink and loop free to prevent backflow of urine to the bladder causing UTI to residents. The DON stated it is the responsibility of licensed staff to ensure the catheter bag is not touching the floor, there are no kinked/looped catheter tubing, and had a leg bag or stat lock to anchor the tubing to prevent pulling and tugging of the catheter. During a review of the facility's recent P&P titled Urinary Tract Infections (Catheter-Associated), Guidelines for Preventing, last reviewed on 4/16/2025, the P&P indicated the purpose of this procedure is to provide guidelines for the prevention of catheter-associated urinary tract infections (CAUTIs). Steps in the Procedure 6. Maintain unobstructed urine flow. a. Keep the catheter and tubing free of kinks. During a review of the facility's recent P&P titled Catheter Care, Urinary, last reviewed on 4/16/2025, the P&P indicated the purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. Maintaining Unobstructed Urine Flow 1. Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks. 3. Position the drainage bag lower than the bladder at all times to prevent urine from flowing back into the urinary bladder. 6. During a review of Resident 125's admission Record, the admission Record indicated the facility admitted the resident on 8/1/2025, with diagnoses including ataxia (a neurological condition that causes lack of muscle coordination and control, making it difficult to perform everyday movements like walking, reaching, or speaking) following nontraumatic intracerebral hemorrhage (means bleeding within the brain tissue that is not caused by an outside force or injury), muscle weakness, and history of falling. During a review of Resident 125's H&P, dated 8/1/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 125's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others, had impaired vision and intact cognition (means that an individual's thinking, reasoning, and other mental abilities are functioning at a normal or expected level for their age and without significant impairment). The MDS indicated the resident required substantial to partial assistance on personal and toileting hygiene. The MDS indicated that the resident was occasionally incontinent of urine and stool (feces). During a review of Resident 125's Order Summary Report, dated 8/1/2025, the Order Summary Report indicated an order for cranberry tablet 450 milligrams (mg, a unit of weight). Give 1 tablet by mouth one time a day for UTI prophylaxis (guard against disease by taking action ahead of time). During a concurrent observation and interview on 8/11/2025, at 9:23 a.m., with LVN 5, inside Resident 125's room, observed two (2) urinals hanging at the left side rails of the resident not labeled with the name and room number of the resident. LVN 5 stated the urinal bottles should be labeled with the name and room number of the resident to prevent accidental switching of urinals causing cross-contamination to residents leading to UTI. During an interview on 8/15/2025, at 11:37 a.m., with the DON, the DON stated the urinal bottles of Resident 125 should have been labeled with the name and room number of the resident to prevent switching of urinals causing cross-contamination on residents. The DON stated it was the responsibility of the CNAs to ensure all urinals were labeled with the name and room number of residents to prevent UTIs on residents. During a review of the facility's recent P&P titled Disinfecting Bedpans & Urinals, last reviewed on 4/16/2025, the P&P indicated to provide guidelines for disinfection of bedpans and urinals. Disposable bedpans and urinals are for single resident use only. [NAME] the resident's name and discard upon discharge. During a review of the facility's recent P&P titled Infection Prevention and Control Program, last reviewed on 4/16/2025, the P&P indicated an infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 7. During a review of Resident 155's admission Record, the admission Record indicated the facility admitted the resident on 4/7/2025, with diagnoses including elevated white blood cell count (the body is fighting off an infection, inflammation, or other medical condition), abnormalities of gait (the walking pattern in humans) and mobility, and colostomy ( surgical procedure that creates an opening (a stoma) in the colon, allowing stool to pass out of the body through the abdomen instead of the anus). During a review of Resident 155's H&P, dated 4/8/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 155's MDS, dated [DATE], the MDS indicated the resident sometimes had the ability to make self-understood and understand others and had moderately impaired cognition. The MDS indicated the resident required partial assistance on toileting and personal hygiene. The MDS also indicated the resident was frequently incontinent of urine. During a review of Resident 155's Order Summary Report, the Order Summary Report indicated an order for: 4/21/2025 On enhanced barrier precaution (is an approach to the use of personal protective equipment (PPE) to reduce transmission of Multidrug-Resistant Organisms (MDROs) between residents in skilled nursing facilities [SNFs]) monitor for behavior (m/b) colostomy. 4/7/2025 Cranberry Tablet 450 mg. Give 1 tablet by mouth one time a day for UTI prophylaxis. During a review of Resident 155's CP Reports titled Colostomy. Resident is at risk for infection, last revised on 7/30/2025, and Enhanced barrier precaution, last revised on 8/9/2025, the CPs indicated interventions to provide colostomy/stoma care (how to change, empty, and clean the pouch system) daily and as needed and cleaning and disinfection of equipment as indicated. During a concurrent observation and interview on 8/11/2025, at 10:24 a.m., with LVN 5, inside Resident 155's room, observed Resident 155's urinal hanging at the right-side rail not labeled with the name and room number of the resident. LVN 5 stated the urinal should be labeled with the name and room number of the resident to prevent infection to residents. During an interview on 8/15/2025, at 11:37 a.m., with the DON, the DON stated the urinal bottle of Resident 155 should have been labeled with the name and room number of the resident to prevent switching of urinals causing cross-contamination on residents. The DON stated it was the responsibility of the CNAs to ensure all urinals were labeled with the name and room number of residents to prevent UTIs on residents. During a review of the facility's recent P&P titled Disinfecting Bedpans & Urinals, last reviewed on 4/16/2025, the P&P indicated to provide guidelines for disinfection of bedpans and urinals. Disposable bedpans and urinals are for single resident use only. [NAME] the resident's name and discard upon discharge. During a review of the facility's recent P&P titled Infection Prevention and Control Program, last reviewed on 4/16/2025, the P&P indicated an infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

Based on observation, interview, and record review, the facility failed to ensure two of seven sampled residents (Residents 33 and 112) received appropriate services to prevent a decline in range of motion (ROM, full movement potential of a joint) by failing to: 1. For Resident 33, provide a safe and appropriate Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) order for wearing a left elbow splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint), left resting hand splint for no more than 30 minutes as determined by occupational therapy (OT, rehabilitative profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) and provide a safe and appropriate order for a left knee splint and left ankle foot orthosis (AFO, an orthotic device designed to correct or address problems with the ankle and foot) for no more than one hour as determined by physical therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function). 2. For Resident 112, provide a safe and appropriate RNA order for wearing a left knee splint and left AFO for no more than three hours as determined by PT and provide a safe and appropriate RNA order for wearing a left elbow splint and left hand splint for no more than four hours as determined by OT. These deficient practices had the potential for injury, pain, and skin integrity issues to Residents 33 and 112 when wearing the splints. Findings: 1. During a review of Resident 33's admission Record (AR), the AR indicated Resident 33 originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to acute and chronic respiratory failure (any condition that affects breathing function and result in lungs not functioning properly) and functional quadriplegia (difficulty moving both arms and legs). During a review of Resident 33's Minimum Data Set (MDS, resident assessment tool) dated 8/12/2025, the MDS indicated Resident 33 had severe cognitive impairment (mental processes involved in gaining knowledge and comprehension, includes thinking, knowing, remembering, judging, problem-solving). The MDS indicated Resident 33 had functional ROM limitations on both sides of the upper extremities (BUE, shoulder, elbow, wrist/hand) and functional ROM limitations on one side of the lower extremity (LE, hip, knee, ankle/foot). The MDS indicated Resident 33 required dependent assistance for oral hygiene, bathing, lower body dressing, sit to lying, and bed to chair transfers. During a review of Resident 33's physician's orders, the physician's orders indicated an order dated 7/10/2025 for RNA nursing program for passive range of motion (PROM, movement at a given joint with full assistance from another person) for BUE and BLE as tolerated followed by left resting hand splint, left elbow splint and left lower extremity AFO for four to six hours or as tolerated seven days a week. The physician's orders indicated an order dated 8/8/2025 for PT clarification order for skilled PT services three times a week for four weeks for orthotics (an external device to support, align, or correct a movable part of the body) and splint management. The physician's orders indicated an order dated 8/8/2025 for OT clarification order for skilled OT services three times a week for four weeks for splinting and orthotic management. The physician's orders indicated an order dated 8/13/2025 for RNA nursing program for PROM for BUE and BLE as tolerated followed by left resting hand splint, left elbow splint, and LLE AFO for four to six hours or as tolerated four times a week. During a review of Resident 112's Care Plan (CP) Report initiated 7/10/2025 and revised 8/12/2025, the CP indicated Resident 33 had limitations in ROM and contractures (loss of motion of a joint). The CP goal was to minimize complications related to decreased mobility or contractures through appropriate interventions through the next assessment. The CP interventions indicated RNA referral by rehab for PROM to BUE and BLE and splinting to left resting hand splint, left elbow splint, and LLE AFO for four to six hours or as tolerated four times a week. During a review of Resident 33's PT Evaluation and Plan of Treatment (EPT) dated 8/8/2025, the PT EPT indicated treatment approaches to include initial encounter of orthotic management and training and subsequent encounter of orthotics. The PT EPT indicated a PT short-term goal for Resident 33 to safely wear a foot drop splint and left ankle for up to two hours with minimal signs and symptoms of redness, swelling, discomfort or pain. During a review of Resident 33's PT Treatment Encounter Note (TEN) dated 8/8/2025, the PT TEN indicated PT analysis of Resident 33's response to wearing a left AFO for 30 minutes. During a review of Resident 33's OT EPT dated 8/8/25, the OT EPT indicated treatment approaches to include initial encounter of orthotic management and training and subsequent encounter of orthotics. The OT EPT indicated an OT short-term goal for Resident 33 to safely wear a resting hand splint on left hand for up to 30 minutes to promote improved joint mobility and ROM and more optimal positioning of left hand/digits with minimal signs and symptoms of redness, swelling, discomfort or pain. During a review of Resident 33's OT TEN dated 8/8/2025, the OT TEN indicated a precaution of left resting hand splint for less than 30 minutes. The OT TEN indicated OT assessed fit of Resident 33's left resting hand splint. During a review of Resident 33's OT TEN dated 8/11/2025, the OT TEN indicated a precaution of left resting hand splint for 30 minutes. The OT TEN indicated OT tried left resting hand splint for 30 minutes without redness or skin break down. During an observation and interview on 8/14/2025 at 9:45 a.m., Restorative Nursing Assistant (RNA) 3 performed RNA treatment with Resident 33 in Resident 33's room. Resident 33 was lying in bed on his back. RNA 3 performed PROM to BUE and BLE. Resident 33 was not able to fully straighten the right elbow or move the right arm to shoulder level. The left elbow was bent about halfway and able to fully straighten the left elbow. The left arm was able to lift to almost shoulder level. Resident 33's left and right legs could not fully straighten or bend. Resident 33's left ankle could not fully bend up. RNA 3 put on a left resting hand splint, left elbow splint, and left AFO. RNA 3 stated he will leave the splint for at least four to six hours, because the RNA order was to wear the splints for four to six hours. During an interview and record review on 8/14/2025 at 11:08 a.m., Physical Therapist (PT) 1 stated it was the responsibility of the PT staff to establish an individualized RNA program for each resident based on their medical condition and needs. PT 1 stated if a resident required splinting, the PT would evaluate and assess the resident for the benefits of a splint and if the resident could benefit from a splint, then PT would trial the splint and slowly increase the tolerance of the splint over time and keep checking the splint and resident for adverse effects. PT 1 stated for example, at first PT would put on a splint for 30 minutes, then check the skin and resident, then increase the time to one hour. If the skin had redness, then staff would take off the splint. PT 1 stated if a resident wore a splint for longer than the established safe wearing time, a resident could have skin issues, and the splint could limit the movement of the limb. PT 1 stated whatever the resident tolerated wearing the splint during PT treatment was how much the resident should wear the splint during the RNA maintenance program. In the same interview and record review, PT 1 reviewed Resident 33's PT EPT dated 8/8/2025 and stated she indicated the PT goals to increase Resident 33's left ankle ROM to prevent contractures and to assess a left foot drop splint (same as an AFO). PT 1 stated PT was still determining an appropriate RNA program for Resident 33. PT 1 stated Resident 33 was trialed to wear the left AFO for 30 min and for one hour during PT treatment and PT staff was still slowly increasing the wear time of the left AFO to make sure Resident 33 could tolerate the left AFO. PT 1 reviewed Resident 33's orders and stated Resident 33 had an order for RNA program to wear the left AFO for four to six hours. PT 1 stated PT staff was assessing the fit and wear time for the same left foot drop splint/AFO that the RNA was putting on Resident 33. PT 1 reviewed PT documentation and stated PT staff did not document or indicate that PT staff assessed Resident 33 could safely wear the left foot drop splint/AFO for four to six hours with RNA. PT 1 stated PT was the discipline responsible for assessing a safe wear time for residents wearing splints and not RNA or nursing. During an interview and record review on 8/14/2025 at 12:16 p.m., the Director of Rehabilitation (DOR) stated splints helped maintain a resident's ROM and prevent further tightness. DOR stated OT staff assessed a resident's tolerance and safe wearing time for a splint because splints could cause pain and skin integrity issues. DOR stated OT staff will increase the time a resident can wear a splint and safely tolerate a splint during OT treatment. DOR reviewed Resident 33's OT EPT dated 8/8/2025 and stated the OT goal was to assess and safely determine the wear time of the left resting hand splint and left elbow splint. DOR reviewed Resident 33's OT TEN and stated OT had only assessed Resident 33 to tolerate the left resting hand splint and left elbow splint for 30 minutes. DOR reviewed Resident 33's orders and stated Resident 33 had an RNA order for put on the left resting hand splint and left elbow splint for four to six hours. DOR stated the RNA program should not put on the left resting hand splint and left elbow splint for four to six hours unless OT staff first determined it was safe to wear for that amount of time. DOR stated OT staff was the discipline that could safely assess the proper wear time of a resident and not RNA or nursing. DOR stated it would put Resident 33 at risk for skin integrity issues and pain if the splint was not put on for the appropriate time. During an interview at 8/14/2025 at 3:00 p.m., the Director of Nursing stated the RNA program was established by PT and OT and the RNA order should be what was safe and appropriate for each resident. During a review of the facility's policy and procedure (P&P) titled Restorative Nursing Services, last reviewed on 4/16/2025, the P&P indicated residents will receive restorative nursing care as needed to help promote optimal safety and independence.and are individualized and resident centered. During an interview and record review on 8/14/2025 at 8:58 a.m., the assistant DON stated the facility did not have any policies related to splinting or orthotics and therapy standards for splinting. 2. During a review of Resident 112's admission Record (AR), the AR indicated Resident 112 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including but not limited to adult failure to thrive and heart failure (condition in which the heart has difficulty pumping enough blood to keep up with demands of body). During a review of Resident 112's MDS dated [DATE], the MDS indicated Resident 112 had severe cognitive impairments. The MDS indicated Resident 112 had functional ROM limitations on one side of the upper extremity and functional ROM limitations on both sides of the lower extremities. The MDS indicated Resident 112 required supervision with eating, partial assistance with oral hygiene, and was dependent on staff for bathing, lower body dressing, sit to lying, and bed to chair transfers. During a review of Resident 112's Order Summary Report (OSR), the OSR indicated an order for RNA nursing program established for RUE and RLE active assistive range of motion (AAROM, movement at a given joint with a person's own effort and assistance from an external force or another person) exercise, LUE and LLE PROM exercise as tolerated, followed by left knee extension splint, left AFO, left elbow splint, and left hand splint for four to six hours as tolerated followed by sitting edge of bed as tolerated seven days a week. During a review of Resident 112's Care Plan Report (CP), the CP dated 10/7/2024 indicated Resident 112 had limitations in ROM/contractures. The CP goal was to minimize complications related to decreased mobility or contractures through appropriate interventions through the next assessment. The CP intervention indicated RNA referral by Rehab for AAROM for RUE and RLE as tolerated seven days a week, PROM to LUE and LLE as tolerated seven days a week, left knee extension splint, left AFO, left elbow splint, and left hand splint for four to six hours as tolerated seven days a week, orthotic application and skin integrity management LUE and LLE, and sitting edge of bed as tolerated seven days a week. During a review of Resident 112's PT Treatment Encounter Note (TEN) dated 10/3/2024 indicated Resident 112 was able to tolerate splinting for three hours without skin irritation or signs of discomfort. During a review of Resident 112's PT Discharge summary dated [DATE], the DC indicated Resident 112 could safely wear a left foot drop splint and left knee extension splint for three hours with minimal signs and symptoms of redness, swelling, discomfort or pain. The PT DC indicated a recommendation for a RNP for splinting and AAROM to RLE and PROM to LLE. During a review of Resident 112's OT Treatment Encounter Note (TEN) dated 10/4/2024 indicated as a precaution that Resident 112 was able to tolerate a left resting hand splint and a left elbow extension splint for four hours. During a review of Resident 112's OT Discharge summary dated [DATE], the DC indicated Resident 112 could safely wear a left elbow extension splint and left resting hand splint for four hours with minimal signs and symptoms of redness, swelling, discomfort or pain. The OT DC indicated a recommendation for a RNP for splinting and AAROM and splint or brace care. During an observation and interview on 8/13/2025 at 10:06 a.m., Restorative Nursing Assistant (RNA) 2 performed RNA treatment with Resident 112 in Resident 112's room. Resident 112 was lying in bed on his back. RNA 2 performed PROM to Resident 112's LUE and LLE. Resident 112 was not able to straighten the left elbow, was able to lift the left arm to below shoulder level, and the left wrist could not fully straighten. Resident 112's left leg was rotated away from the body, and the left knee could not fully straighten. After completing ROM exercises on all extremities and sitting at edge of bed with Resident 112, RNA 2 put on a left elbow splint, left resting hand splint, left knee extension splint, and left AFO. Resident 112 stated he did not want to wear the splints for too long and said he wanted to wear the splints for only two hours. Resident 112 stated he would call RNA 2 if the splints hurt. RNA 2 stated sometimes Resident 112 did not want to wear the splints for very long. During an interview and record review on 8/14/2025 at 11:08 a.m., Physical Therapist (PT) 1 stated it was the responsibility of the PT staff to establish an individualized RNA program for each resident based on their medical condition and needs. PT 1 stated if a resident required splinting, the PT would evaluate and assess the resident for the benefits of a splint and if the resident could benefit from a splint, then PT would trial the splint and slowly increase the tolerance of the splint over time and keep checking the splint and resident for adverse effects. PT 1 stated for example, at first PT would put on a splint for 30 minutes, then check the skin and resident, then increase the time to one hour. If the skin has redness, then staff would take off the splint. PT 1 stated if the resident wore a splint for longer than the established time, the resident could have skin issues, and the splint could limit the movement of the limb. PT 1 stated whatever the resident tolerated wearing the splint during PT treatment was how much the resident should wear the splint during the RNA maintenance program. In the same interview and record review, PT 1 reviewed Resident 112's PT documentation and PT Discharge summary dated [DATE] and stated at the end of skilled PT treatment, Resident 112 could safely tolerate a left knee splint and a left AFO for a maximum of three hours. PT 1 reviewed Resident 112's current RNA treatment orders and stated the RNA order indicated to wear the left knee extension splint and left AFO for four to six hours. PT 1 stated Resident 112's RNA program orders for the left knee splint and left AFO should only be for two to three hours and not four to six hours because Resident 112 could only tolerate the left knee and left AFO for three hours during PT treatment. If Resident 112 was wearing the left knee splint and left AFO for longer then three hours, then Resident 112 could have discomfort, skin issues like itchiness. PT 1 stated PT was the discipline responsible for assessing a safe wear time for residents wearing splints and not RNA or nursing. During an interview and record review on 8/14/2025 at 12:16 p.m., the Director of Rehabilitation (DOR) stated splints help maintain a resident's ROM, prevent further tightness. DOR stated OT staff assessed a resident's tolerance and safe wearing time for a splint because splints could cause pain and skin integrity issues. DOR stated OT staff will increase the time a resident can wear a splint and safely tolerate a splint during OT treatment. DOR reviewed Resident 112's OT DC Summary dated 10/4/2024 and stated the maximum time OT indicated Resident 112 could safely tolerate the left elbow splint and left resting hand splint was four hours. DOR reviewed Resident 112's current RNA orders and stated Resident 112 had an RNA order to wear the left elbow splint and left resting hand splint for four to six hours. DOR stated OT staff did assess if Resident 112 could tolerate the splint for more than four hours, but it was not documented, and DOR could not confirm if OT staff assessed Resident 112 could safely wear the left elbow splint and left resting hand splint for five or six hours. DOR stated if Resident 112 was wearing the splint for longer than was determined by OT, then Resident 112 was at risk for injury. DOR stated OT staff was the discipline that could safely assess the proper wear time of a resident and not RNA or nursing. During an interview at 8/14/2025 at 3:00 p.m., the Director of Nursing stated the RNA program was established by PT and OT and the RNA order should be what was safe and appropriate for each resident. During a review of the facility's policy and procedure (P&P) titled Restorative Nursing Services, last reviewed on 4/16/2025, the P&P indicated residents will receive restorative nursing care as needed to help promote optimal safety and independence.and are individualized and resident centered. During an interview and record review on 8/14/2025 at 8:58 a.m., the assistant DON stated the facility did not have any policies related to splinting or orthotics and therapy standards for splinting.

Based on observation, interview, and record review, the facility failed to provide an environment that is free from accident hazards over which the facility has control for six of seven sampled residents (Residents 66, 158, 124, 112, 40, and 125) investigated under the Accidents care area by: 1.Failing to ensure Resident 66's bed lock (a mechanism that prevents a hospital bed from rolling or having its position adjusted) was engaged while the resident was in bed. 2.Failing to ensure Resident 158's bed was at the lowest position. 3.Failing to ensure there were no furniture or equipment on top of Residents 40's floor mats (a cushioned floor pad designed to help prevent injury should a person fall). 4.Failing to ensure there were no furniture or equipment on top of Residents 125's floor mats. 5.Failing to ensure fall mats were provided for Resident 124 per the physician's orders and resident's plan of care. These deficient practices increased the risk of accidents such as falls with injuries. 6.Failing to ensure Resident 112's three bottles of eye drops (medication used to treat and prevent dry eyes) were not left unattended and readily available in the resident's shared room. This deficient practice had the potential to result in injury from residents obtaining medication without staff knowledge resulting in overuse with adverse effects or accidental ingestion causing harm to residents Findings: 1. During a review of Resident 66's admission Record, the admission Record indicated the facility originally admitted the resident on 5/22/2024 and readmitted the resident on 8/8/2024 with diagnoses including but not limited to, adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity) and early onset Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities). During a review of Resident 66's History and Physical, dated 8/8/2025, the History and Physical indicated the resident had cognitive (relating to or involving the processes of thinking and reasoning) impairment and to monitor her for safety. During a review of Resident 66's Minimum Data Set (MDS – a resident assessment tool), dated 5/13/2025, the MDS indicated Resident 66 had severely impaired cognitive skills for daily decision making and was dependent on staff for all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a concurrent observation and interview on 8/13/2025 at 2:52 p.m. with Licensed Vocational Nurse (LVN) 6 and Certified Nursing Assistant (CNA) 5 at Resident 66's bedside, Resident 66 was in bed, and the pedal brake was not engaged. Observed Resident 66's foot of bed moved side to side as LVN 6 removed Resident 66's hand mitt (a soft, padded mitten used in healthcare settings to prevent patients from interfering with medical devices, dressings, or treatment) to check her skin with the assistance of CNA 5. LVN 6 and CNA 5 completed care and walked away leaving the bed unlocked. LVN 6 stated the bed should be locked for the resident's safety. During an interview on 8/15/2025 at 10:50 a.m. with the Director of Nursing (DON), the DON stated the resident's bed should be locked to prevent it from rolling. The DON stated if the bed is not locked there is a risk of the resident falling or becoming injured. During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, last reviewed 4/16/2025, the P&P indicated the facility strives to make the environment as free from accident hazards as possible. During a review of the facility's P&P titled, Accident/Incident Prevention, last reviewed 4/16/2025, the P&P indicated the facility provides an environment that is free from accident hazards over which the facility has control and has procedures to prevent accidents. 2. During a review of Resident 158's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility originally admitted the resident on 6/6/2024 and readmitted in the facility on 4/7/2025, with diagnoses including dependence on respirator (also known as ventilator – a machine used to help a person breath when they are unable to do so on their own) status , generalized muscle weakness, and congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 158's History and Physical (H&P) dated 7/9/2025, the H&P indicated Resident 158 was incapacitated (refers to a person's inability to manage their own affairs due to physical or mental limitations). During a review of Resident 158's Minimum Data Set (MDS, a resident assessment tool), dated 6/13/2025, the MDS indicated Resident 158 had an intact cognition (mental action or process of acquiring knowledge and understanding) and was unable to understand others and make her needs known. The MDS further indicated Resident 158 required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 158's care plan (CP) on risk for falls or injury initiated on 7/17/2024, the CP indicated to provide resident with a safe and clutter-free environment as one of the interventions to reduce risk of falls and injury daily. During a review of Resident 158's fall risk evaluations dated 12/9/2024, 3/18/2025, 4/7/2025, the fall risk evaluations indicated Resident 158 was a high risk for falls. During an observation on 8/11/2025 at 9:45 a.m., outside Resident 158's room by the doorway, observed Resident 158 lying in bed placed in a high position without any staff present in the room. During a concurrent observation and interview on 8/11/2025 at 9:49 a.m. inside Resident 158'a room, with Licensed Vocational Nurse (LVN) 9 in the presence of Respiratory Therapist (RT) 1, LVN 9 and RT 1 stated Resident 158's was placed in a high position. LVN 9 stated residents should not be left unattended with the bed in high position. LVN 9 stated staff are supposed to place the bed at a low position after providing care as it placed the residents at risk for falls and injury. LVN 9 and RT 1 measured the height of Resident 158's bed from the top of the mattress to the floor. LVN 9 and RT 1 stated the height of the bed was measured at 31 inches (a unit of measurement). LVN 9 and RT 1 stated they were not sure what was the acceptable height of bed to be considered a low bed. LVN 9 and RT 1 stated that Resident 158 should not have been left unattended with the bed in high position and the bed should have been placed in a low position as it placed Resident 158 at risk for accidents such as falls and/or injury. During a follow up interview on 8/11/2025 at 10:05 a.m. with RT 1, RT 1 stated a bed is considered in low position if the top of the mattress measures 17 inches from the floor. RT 1 stated that Resident 158's bed should have been placed in a low position to prevent Resident 158 from incurring injury during a fall. During an interview on 8/11/2025 at 11:40 a.m. with the Director of Nursing (DON), the DON stated that residents should not be left unattended with the bed in a high position. The DON stated the staff are supposed to place the bed in a low position after providing care and/or prior to leaving the room to ensure resident safety. The DON stated resident 158 should not have been left unattended with the bed in a high position. The DON stated Resident 158's bed should have been placed in a low position after providing care and/or prior to leaving the room as it placed Resident 158 at risk for falls/accidents and could incur injuries from the fall. During a review of the facility's policy and procedure (P&P) titled, Accident/Incident Prevention, last reviewed on 4/16/2025, the P&P indicated the facility strives to prevent accidents by providing an environment that is free from accident hazards over which the facility has control, as well as identification of each resident at risk for accidents/incidents and the provision of adequate care plans with procedures to prevent accidents. The P&P further indicated that in order to provide an environment that is free of accident hazards, the facility will provide care planning with implementation plans. During a review of the facility's P&P titled, Safety and Supervision of Residents, last reviewed on 4/16/2025, the P&P indicated the facility strives to make the environment as free from accident hazards as possible and resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The P&P further indicated: - Individualized, Resident-Centered Approach to Safety: 1. The individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. 2. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. 3. During a review of Resident 40's admission Record, the admission Record indicated the facility admitted the resident on 11/6/2023, and readmitted the resident on 1/31/2025, with diagnoses including encephalopathy (a disease or disorder that affects the brain, causing it to not function normally), seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), and history of falling. During a review of Resident 40's History and Physical (H&P), dated 2/1/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 40's MDS dated [DATE], the MDS indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident was dependent to requiring supervision assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 40's Order Summary Report, dated 1/31/2025, the Order Summary Report indicated an order for [Falling Star Program] Frequent visual monitoring due to high risk for fall and injury. Document every shift. During a review of Resident 40's Interdisciplinary Team (IDT, group of people with different specializations (disciplines) who work together actively and collaboratively towards a shared goal, combining their knowledge and perspectives to achieve a more comprehensive solution than they would individually)- For Expected Behavior related to (R/T) Movement From Low Bed to Floor Mat, dated 2/13/2024, the IDT indicated a recommendation to continue with low bed (a bed where the mattress sits closer to the floor, often under 13 inches tall) and floor mat. During a review of Resident 40's Fall Risk Evaluation, dated 7/29/2025, the Fall Risk Evaluation indicated the resident was at high risk for falls. During a review of Resident 40's Care Plan (CP) Report titled Resident is at risk for falls/injury, last revised on 11/15/2023, the CP indicated an intervention to provide resident with a safe and clutter-free environment. During a concurrent observation and interview on 8/11/2025, at 11:16 a.m., with the Assistant Director of Staff Development (ADSD), inside Resident 40's room, observed Resident 40 had bilateral floor mat, on the right side of the floor mat there was a wheelchair on top of them. The ADSD stated there should be no wheelchair on top of Resident 40's floor mat to prevent falls with injury. The ADSD stated it defeats the purpose of having a floor mat at the resident's bedside because when they fall, they will hit the hard surface of whatever was on top of the floor mat causing injury. During a concurrent interview and record review on 8/13/2025, at 11:13 a.m., with Licensed Vocational Nurse (LVN) 5, reviewed Resident 40's Order Summary Report, IDT, Fall Risk Evaluation, and Care Plan. LVN 5 stated the resident was high risk for falls with injury and the resident was on a Falling Star Program. LVN 5 stated the resident had bilateral floor mat as recommended by the IDT. LVN 5 stated the floor mat reduces the chances of falls with injury. LVN 5 stated there should be no furniture or equipment on top of Resident 40's floor mat to prevent falls with injury, LVN 5 stated by placing furniture or equipment on top of the fall mat it defeats the purpose of placing a soft mat where the resident can fall, the resident will hit the hard surfaces of whatever was on top of the floor mat causing injury to the resident such as abrasion, hematoma (a collection of blood outside of a blood vessel, often appearing as a bruise), or even fracture (a break in a bone). During an interview on 8/15/2025, at 11:37 a.m., with the Director of Nursing (DON), the DON stated there should be no furniture or equipment on top of Resident 40's floor mat to prevent falls with injury. The DON also stated placing heavy objects on top of the floor mat creates a permanent dent on the floor mat reducing its ability to lessen the impact of the fall of the resident causing injuries. During a review of the facility's recent policy and procedure (P&P) titled Accident/Incident Prevention, last reviewed on 4/16/2025, the P&P indicated this facility strives to prevent accidents by providing an environment that is free from accident hazards over which the facility has control, as well as identification of each resident at risk for accident/incidents and the provision of adequate care plans with procedures to prevent accidents. During a review of the facility-provided Instructions for Floor Mat (FM) 1, undated, the Information indicated when moving equipment such as lifts and wheelchairs across the mat, always make sure wheel locks are not engaged, as locked wheels may damage the surface. Sharp objects may cause damage to the mat. Never leave heavy objects on mat surface for extended periods, as indentations and damage may occur. During a review of the facility's recent P&P titled Safety and Supervision of Residents, last reviewed on 4/16/2025, the P&P indicated our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. 4. During a review of Resident 125's admission Record, the admission Record indicated the facility admitted the resident on 8/1/2025, with diagnoses including ataxia (a neurological condition that causes lack of muscle coordination and control, making it difficult to perform everyday movements like walking, reaching, or speaking), syncope (commonly known as fainting or passing out, is a temporary loss of consciousness due to a sudden and brief drop in blood flow to the brain), and history of falling. During a review of Resident 125's H&P, dated 8/1/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 125's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (means that an individual's thinking, reasoning, and other mental abilities are functioning at a normal or expected level for their age and without significant impairment). The MDS indicated the resident required substantial to supervision assistance on mobility and activities of daily living (ADLs). The MDS indicated the resident had a fall in the last month prior to admission in the facility. During a review of Resident 125's Order Summary Report, dated 8/1/2025, the Order Summary Report indicated an order for: - [Falling Star Program]. Frequent visual monitoring due to high risk for fall and injury. Document every (q) shift. -Support & safety device- Low bed with floor mat to decrease potential injury. Every shift. During a review of Resident 125's Fall Risk Evaluation, dated 8/1/2025, the Fall Risk Evaluation indicated the resident was high risk for falls. During a review of Resident 125's CP Report titled Resident is at risk for falls/injury, last revised on 8/11/2025, the CP indicated an intervention to provide resident with a safe and clutter-free environment. During a concurrent interview and record review on 8/13/2025, at 9:23 a.m., with LVN 5, reviewed Resident 125's Order Summary Report, Fall Risk Evaluation, and Care Plan. LVN 5 stated the resident was high risk for falls with injury and the resident was on a Falling Star Program. LVN 5 stated the resident had bilateral floor mat. On the right-side of floor mat there was a bedside drawer on top and on the left-side floor mat there was a side table on top. LVN 5 stated the floor mat reduces the chances of falls with injury. LVN 5 stated there should be no furniture or equipment on top of Resident 125's floor mat to prevent falls with injury, LVN 5 stated by placing furniture or equipment on top of the fall mat it defeats the purpose of placing a soft mat where the resident can fall, the resident will hit the hard surfaces of whatever was on top of the floor mat causing injury to the resident such as abrasion, hematoma, or even fracture. During an interview on 8/15/2025, at 11:37 a.m., with the DON, the DON stated there should be no furniture or equipment on top of Resident 125's floor mat to prevent falls with injury. The DON also stated placing heavy objects on top of the floor mat creates a permanent dent on the floormat reducing its ability to lessen the impact of the fall of the resident causing injuries. During a review of the facility's recent P&P titled Accident/Incident Prevention, last reviewed on 4/16/2025, the P&P indicated this facility strives to prevent accidents by providing an environment that is free from accident hazards over which the facility has control, as well as identification of each resident at risk for accident/incidents and the provision of adequate care plans with procedures to prevent accidents. During a review of the facility-provided Instructions for FM 1, undated, the Information indicated when moving equipment such as lifts and wheelchairs across the mat, always make sure wheel locks are not engaged, as locked wheels may damage the surface. Sharp objects may cause damage to the mat. Never leave heavy objects on mat surface for extended periods, as indentations and damage may occur. During a review of the facility's recent P&P titled Safety and Supervision of Residents, last reviewed on 4/16/2025, the P&P indicated our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. 5. During a review of Resident 124's admission Record (AR), the AR indicated the facility originally admitted the resident on 11/5/2015 and most recently admitted the resident on 4/20/2022 with diagnoses that included seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), traumatic brain injury (TBI-a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head), anoxic brain injury (a type of acquired brain injury that occurs when cells in the brain do not receive enough oxygen), and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 124's MDS dated [DATE], the MDS indicated the resident was rarely / never able to understand others and was rarely / never able to make themself understood. The MDS further indicated that the resident was dependent on staff for bathing, lower body dressing, oral and personal hygiene, toileting, and transfers; the resident required partial / moderate assistance for rolling left and right. During a review of Resident 124's History and Physical (H&P) dated 10/22/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 124's Order Summary Report, the Order Summary Report indicated the following physician's orders: - [Falling Star Program], frequent visual monitoring due to high risk for fall and injury. Document every shift, dated 10/20/2023. -Low bed with floor mat to decrease potential injury. Ensure equipment is in place and functioning properly, every shift, dated 4/20/2022. During a review of Resident 124's care plan (CP) titled, Resident is at risk for falls / injury related to: impaired vision, impaired cognition, poor safety awareness / judgment, decreased strength and endurance,., history of falls,., revised 4/10/2019, and last reviewed 6/19/2025, the CP indicated a goal that the resident would have a reduced risk of falls and injury with interventions including to provide floor mats. During a concurrent observation and interview on 8/11/2025 at 9:25 a.m., observed Resident 124 lying in bed awake. Resident 124 did not respond to the surveyor. Observed the bed elevated and no floor mats. During an observation on 8/12/2025 at 2 p.m., observed Resident 124 sitting up in bed with no fall mats at bedside. During a concurrent observation and interview on 8/12/2025 at 3:30 p.m., with Certified Nursing Assistant (CNA) 10, observed Resident 124 sitting in bed awake. CNA 10 stood at the resident's doorway and stated there were no fall mats on either side of Resident 124's bed. CNA 10 stated Resident 124 was not at risk for falls. During a concurrent observation, interview, and record review on 8/12/2025 at 3:40 p.m., with Licensed Vocational Nurse (LVN) 10, LVN 10 reviewed Resident 124's physician orders and care plans. LVN 10 stated Resident 124 was at risk for falls and has a physician's order and care plan for floor mats, so fall mats should be in place. Observed LVN 10 enter Resident 124's room and stated the resident did not have fall mats. LVN 10 stated Resident 124 should have fall mats at all times while in bed to prevent an injury if the resident falls. During a concurrent interview and record review on 8/15/2025 at 12 p.m., with the Director of Nursing (DON), the DON reviewed the facility P&P regarding fall prevention. The DON Stated fall mats decrease the severity of injuries from falls. The DON stated the facility P&P was not followed when Resident 124 did not have fall mats potentially resulting in injuries like fractures (broken bones) to the resident. During a review of the facility policy and procedures (P&P) titled, Accident / Incident Prevention, last reviewed 4/16/2025, the P&P indicated the facility strives to prevent accidents by providing an environment that is free from accident hazards over which the facility has control, as well as identification of each resident at risk for accidents and the provision of adequate care plans with procedures to prevent accidents. During a review of the facility P&P titled, Falling Star Program, last reviewed 4/16/2025, the P&P indicated residents at risk for falls will participate in the falling star program. Residents will be assessed for fall risk and appropriate interventions will be provided. During a review of the facility P&P titled, Safety and Supervision of Residents, last reviewed 4/16/2025, the P&P indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents. 6. During a review of Resident 112's AR, the AR indicated the facility originally admitted the resident on 7/17/2020 and most recently admitted the resident on 7/13/2024 with diagnoses that included myocardial infarction (MI-heart attack), failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), age related bilateral nuclear cataracts (a type of cataract [a clouding of the eye's lens leading to blurry or dim vision] that affects the central part of the lens), and presbyopia (gradual loss of eye's ability to focus on nearby objects). During a review of Resident 112's MDS dated [DATE], the MDS indicated the resident was able to understand others and was able to make themself understood. The MDS further indicated that the resident required partial / moderate assistance from staff for oral hygiene; and was dependent on staff for bathing, lower body dressing, personal hygiene; and mobility. During a review of Resident 112's H&P dated 7/13/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 112's Order Summary Report, the Order Summary Report indicated a physician's order for hydroxypropyl methylcellulose ophthalmic solution (medication to relieve dryness and irritation caused by reduced tear flow), instill one drop in both eyes every four hours as needed for dry eyes, dated 8/18/2024. During a review of Resident 112's CP titled, Potential for alteration in visual function., initiated 7/22/2020 and last reviewed 6/4/2025, the CP indicated a goal that the resident would have a reduced risk of redness, irritation or infection daily with interventions including to provide treatment per physician orders and administer eye medication / drops as ordered. During a review of Resident 112's medication administration records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for 8/2025, the MAR indicated hydroxypropyl methylcellulose ophthalmic solution was not administered to the resident in 8/2025. During a review of Resident 112's Self-Administration of Drugs Assessment form, dated 7/13/2024, the Self-Administration of Drugs Assessment form indicated the resident was not safe for self-administration of medication. During a concurrent observation and interview on 8/12/2025 at 8:51 a.m., observed Resident 112 lay in bed. Observed on the bedside rolling table a bottle of pheniramine maleate and naphazoline hydrochloride eye drops (a medication to relieve itching and redness caused by allergens), a bottle of naphazoline eye drops (a medication for eye redness, dryness, and irritation), and a bottle of carboxymethylcellulose sodium ophthalmic (a medication for dry eyes). Resident 112 stated Resident 112 used the three bottles of eye drops approximately every ten minutes and would not be able to see without them. During an observation and interview on 8/11/2025 at 9:40 a.m., observed LVN 4 at Resident 112's doorway. LVN 4 stated LVN 4 would give Resident 112 medication. Observed the three eye drops remained on the resident's bedside rolling table. During a concurrent observation and interview on 8/12/2025 at 8:40 a.m., with CNA 8, CNA 8 entered Resident 112's room and placed the resident's breakfast tray on the rolling table. Observed the three bottles of eye drops remained on the rolling table. CNA 8 exited the room and did not remove the eye drops. Upon exiting the room CNA 8 stated CNA 8 did not know if the resident had any eye drops at bedside. CNA 8 re-entered Resident 112's room. CNA 8 confirmed Resident 112 had three bottles of eye drops at bedside. During a concurrent interview and record review on 8/12/2025 at 11:25 a.m., with the Assistant Director of Nursing (ADON), the ADON reviewed Resident 112's Self-Administration of Drugs Assessment form. The ADON stated medications should not be left at bedside to ensure medications are administered per physician's orders with the correct dose and at the right time to the residents. The ADON stated if a resident wants to self-administer medications, then the facility will assess the resident, get a physician's order, develop and implement a CP, and place the medications in a locked box. The ADON stated all staff are responsible to assess the resident environment to ensure medications are not left at bedside. The ADON stated the ADON was made aware Resident 112 had eye drops at bedside. The ADON stated Resident 112 was not safe to self-administer medications. The ADON stated when the eye drops were left at Resident 112's bedside there was the potential that the resident would not administer the eye drops per physician orders or that other confused residents would use t

Based on observation, interview and record review, the facility failed to ensure residents were free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which are not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) by failing to: Rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq, beneath the skin) insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) administration sites for three of three sampled residents (Residents 4, 13, and 35) reviewed for insulin. This deficient practice had the potential for adverse effect (unwanted, unintended result) of the same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Cross reference F658. Ensure one of four residents (Resident 48) observed for medication administration was not allowed self-administration of Breo inhaler when it was determined to be unsafe by the interdisciplinary team (IDT - a multi-discipline group of healthcare professionals involved in periodically meeting and planning care for individual residents). This deficient practice of allowing Resident 48 to self-administer medication without an IDT evaluation for safety increased the risk that she may have administered the wrong dose of Breo due to poor technique possibly resulting in medical complications resulting in hospitalization or death. Cross reference F554. Findings: 1.During a review of Resident 4's admission Record, the admission Record indicated the facility admitted the resident on 9/4/2024, and readmitted the resident on 10/27/2024, with diagnoses including Type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), respiratory failure (the lungs are not able to get enough oxygen into the blood or remove enough carbon dioxide), and dependence on respirator (if a patient is unable to wean off a ventilator and breathe independently). During a review of Resident 4's History and Physical (H&P), dated 10/27/2024, the H&P indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 4's Minimum Data Set (MDS, a resident assessment tool), dated 6/11/2025, the MDS indicated the resident rarely to never had the ability to make self understood and understand others and had severely impaired cognition (refers to a significant decline in a person's ability to think, remember, learn, or make decisions, to the point where it substantially impacts their daily life and independence). The MDS indicated Resident 4 was on a high-risk drug class hypoglycemic medication (are drugs that lower blood sugar levels). During a review of Resident 4's Order Summary Report, indicated an order for: 6/16/2025 Insulin Glargine-yfgn Subcutaneous Solution 100 units per milliliter (unit/ml, is the number of units of insulin in 1 milliliter) (Insulin Glargine-yfgn). Inject 16 unit subcutaneously at bedtime for DM. Rotate Site (hold if blood sugar [bs] less than [<]100). 6/24/2025 Insulin Aspart Injection Solution 100 unit/ml (Insulin Aspart). Inject as per sliding scale (the amount of insulin to be administered changes or slides up or down based on the person's blood sugar): if 0 - 150 = 0 <70 may give 8 ounces (oz, a unit of volume) orange juice and notify MD; 151 - 200 = 2 unit; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units >350 give 10 units and notify MD, subcutaneously every 6 hours for DM. Rotate Sites. During a review of Resident 4's Location of Administration Report of Insulin from 6/2025 to 8/2025, the Location of Administration indicated: -Insulin Aspart Injection Solution 100 unit/ml was administered on, 7/27/2025 at 12:31 a.m. on the Abdomen – Left Lower Quadrant (LLQ) 7/28/2025 at 5:06 a.m. on the Abdomen – LLQ -Insulin Lispro Injection Solution 100 unit/ml was administered on, 6/14/2025 at 5:10 a.m. on the Abdomen - LLQ 6/15/2025 at 5:21 a.m. on the Abdomen – LLQ -Insulin Glargine-yfgn Subcutaneous Solution 100 unit/ml was administered on, 8/7/2025 at 9:08 p.m. on the Abdomen – Right Lower Quadrant (RLQ) 8/8/2025 at 8:14 p.m. on the Abdomen – RLQ During a review of Resident 4's Care Plan (CP) Report titled Resident is at risk for hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar), last revised on 9/10/2024, the CP indicated an intervention to administer medications as ordered. During a concurrent interview and record review on 8/13/2025, at 11:36 a.m., with Licensed Vocational Nurse (LVN) 5, reviewed Resident 4's Medical Diagnosis, Order Summary Report, Location of Administration Report for Insulin from 6/2025 to 8/2025, and Care Plan. LVN 5 stated there were multiple instances where the licensed nurse staff did not rotate the sites of administration of insulin on Resident 4. LVN 5 stated the staff should rotate insulin administration sites on residents to prevent hematoma (a collection of blood outside of a blood vessel, often appearing as a bruise), skin irritation, and lipodystrophy on residents. LVN 5 stated injecting insulin on the sites where lipodystrophy occurred can result to malabsorption of insulin that can cause hyper or hypoglycemia on residents. LVN 5 stated not rotating insulin administration sites is a medication error. During an interview on 8/15/2025, at 11:37 a.m., with the Director of Nursing (DON), the DON stated the licensed staff should have rotated the insulin sites of administration to Resident 4 to prevent lipodystrophy on residents. The DON stated frequent repetition of insulin site administration could lead to lipodystrophy on residents which causes malabsorption of insulin producing hypo or hyperglycemia on residents. The DON stated that not rotating insulin administration site is a medication error. During a review of the facility's recent policy and procedure (P&P) titled Adverse Consequences and Medication Errors, last reviewed on 4/16/2025, the P&P indicated the interdisciplinary team evaluates medication usage in order to prevent and detect adverse consequences and medication-related problems such as adverse drug reactions (ADRs) and side effects. Adverse consequences shall be reported to the attending physician and pharmacist, and to federal agencies as appropriate. Policy Interpretation and Implementation 5. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer's specifications, or accepted professional standards and principles of the professional(s) providing services. During a review of the facility's recent P&P titled Physician's Orders: Follow up, last reviewed on 4/16/2025, the P&P indicated physician's orders will be noted by the charge nurse on duty at the time the order(s) is/are written. Subsequent transcriptions will be accomplished as indicated; e.g., transcription of medication on MAR, treatment Sheet, etc. During a review of the facility-provided Highlights of Prescribing Information on the use of Insulin Aspart injection, for subcutaneous or intravenous use, with initial U.S. approval in 2000, the Highlights of Prescribing Information indicated to rotate injection sites within the same region from one injection to the next to reduce risk of lipodystrophy and localized cutaneous amyloidosis. During a review of the facility-provided Highlights of Prescribing Information on the use of Insulin Lispro injection, for subcutaneous or intravenous use, with initial U.S. approval in 1996, the Highlights of Prescribing Information indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis. During a review of the facility-provided Highlights of Prescribing Information on the use of Insulin Glargine, U-300, injection, for subcutaneous use, with initial U.S. approval in 2015, the Highlights of Prescribing Information indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis. 2.During a review of Resident 13's admission Record, the admission Record indicated the facility admitted the resident on 3/1/2019, and readmitted the resident on 5/29/2025, with diagnoses including chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), dependence on respirator, and type 2 diabetes mellitus. During a review of Resident 13's H&P, dated 5/29/2025, the H&P indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 13's MDS, dated [DATE], the MDS indicated the resident rarely to never had the ability to make self-understood and understand others and had severely impaired cognition. The MDS indicated Resident 13 was on a high-risk drug class hypoglycemic medication. During a review of Resident 13's Order Summary Report, dated 5/29/2025, the Order Summary Report indicated an order for: - Insulin Regular Human Injection Solution 100 unit/ml (Insulin Regular (Human)). Inject as per sliding scale: if 60 - 130 = 0 may give 8 oz of orange juice (OJ) for BS< 60; 131 - 160 = 2 units (U); 161 - 200 = 3U; 201 - 250 = 4U; 251 - 300 = 6U; 301 - 350 = 8U; 351 - 400 = 10U BS greater than [ >]400 GIVE 12U and call MD, subcutaneously every 6 hours for DM 2. - Insulin Glargine Subcutaneous Solution (Insulin Glargine). Inject 20 unit subcutaneously at bedtime for DM 2 (rotate injection sites) Hold if bs<100. During a review of Resident 13's Location of Administration Report for Insulin from 6/2025 to 8/2025, the Location of Administration Report indicated: -Insulin Glargine Subcutaneous Solution was administered on, 6/12/2025 at 9:22 p.m. on the Abdomen – Left Upper Quadrant (LUQ) 6/14/2025 at 9:02 p.m. on the Abdomen – LUQ -Insulin Regular Human Injection Solution 100 unit/ml was administered on, 6/29/2025 at 12:09 a.m. on the Abdomen – LLQ 6/30/2025 at 12:22 a.m. on the Abdomen – LLQ 8/2/2025 at 2:57 p.m. on the Arm-Upper arm (rear) (right) 8/2/2025 at 7:39 p.m. on the Arm-Upper arm (rear) (right) 8/6/2025 at 2:59 a.m. on the Arm - left 8/7/2025 at 11:54 p.m. on the Arm – left 8/8/2025 at 8:57 p.m. on the Abdomen-LUQ 8/10/2025 at 10 p.m. on the Abdomen-LUQ 8/10/2025 at 5:10 p.m. on the Abdomen-RLQ 8/11/2025 at 5:35 p.m. on the Abdomen-RLQ During a review of Resident 13's CP Report titled Resident is at risk for hypoglycemia and hyperglycemia, last revised on 4/25/2025, the CP indicated an intervention to administer medications as ordered. During a concurrent interview and record review on 8/13/2025, at 11:45 a.m., with LVN 5, reviewed Resident 13's Medical Diagnosis, Order Summary Report, Location of Administration Report for Insulin from 6/2025 to 8/2025, and Care Plan. LVN 5 stated there were multiple instances where the licensed staff did not rotate the sites of administration of insulin on Resident 13. LVN 5 stated the staff should rotate insulin administration sites on residents to prevent hematoma, skin irritation, and lipodystrophy on residents. LVN 5 stated injecting insulin on the sites where lipodystrophy occurred can result to malabsorption of insulin that can cause hyper or hypoglycemia on residents. LVN 5 stated not rotating insulin administration sites is a medication error. During an interview on 8/15/2025, at 11:37 a.m., with the DON, the DON stated the licensed staff should have rotated the insulin sites of administration to Resident 13 to prevent lipodystrophy on residents. The DON stated frequent repetition of insulin site administration could lead to lipodystrophy on residents which causes malabsorption of insulin producing hypo or hyperglycemia on residents. The DON stated that not rotating insulin administration site is a medication error. During a review of the facility's recent P&P titled Adverse Consequences and Medication Errors, last reviewed on 4/16/2025, the P&P indicated the interdisciplinary team evaluates medication usage in order to prevent and detect adverse consequences and medication-related problems such as adverse drug reactions (ADRs) and side effects. Adverse consequences shall be reported to the attending physician and pharmacist, and to federal agencies as appropriate. Policy Interpretation and Implementation 5. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer's specifications, or accepted professional standards and principles of the professional(s) providing services. During a review of the facility's recent P&P titled Physician's Orders: Follow up, last reviewed on 4/16/2025, the P&P indicated physician's orders will be noted by the charge nurse on duty at the time the order(s) is/are written. Subsequent transcriptions will be accomplished as indicated; e.g., transcription of medication on MAR, treatment Sheet, etc. During a review of the facility-provided Highlights of Prescribing Information on the use of Humulin R (insulin human) injection, for subcutaneous or intravenous use, with initial U.S. approval in 1982. the Highlights of Prescribing Information indicated to rotate injection sites to reduce the risk of lipodystrophy and localized cutaneous amyloidosis. During a review of the facility-provided Highlights of Prescribing Information on the use of Insulin Glargine, U-300, injection, for subcutaneous use, with initial U.S. approval in 2015, the Highlights of Prescribing Information indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis. 3.During a review of Resident 35's admission Record (AR), the AR indicated the facility admitted the resident on 3/7/2022 and most recently admitted the resident on 7/26/2025 with diagnoses that included severe acute bronchitis (inflammation of the airway that carries air to and from the lungs) from respiratory syncytial virus (RSV, a respiratory virus that infects the lungs and breathing passages), sepsis (a life-threatening blood infection), dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that interfere with daily life), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 35's Minimum Data Set (MDS – resident assessment tool) dated 8/25/2025, the MDS indicated the resident rarely/never was able to understand others and rarely/never was able to make themself understood. The MDS further indicated Resident 35 was dependent on staff for eating, bathing, dressing, oral and personal hygiene, toileting, and mobility. During a review of Resident 35's Care Plan (CP) titled, Resident is at risk for hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) related to diabetes mellitus, initiated 6/16/2022 and last revised on 10/31/2025, the CP indicated to administer medication as ordered. During a review of Resident 35's Order Summary Report, the Order Summary Report indicated the following order: -Insulin lispro (a fast acting insulin), inject per sliding scale (a method of managing blood sugar levels in people with diabetes where the amount of insulin given is adjusted based on the current blood sugar reading): if 150 - 199 = 1 unit (a measurement); 200- 249 = 2 units; 250 - 299 = 3 units; 300 - 349 = 4 units; 350 - 399 = 5 units; 400 and above = 6 units and call the physician, subcutaneously before meals and at bedtime for DM, rotate injection sites, dated 7/26/2025. During a concurrent interview and record review on 8/13/2025 at 12:47 p.m. with Licensed Vocational Nurse (LVN) 5, LVN 5 reviewed Resident 35's physician orders, care plans, and Location of Administration Report for insulin lispro for 8/2025. LVN 5 stated the process for insulin administration is to check the resident's blood sugar and administer insulin according to the sliding scale. LVN 5 stated the standard of practice and physician order is to rotate insulin administration sites. LVN 5 stated insulin can be administered in numerous sites on the body including the upper, middle, and lower area of the abdomen; and right and left arm. LVN 5 stated it is important to always administer insulin in a different site to ensure the insulin is absorbed properly by the body and there is no bruising at sites used repetitively. LVN 5 reviewed the Location of Administration form for insulin lispro and noted the following administration sites: - On 8/1/2025 at 11:30 a.m. administered on the Abdomen-Left Lower Quadrant (LLQ) - On 8/1/2025 at 4:40 p.m. administered on the Abdomen-LLQ, not rotated from previous site. - On 8/1/2025 at 9 p.m. administered on the Abdomen-LLQ, not rotated from previous site. - On 8/2/2025 at 11:30 a.m. administered on the Abdomen-LLQ, not rotated from previous site. - On 8/2/2025 at 4:30 p.m. administered on the Abdomen-LLQ, not rotated from previous site. - On 8/2/2025 at 9 p.m. administered on the Abdomen-LLQ, not rotated from previous site. - On 8/3/2025 at 9 p.m. administered on the Abdomen-Right Lower Quadrant (RLQ) - On 8/4/2025 at 6:30 a.m. administered on the Abdomen – RLQ, not rotated from previous site. - On 8/5/2025 at 4:30 p.m. administered on the Abdomen-LLQ - On 8/6/2025 at 6:30 a.m. administered on the Abdomen-LLQ, not rotated from previous site. - On 8/6/2025 at 4:30 p.m. administered on the Abdomen-LLQ - On 8/6/2025 at 9 p.m. administered on the Abdomen-LLQ, not rotated from previous site. - On 8/8/2025 at 11:30 a.m. administered on the Abdomen-LLQ - On 8/8/2025 at 4:30 p.m. administered on the Abdomen-LLQ, not rotated from previous site. - On 8/8/2025 at 9 p.m. administered on the Abdomen-LLQ, not rotated from previous site. - On 8/9/2025 at 11:30 a.m. administered on the Abdomen-LLQ, not rotated from previous site. - On 8/9/2025 at 4:30 p.m. administered on the Abdomen-LLQ, not rotated from previous site. - On 8/9/2025 at 9 p.m. administered on the Abdomen-LLQ, not rotated from previous site. - On 8/12/2025 at 11:30 a.m. administered on the Abdomen-LLQ - On 8/12/2025 at 4:30 p.m. administered on the Abdomen-LLQ, not rotated from previous site. - On 8/12/2025 at 9 p.m. administered on the Abdomen-LLQ, not rotated from previous site. LVN 5 further stated Resident 35 had a lot of sites that were used back-to-back and not rotated, but they should have been rotated. LVN 5 stated the licensed nurses that administered Resident 35's insulin did not follow the physician's orders because the sites were not rotated. During an interview on 8/15/2025 at 11:37 a.m., with the Director of Nursing (DON), the DON stated the licensed staff should rotate the insulin sites of administration on residents. The DON stated frequent repetition of insulin site administration could lead to lipodystrophy causing malabsorption of insulin producing hypoglycemia or hyperglycemia in residents. The DON stated that not rotating insulin administration site is a medication error. During a review of the facility's recent policy and procedure (P&P) titled Adverse Consequences and Medication Errors, last reviewed on 4/16/2025, the P&P indicated the interdisciplinary team evaluates medication usage in order to prevent and detect adverse consequences and medication-related problems such as adverse drug reactions (ADRs) and side effects. Adverse consequences shall be reported to the attending physician and pharmacist, and to federal agencies as appropriate. Policy Interpretation and Implementation 5. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer's specifications, or accepted professional standards and principles of the professional(s) providing services. During a review of the facility-provided Highlights of Prescribing Information on the use of Insulin Lispro injection, for subcutaneous or intravenous use, with initial U.S. approval in 1996, the Highlights of Prescribing Information indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis. During a review of the policy and procedure (P&P) titled, Subcutaneous Medication Administration, last reviewed 4/15/2025, the P&P indicated the purpose was to administer medication in the subcutaneous tissue in order to promote slow medication absorption and prolong medication action. Select an appropriate side for injection. 4.During an observation on 8/12/25 at 9:53 AM, Resident 48 was observed self-administering Breo inhaler as prepared by the licensed vocational nurse (LVN 4.) During a review of Resident 48's admission Record, dated 7/12/2025, indicated the resident was admitted to the facility on [DATE]. During a review of Resident 48's History and Physical (H&P – a record of a comprehensive physician's assessment), dated 7/3/2025, indicated the resident had a diagnosis of shortness of breath. During a review of Resident 48's Order Summary Report (a monthly summary of all active physician orders), dated 7/31/2025, indicated the resident was prescribed Breo inhaler to administer one puff by mouth daily for shortness of breath to be clinician administered. During a review of Resident 48's Self-Administration of Medication Evaluation (an evaluation to determine if a resident has a desire or capacity to self-administer medication), dated 7/2/2025, indicated IDT has determined that it is not safe for resident to administer drugs due to cognitive impairment d/t physical/functional impairment secondary to multiple diagnosis. Resident prefers licensed nurses to administer medications. Further review of the assessment indicated Resident 19 was not approved for the self-administration of medications. During an interview on 8/12/2025 at 10:13 AM with LVN 4, LVN 4 stated she allowed Resident 48 to self-administer the Breo inhaler because this is what the resident prefers. LVN 4 stated the order for Resident 48's Breo indicated it should be clinician administered and not self-administered. LVN 4 stated Resident 48's medication self-administration assessment indicated she should not self-administer medication due to her cognitive impairment. LVN 4 stated allowing residents to self-administer medication should only be allowed once the IDT determines the resident can do so safely and competently. LVN 4 stated there is a risk that poor technique from this inhaler could lead to breathing problems for Resident 48 possibly leading to hospitalization. During a review of the facility's policy Self-Administration of Medications, dated April 2008, indicated Residents who desire to self-administer medication are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility. During a review of the facility's policy Adverse Consequences and Medication Errors, revised March 2023, indicated A 'medication error' is defined as the preparation or administration of drugs. which is not in accordance with the physician's orders. or accepted professional standards. examples of medication errors include: . failure to follow. accepted professional standards.

Based on observation, interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 1) on 9/15/2024 when Resident 2 punched Resident 1 on the face. This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility. Resident 1 sustained swelling on the left side of his face and right side of his face, and purple discoloration (change in natural skin color) to the right eye and left eye. Based on the reasonable person concept (refers to a tool to assist the survey team's assessment of the severity level of negative, or potentially negative, psychosocial outcome the deficiency may have had on a reasonable person in the resident's position) due to Resident 1's severely impaired cognition (ability to think and make decisions), an individual subjected to physical abuse may have psychological (mental or emotional) effects including feelings of hopelessness (a feeling or state of despair or lack of hope), helplessness (the belief that there is nothing that anyone can do to improve a bad situation), and humiliation. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated the facility originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), metabolic encephalopathy (a brain dysfunction that occurs due to chemical imbalance), and Alzheimer's disease (a progressive disease that destroys memory and thinking skills). During a review of Resident 1's Minimum Data Set (MDS- a standardized assessment and screening tool), dated 7/24/2024, indicated Resident 1 had severely impaired cognition and was dependent on staff with oral hygiene, toilet hygiene, bathing, dressing, and personal hygiene. During a review of Resident 1's Change of Condition (COC - a significant change in a resident's health status), dated 9/15/2024, timed at 2:01 p.m., the COC indicated that on 9/15/2024 at 1:45 p.m., Resident 3 (Resident 1 and Resident 2's roommate) was lying down in his bed when Resident 1 came from outside the room. Resident 1 wheeled towards his (Resident 1's) bed to lie down. Resident 2, who was sitting on his (Resident 2's) bed, stood up and walked towards Resident 1's bed, grabbed Resident 1's call light, and hit Resident 1 in the face and went back to his (Resident 2's) bed. Resident 3 immediately went to the nursing station to ask for help. Upon Registered Nurse Supervisor's (RN Supervisor's) assessment, Resident 1 was noted with discoloration and swelling on the left and right eye requiring an ice pack to be placed on Resident 1's face. During a review of Resident 1's Medication Administration Record (MAR- a report detailing the medications administered to a resident), dated 9/15/2024 at 4:05 p.m., the MAR indicated Resident 1 received Tylenol (a medication used to treat pain) 650 mg (milligram- unit of measurement) by mouth for mild pain (pain rated at one to four on a pain scale from zero [0] to 10, where 10 is the worst possible pain) of 3 out of 10 pain level related to Resident 1's complaint of pain on his right eye and left eye. Further review of Resident 1's MAR, dated 9/16/2024 at 4:01 a.m., indicated Resident 1 received Tylenol 650 mg by mouth for a pain level of 3 out of 10. During a concurrent observation and interview on 9/17/2024 at 1:00 p.m., with Resident 1, Resident 1 was observed with swelling on the left side and right side of his face and purple discoloration to the right eye and left eye. Resident 1 stated that his eyes hurt when he closes and opens them. Resident 1 was unable to recall much of the incident with Resident 2 but remembers someone standing over him and punching him in the face. During a review of Resident 3's Admission Record, the Admission Record indicated the facility originally admitted Resident 3 on 1/24/2020 and readmitted on [DATE] with diagnoses including type two diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel.), chronic pulmonary embolism (blockage of the pulmonary arteries), and a history of falling. During a concurrent observation and interview 3 on 9/17/2024 at 1:30 p.m. with Resident, Resident 3 was in bed awake, alert, and verbally responsive. Resident 3, while demonstrating with his two (right and left) closed fists up in the air using forward and backward motion, stated he saw Resident 2 punching Resident 1 with closed fists at Resident 1's face. Resident 3 stated no words were exchanged prior to the incident, but he (Resident 3) just saw Resident 2 punching Resident 1's face. Resident 3 stated he then went to the nurse's station to tell the charge nurse immediately. During a review of Resident 2's Admission Record, the Admission Record indicated the facility originally admitted Resident 2 on 12/30/2021 and readmitted on [DATE] with diagnoses that included dementia, bipolar disorder (a serious mental illness that causes unusual shifts in mood), and schizoaffective disorder (a mental illness that can affect your thoughts, mood, and behavior). During a review of Resident 2'S MDS, dated [DATE], indicated Resident 2 had severely impaired cognition and required supervision with eating, oral hygiene, and personal hygiene. During a review of Resident 2's current Plan of Care, dated 1/3/2023, the Plan of Care indicated Resident 2 had altered behavior patterns manifested by episodes of outbursts of anger, and episodes of inability to cope with stimuli (anything that can trigger a physical or behavioral change) leading to episodes of anger. The interventions included to assess what may cause the behavior, what may trigger the behavior and attempt to reduce and eliminate those triggers if possible. The Plan of Care further indicated that on 9/15/2024 Resident 2 had an episode of being physically aggressive towards Resident 1. During an interview on 9/17/2024 at 2:00 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 3 came to the nurse's station to notify her (cannot recall the time) that he (Resident 3) witnessed Resident 2 punching Resident 1 in the face with closed fists. LVN 1 stated Resident 1 was noted with swelling and redness to the right side of the face including the eyes. LVN 1 stated she asked Resident 1 what happened, and Resident 1 told her that he (Resident 1) was punched in the face. LVN 1 asked Resident 2 why he punched Resident 1 in the face, but she (LVN 1) stated he (Resident 2) had no response. During a concurrent interview and record review on 9/17/2024 at 3:00 p.m., with RN Supervisor, Resident 1's COC form, Physician's Order and MAR were reviewed. RN Supervisor stated she was notified (cannot recall the time) by LVN 1 that Resident 2 punched Resident 1 in the face, and she (RN Supervisor) went immediately to assess both residents (Residents 1 and 2). RN Supervisor stated, that when she went inside the room, she noted Resident 1 with a swollen face with redness to the right eye. RN Supervisor stated she asked Resident 2 what happened, and he stated he was provoked, but did not disclose further information. RN Supervisor requested for LVN 1 to apply ice to Resident 1's face and administer Tylenol for pain. RN Supervisor further stated the local law enforcement were notified and Resident 2 was transferred to the hospital for further behavioral evaluation. During an interview on 9/19/2024 at 11:00 a.m., with the Director of Nurses (DON), the DON stated, the incident was unpredictable, but she provided training to the staff regarding prevention of abuse and communication between LVNs and Certified Nurse Assistants. The DON stated that daily huddles should be conducted to notify of any resident experiencing any significant behavioral issues. During a review of the current facility-provided policy and procedure titled, Monitoring Residents undated, indicated those residents identified to have behavioral symptoms potential for conflict and anger shall be monitored in accordance with plan of care developed to address such problems. Monitoring of such residents shall be the responsibility of, but not limited to, direct caregivers, charge nurses, nursing supervisors, and members of the interdisciplinary team. During a review of the current facility-provided policy and procedure titled, Abuse & Mistreatment of Residents, undated, indicated to uphold a resident's right to be free from verbal, sexual, and mental abuse, corporal punishment, involuntary seclusion, and exploitation. Abuse is defined as the willful infliction of injury, unreasonable confinement, or punishment with resulting physical hard or pain or mental anguish, deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Residents identified to have behavioral symptoms with a potential for conflict and anger shall be monitored in accordance with plans of care developed to address such problems. Monitoring of such residents shall be the responsibility of, but not limited to, direct caregivers, Charge Nurses. Nursing Supervisors, and members of the interdisciplinary team.

Based on interview and record review, the facility failed to ensure Registered Nurse 1 (RN 1) had the skills and knowledge to provide nursing services to one of five sampled resident (Resident 1) by failing to ensure: 1. RN 1 followed the facility ' s policy and procedure (P&P) titled, Change of Condition, (COC - a major decline in a resident ' s status) and called Resident 1 ' s Medical Doctor (MD) 1 to secure orders or request for interventions from MD 1 to address Resident 1 ' s COC when Respiratory Therapist 2 (RT 2) endorsed RN 1 to notify MD 1, after RT 2 replaced Resident 1 ' s tracheal tube (size 7.5 millimeter (mm, one thousandth of a meter) with a smaller-sized tube (6 mm) and RT 2 noted Resident 1 had bilateral (both lungs) diminished (decreased) breath sounds and minimal airflow from the airway (a passageway for air into or out of the lungs). 2. RN 1 followed the facility ' s policy titled, Cardiopulmonary Resuscitation, (CPR- an emergency procedure used to restart a person's heartbeat and breathing after one or both have stopped) and immediately called the paramedics (health professionals certified to perform advanced life support procedures) on [DATE] at 5:55 am upon finding Resident 1 with vital signs (clinical measurements, specifically pulse rate/heart rate, temperature, respiration rate [number of breaths a person takes per minute], and blood pressure [the force of the blood pushing against the walls of the arteries], that indicated the state of a patient ' s/resident ' s essential body functions) unappreciated (not located, felt, or heard). RN 1 called the paramedics at 6:01 a.m. (6 mins after). As a result, on [DATE] at 5:55 a.m., Registered Nurse 1 (RN 1) and Licensed Vocational Nurse 2 (LVN 2) found Resident 1 with breathing difficulty, and Resident 1 starting to turn blue. The paramedics arrived at 6:08 a.m. The paramedic found Resident 1 lying in bed with rigor (stiffening of the body muscles due to chemical changes after death) and lividity (the bluish-purple discoloration of skin after death) and pronounced Resident 1 dead on [DATE], at 6:13 a.m. On [DATE] at 2:02 p.m., while onsite at the facility, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility ' s failure to ensure RN 1 had the skills and knowledge to identify Resident 1 ' s COC and immediately call 911 (phone number for emergency services) when Resident 1 did not have a vital signs under 42 CFR S483.35 Nursing Services. On [DATE] at 12:12 p.m., the ADM and DON submitted an IJ Removal Plan (a detailed plan to address the IJ findings). While onsite at the facility, the SSA verified the IJ situation was no longer present and confirmed the facility ' s implementation of the IJ Removal Plan through observations, interviews, and record reviews, the SSA accepted the IJ Removal Plan and removed the IJ situation in the presence of the ADM and DON on [DATE], at 3:30 p.m. The acceptable IJ Removal Plan included the following summarized actions: 1. On [DATE], the DON provided one on one (1:1, one staff to one staff) in-service education and COC competency to RN 1 regarding the proper procedures for assessing, identifying, and addressing a resident ' s COC, monitoring for any change of condition, and prompt notification of the physician to request for appropriate interventions for a COC. 2. On [DATE], the DON and the Sub-Acute unit (unit with patients/residents who required lesser degree than acute care) RN 1 initiated in-service/education for all interdisciplinary (IDT- a group of healthcare professional from different discipline who participate in the care of the residents) staff (Nursing, Respiratory, Environmental, Dietary, Activities, Medical Records, Social Services, and Rehab Services) regarding the proper procedures for identifying a resident ' s COC, reporting a COC, monitoring for any COC, and prompt notification of the physician to request for appropriate interventions for a COC. All decannulations (removal of the tracheostomy tube) or trach changes that require a smaller tracheal tube will be reported to the physician promptly for interventions. 3. On [DATE], the DON and RN (unidentified) reviewed 15 residents ' medical records with a change of condition in the last 72 hours. All documentation reflected that the physician was notified promptly regarding the change of condition as required. 4. On [DATE], the DON and the Quality Assurance (QA) Consultant created a new COC Validation Competency which included recognizing signs and symptoms of respiratory distress (a condition where the body needs more oxygen), identifying a COC, notifying the physician regarding a COC immediately and documenting in the resident's medical record. 5. On [DATE], all 43 residents with tracheostomy tubes were assessed by the respiratory therapist and no other residents were identified with abnormal findings. All residents had the proper trach size as ordered by the physician and no issues with tracheal tube placement. There were no residents with decannulation in the last 72 hours. 6. The DON/ Designee will randomly review at least 10 residents ' medical records with COC charts per month for 3 months and then quarterly thereafter. 7. On [DATE], The Director of Staff Development (DSD) reviewed all RNs competencies to ensure completion. No other RNs were affected. 8. RN 1 will receive and pass competency training monthly for 3 months and then annually thereafter. The DON/DSD/ Designee will repeat in-service training monthly for 3 months and then quarterly and as needed regarding the proper procedures for identifying a resident's change of condition, reporting a change of condition, monitoring for any change of condition, and prompt notification of the physician to request for appropriate interventions for a change of condition, calling the paramedics in a timely manner during an emergency, and contacting the medical director if a physician does not answer. 9. The DON/Designee will complete 10 competencies per month for IDT staff using the COC Competency and Validation form. 10. Any negative findings of the residents ' medical records audit will be reported by the Medical Records Director/ Designee to the Quality Assurance Committee monthly for 3 months and then quarterly thereafter for review and further action as needed. Cross Reference: F580 and F695 Findings: A review of Resident 1 ' s Admission Record indicated the facility admitted the resident on [DATE] with diagnoses that included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), tracheostomy (an opening surgically created through the neck into the trachea to allow air to fill the lungs), dysphagia (swallowing difficulties), encephalopathy (a group of conditions that cause brain dysfunction) and respiratory (pertaining to the lungs) failure. A review of Resident 1 ' s Care Plan titled, Tracheostomy tube care with risk for accidental decannulation and associated respiratory distress, developed on [DATE], indicated Resident 1 needed special treatments for tracheal tube care with risk for accidental decannulation and associated respiratory distress. The approached interventions included when decannulation occurs RT (any RT) or RN (any RN) to replace the tracheostomy tube with the same size or smaller size ASAP (right away), observe and monitor vital signs, notify physician and responsible party of change of condition, and keep extra trach tubes with the same size or smaller size at the resident ' s bedside with other tracheostomy supplies. A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated [DATE] indicated Resident 1 had the ability to be understood and had the ability to understand. The MDS indicated Resident 1 was dependent on staff on oral care, toileting, showering, upper and lower body dressing, putting on and taking off footwear and personal hygiene. A review of the Physician ' s Orders for Resident 1, dated [DATE] at 1:47 p.m., indicated to place Resident 1 on a T-bar (T-shaped tubing connected to an endotracheal tube [a small, usually plastic tube inserted into the trachea through the mouth or nose to maintain an unobstructed passageway especially to deliver oxygen to the lungs] used to deliver oxygen therapy in an intubated patient who does not require mechanical ventilation [a type of therapy that helps the patient/resident breathe or breathes when the patient/resident cannot breathe]) as tolerated ,d+[DATE] (24 hours a day, seven days a week) on oxygen, every shift. A review of Resident 1 ' s Respiratory Daily Notes entered by RT 2, dated [DATE] at 11:36 p.m., indicated Resident 1 was on a T-bar, at 5 liters of oxygen per minute (LPM-unit of measurement), with thick white sputum (a mixture of saliva and mucus coughed up from the respiratory tract), and bilateral rhonchi (large airway sounds, are continuous gurgling or bubbling sounds typically heard during both inhalation [breathe in] and exhalation [breathe out]). The notes indicated Resident 1 ' s tracheal tube was midline (refers to the imaginary line that divides the body into symmetrical left and right halves) and intact, airway was patent (open) and secured. During a review of Resident 1 ' s Tracheostomy Tube Change form, dated [DATE] at 3:32 a.m. and an interview with RT 2, RT 2 stated on [DATE], at 3:32 a.m. Resident 1 ' s original tracheal tube was the Bivona 75HA60 (type of tracheal tube) which was 7.5 mm in size, and it was decannulated outside of Resident 1 ' s stoma (an opening made during surgery). RT 2 stated It appeared that Resident 1 was on his (Resident 1 ' s) side and his position may have caused his Bivona to come out of his stoma. RT 2 stated the Portex 7 mm (a type of tracheal tube) uncuffed (not cuffed) was not successfully inserted. RT 2 stated a Portex 6 mm uncuffed was inserted and a catheter (a flexible tube) was able to pass through Resident 1 ' s tracheostomy with little resistance. RT 2 stated Resident 1 ' s breath sounds were diminished with minimal airflow noted from the airway. RT 2 stated RT 2 recommended/endorsed RN 1 to obtain an order from MD 1 for an x-ray (a type of medical imaging that creates pictures of the bones and soft tissues) to confirm Resident 1 ' s new tracheal tube (Portex 6 mm) placement. The Tracheostomy Tube Change form indicated for staff (in general) to notify the physician (MD 1) if a smaller size tracheal tube was used. A review of Resident 1 ' s Change of Condition notes entered by RN 1, dated [DATE] at 5:14 a.m., indicated Resident 1 expired (died ). The notes indicated (on [DATE]), at 4 a.m., during rounds, charge nurse (LVN 2) noted that Resident 1 ' s tracheal tube was not fully secured (not attached firmly so that it cannot be moved). RT 2 and RN 1 were notified immediately. Vital signs checked after RT 2 replaced Resident 1 ' s displaced tracheal tube. The notes indicated (on [DATE]), at around 5:55 a.m. Resident 1 was noted with breathing difficulty, Resident 1 ' s vital signs were unappreciated (unrecognized), and MD 1 was notified. The notes indicated on ([DATE]) at 6:08 a.m., the paramedics arrived and took over the care and the paramedics pronounced Resident 1 expired at 6:13 a.m. A review of the Los Angeles Fire Department (LAFD) Care Report for Resident 1, dated [DATE], at 6:01 a.m., indicated LAFD received dispatch notification (on [DATE]), at 6:01 a.m. with dispatch complaint as cardiac arrest (occurs when the heart suddenly and unexpectedly stops pumping). The report indicated the paramedics arrived on scene (at the facility) at 6:08 a.m. and at 6:12 a.m., exam indicated Resident 1 was unresponsive, pale, with bilateral eyes fixed (did not react to light) and dilated (became wider/larger). The report indicated Resident 1 was lying in hospital bed of nursing home obviously dead. The report indicated Resident 1 had rigor and lividity. Resident 1 was determined dead at 6:13 a.m. During an interview on [DATE] at 2:29 p.m., RN 1 stated that (on [DATE]) at around 4 a.m. LVN 2 and RT 2 told RN 1 that Resident 1 ' s tracheostomy tube was partially displaced, and RT 2 replaced Resident 1 ' s tracheostomy tube. RN 1 stated at 5:55 a.m. LVN 2 and RN 1 walked into Resident 1 ' s room and saw Resident 1 was gasping for air like he (Resident 1) could not breathe. RN 1 stated he (RN 1) yelled for help. RN 1 stated RT 3 who was close by arrived and asked RN 1 to call code blue, (generally used to indicate a patient requiring resuscitation or otherwise in need of immediate medical attention, most often as the result of a respiratory or cardiac arrest [occurs when the heart suddenly and unexpectedly stops pumping]) and RT 3 came into Resident 1 ' s room and started CPR. RN 1 stated the crash cart (a wheeled container carrying medicine and equipment for use in emergency resuscitations) was nearby and it (the crash cart) was pulled into Resident 1 ' s room. RN 1 stated there was a phone on top of the crash cart and he (RN 1) called 911. RN 1 stated RT 3 checked Resident 1 ' s tracheostomy tube and changed the oxygen via artificial manual breathing unit (ambu bag - a type of device known as a bag valve mask, which is used to provide respiratory support to patients) to a full-face mask. RN 1 stated he did not assist with the CPR as it was all done by RT 3. During an interview on [DATE] at 3 p.m., LVN 2 stated (on [DATE]) at 4 a.m., she (LVN 2) found Resident 1 ' s tracheostomy tube was out (displaced) and called RT 2. LVN 2 stated RT 2 placed Resident 1 ' s tracheal tube, and Resident 1 ' s vital signs were taken and were within normal ranges (the results were normal, and no further investigation or treatment is needed). LVN 2 stated (on [DATE]), at 5:55 a.m. RN 1 called LVN 2 for help when RN 1 saw Resident 1 was having difficulty breathing/labored breathing (breathing that requires observed effort or an increased amount of energy). LVN 2 stated she (LVN 2) tried to obtain Resident 1 ' s vital signs but she was not able to get the vital signs reading. LVN 2 stated Resident 1 started to turn blue. LVN 2 stated RN 1 called the code blue and RT 3 then got inside Resident 1 ' s room. LVN 2 stated Resident 1 lost consciousness and RT 3 started CPR on Resident 1. LVN 2 stated the paramedics arrived at the facility (on [DATE]) at around 6:08 a.m., and the paramedics took over Resident 1 ' s care. During an interview on [DATE] at 3:30 p.m., RT 2 stated that (on [DATE]) at around 3:30 a.m. Resident 1 ' s tracheostomy tube came out (displaced) while Resident 1 was lying on Resident 1 ' s side (did not indicate which side). RT 2 stated when he (RT 2) asked Resident 1 how long the tracheostomy tube had been out Resident 1 stated he (Resident 1) did not know. RT 2 stated he (RT 2) then did an emergency tracheostomy tube change. RT 2 stated emergency tracheostomy tube change meaning he must insert a new tracheal tube. RT 2 stated Resident 1 ' s tracheal tube was a size 7.5 mm and he tried to insert a size 7 mm, but it (the new tracheal tube size 7 mm) did not go through. RT 2 stated he then inserted a smaller tracheostomy tube size 6 mm and Resident 1 ' s oxygen saturations (the amount of oxygen being carried by red blood cells and normal level is usually 95% or higher) went from 95% to 98%. RT 2 stated he informed RN 1 to get an x-ray to confirm the new tracheal tube placement. RT 2 stated Resident 1 ' s breath sounds were diminished with minimal airflow due to a smaller size of the new tracheal tube. During an interview on [DATE] at 4:30 p.m., RN 1 stated RT 2 did ask RN 1 to obtain an order for an x-ray on Resident 1 to confirm the new tracheal tube placement, but RT 2 said Resident 1 was okay. RN 1 stated RT 2 mentioned it casually and he (RN 1) did not call MD 1 to obtain a new order for the X-ray to confirm Resident 1 ' s new tracheal tube placement as requested by RT 2. RN 1 stated he (RN 1) informed MD 1 when Resident 1 was having distress on [DATE] at 5:55 a.m. RN 1 stated there were no prior notifications made to MD 1. During a concurrent interview with RT 5 and a review of Resident 1 ' s Tracheostomy Tube Change form, dated [DATE], on [DATE] at 10:33 a.m., RT 5 stated that when RT 2 was unable to insert the current size (same size) tracheal tube, RT 2 must notify the doctor and get a new order for the new size of the tracheal tube. RT 5 stated when RT 2 noticed Resident 1 had diminished breath sounds as indicated on RT 2 ' s notes, RT 2 needed to send Resident 1 to a General Acute Care Hospital (GACH) for further evaluation. RT 5 stated Resident 1 ' s minimal airflow was not a good thing. RT 5 stated it would be a concern when Resident 1 ' s diminished breath sounds was a new onset. RT 5 stated on [DATE] at around 5:58 a.m., RN 2 called her in Resident 1 ' s room. RT 5 stated RT 3 and RT 6 were already performing chest compressions on Resident 1. RT 5 stated Resident 1 was lying flat in bed, pulseless (without a heart rate), and Resident 1 ' s nail beds were pale. During an interview on [DATE] at 11:39 a. m., RN 2 stated on [DATE] at around 5:50 a.m., while getting a report from RN 1, RN 1 stated Resident 1 needed a follow up due to prior issue with tracheostomy. RN 2 stated he (RN 2) did an initial round and saw Resident 1 was pale in color. RN 2 stated he yelled, I need help here. RN 2 stated Resident 1 was still breathing but he (Resident 1) was struggling to breathe. RN 2 stated when RT 2 downsized Resident 1 ' s tracheal tube, and RT 2 endorsed to RN 1 to notify MD 1 then RN 1 must notify MD 1. RN 2 stated RT 2 can also communicate to the doctor (MD 1). During an interview on [DATE] at 1:07 p.m., RT 2 stated RNs (any RN) must notify the doctor when RTs (any RT) downsized the resident ' s tracheal tube. RT 2 stated RNs must update the doctor because it is a new airway and RNs must obtain new orders for the new tracheal tube size. During an interview on [DATE] at 1:17 p.m., RT 3 stated that on [DATE] at 5:55 a.m. he (RT 3) was close by when RN 1 called to help Resident 1. RT 3 stated he ran into Resident 1 ' s room and he (RT 3) was the first staff assessing Resident 1. RT 3 stated Resident 1 was not breathing, the resident had no pulse, and the resident ' s color was dark. RT 3 stated he (RT 3) checked and saw Resident 1 ' s tracheostomy tie was loose, and Resident 1 was not breathing. RT 3 stated the canula (a small tube that is inserted into a body cavity for medical purposes) was still in and he tightened the tracheostomy tie. RT 3 stated when there is a need to downsize the tracheal tube due to decannulation, one must notify the doctor and ask for a new order for the new tracheal tube size. During an interview on [DATE] at 4:30 p.m., MD 1 stated he (MD 1) was notified of Resident 1 ' s change in condition only when Resident 1 required emergency services on [DATE], at 5:55 a.m. During an interview on [DATE] at 9:32 a.m., RN 1 stated if RT 2 had told RN 1 that Resident 1 had diminished equal breath sounds and minimal airflow, he (RN 1) would monitor Resident 1. RN 1 stated he would do a COC but would have not reported to MD 1 at 4 a.m. because MD 1 would have not responded to his (RN 1 ' s) call at that time (4 a.m.) RN 1 stated he would have waited until the morning (unspecified time) to inform MD 1. During a concurrent review of Resident 1 ' s Trach tube change document, dated [DATE] and interview with the DON on [DATE] at 10:11 a.m., the DON stated, tracheal tube decannulation is not expected but it can happen. The DON reviewed Resident 1 ' s Trach Tube Change Document, and stated staff (in general) needed to notify the physician when a smaller tracheal tube is used. The DON stated MD 1 was not notified when RT 2 downsized Resident 1 ' s tracheal tube. The DON stated the start of the COC for Resident 1 was when Resident 1 ' s tracheal tube decannulation occurred. The DON stated when there was a COC, the resident ' s family member and doctor must be notified. The DON stated RN 1 should have called MD 1 when Resident 1 was not stable. The DON stated that based on Resident 1 ' s Trach tube change notes written by RT 2, Resident 1 was not stable when Resident 1 had diminished bilateral breath sounds with minimal airflow. During a concurrent review of Resident 1 ' s Tracheostomy Notes and interview with the DON on [DATE] at 10:55 a.m., the DON stated Resident 1 ' s Tracheostomy notes, dated [DATE] indicated that Resident 1 had been rhonchi throughout his (Resident 1 ' s) stay then after the tracheostomy tube change on [DATE] due to the tracheal tube decannulation, Resident 1 had diminished bilateral breath sounds with minimal airflow. The DON stated, it was a new change of condition. A review of the current facility-provided P&P titled, Change of Condition, last revised on [DATE], indicated, to ensure proper assessment and follow-through for any resident with a change of condition. c. Upon a change in condition for any reason, nursing staff member are to take the following actions. Physician shall be called promptly. If for some reason physician cannot be reached, alternative physician shall be contacted. If alternate cannot be reached, Medical Director is to be contacted. All contacts or attempt to contact shall be documented and include the correct time of the activity. If no physician is available, arrangements are to be made for physician services that may include transfer to ER (emergency room ) for appropriate care. A review of the current facility-provided P&P titled, Reinsertion (putting something back into or inside of something else) of Accidental Extubation (removal) of Trach Tube, undated, indicated sub-acute licensed staff, including RCPs (Respiratory Care Practitioners), RNs, and LVNs, must reinsert trach tubes that have been accidentally extubated. 3. Unsuccessful attempts to reinsert trach tube will be brought to the attention of the RCP or Nurse Manager. 4. Orders to replace extubated trach tube will be included in the physicians ' orders. A review of the current facility-provided P&P titled, Cardiopulmonary Resuscitation, undated, indicated to provide life support to an individual. Steps: 1. Determine consciousness of individual shake and shout, Are you alright? 2. Call for help: 911 or EMS (Emergency Medical Services). 3. Position the individual flat on back. 4. Tilt head back and open airway. 5. Check for breathing. 6. Give two full breaths. 7. Check for pulse.

Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Change of Condition (COC - a major decline in a resident ' s status), and notify the physician for one of five sampled residents (Resident 1) who had a significant COC that started on [DATE] at 4 a.m. On [DATE], at 4 a.m., Resident 1 ' s tracheal tube (trach tube, a two-inch-to three-inch-long curved metal or plastic tube placed in a surgically created opening [tracheostomy] in the windpipe to keep it open) was partially (not completely) displaced (removed from the usual or proper place). Respiratory Therapist 2 (RT 2) was unable to replace the tracheal tube with the same size (7.5 millimeter (mm, one thousandth of a meter) but was able to replace the tracheal tube with a smaller-sized tube (6 mm). RT 2 noted Resident 1 with bilateral (both lungs) diminished (decreased) breath sounds and minimal airflow from the airway (a passageway for air into or out of the lungs). RT 2 endorsed Registered Nurse 1 (RN 1) to notify Resident 1 ' s Medical Doctor (MD 1), but RN 1 did not notify MD 1 regarding Resident 1 ' s COC and RT 2 replaced Resident 1 ' s tracheal tube with a different tracheal tube. As a result, on [DATE] at 5:55 a.m., RN 1 and Licensed Vocational Nurse 2 (LVN 2) found Resident 1 with breathing difficulty, vital signs (clinical measurements, specifically pulse/heart rate, temperature, respiration rate [number of breaths a person takes per minute], and blood pressure [the force of the blood pushing against the walls of the arteries], that indicated the state of a patient ' s/resident ' s essential body functions) unappreciated (not located, felt, or heard), and Resident 1 starting to turn blue. The paramedics (health professionals certified to perform advanced life support procedures) arrived at the facility at 6:08 a.m. The paramedic found Resident 1 lying in bed with rigor (stiffening of the body muscles due to chemical changes after death) and lividity (the bluish-purple discoloration of skin after death) and pronounced Resident 1 dead on [DATE], at 6:13 a.m. On [DATE] at 2:02 p.m., while onsite at the facility, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility ' s failure to notify the physician regarding Resident 1 ' s COC under 42 CFR S483.10(g)(14) Notification of Changes. On [DATE] at 12:12 p.m., the ADM and DON submitted an IJ Removal Plan (a detailed plan to address the IJ findings). While onsite at the facility, the SSA verified that the IJ situation was no longer present and confirmed the facility ' s implementation of the IJ Removal Plan through observations, interviews, and record reviews, the SSA accepted the IJ Removal Plan and removed the IJ situation in the presence of the ADM and DON on [DATE], at 3:30 p.m. The acceptable IJ Removal Plan included the following summarized actions: 1. On [DATE], the DON provided one on one (1:1) in-service education and COC competency to RN 1 regarding the proper procedures for assessing, identifying, and addressing a resident ' s COC, monitoring for any change of condition, and prompt notification of the physician to request for appropriate interventions for a COC. 2. On [DATE], the DON and Sub-Acute unit (unit with patients/residents who required lesser degree than acute care) RN 1 initiated in-service/education for all interdisciplinary (IDT- a group of healthcare professional from different discipline who participate in the care of the residents) staff (Nursing, Respiratory, Environmental, Dietary, Activities,, Medical Records, Social Services, and Rehab Services) regarding: the proper procedures for identifying a resident ' s COC, reporting a COC, monitoring for any COC, and prompt notification of the physician to request for appropriate interventions for a COC. All decannulations (removal of the tracheostomy tube) or trach changes that require a smaller tracheal tube will be reported to the physician promptly for interventions. 3. On [DATE], the DON and a RN reviewed 15 residents ' medical records with a change of condition in the last 72 hours. All documentation reflected that the physician was notified promptly regarding the change of condition as required. 4. On [DATE], the DON and the Quality Assurance (QA) Consultant created a new COC Validation Competency which included recognizing signs and symptoms of respiratory distress (a condition where the body needs more oxygen), identifying a COC, notifying the physician regarding a COC immediately and documenting in the resident's medical record. 5. On [DATE], all 43 residents with tracheostomy tubes were assessed by the respiratory therapists and no other residents were identified with abnormal findings. All residents had the proper trach size as ordered by the physician and no issues with tracheal tube placement. There were no residents with decannulation in the last 72 hours. 6. The DON/ Designee will randomly review at least 10 residents ' medical records with COC per month for 3 months and then quarterly thereafter. Cross Reference F695 and F726 Findings: A review of Resident 1 ' s Admission Record indicated the facility admitted the resident on [DATE] with diagnoses that included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), tracheostomy (an opening surgically created through the neck into the trachea to allow air to fill the lungs), dysphagia (swallowing difficulties), encephalopathy (a group of conditions that cause brain dysfunction ), and respiratory (pertaining to the lungs) failure. A review of Resident 1 ' s Care Plan titled, Tracheostomy tube care with risk for accidental decannulation and associated respiratory distress, developed on [DATE], indicated Resident 1 needed special treatments for tracheal tube care with risk for accidental decannulation and associated respiratory distress. The approached interventions included when decannulation occurs RT (any RT) or RN (any RN) to replace the tracheostomy tube with the same size or smaller size ASAP (right away), observe and monitor vital signs, notify physician and responsible party of change of condition, and keep extra trach tubes with the same size or smaller size at the resident ' s bedside with other tracheostomy supplies. A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated [DATE] indicated Resident 1 had the ability to be understood and had the ability to understand. The MDS indicated Resident 1 was dependent on staff on oral care, toileting, showering, upper and lower body dressing, putting on and taking off footwear and personal hygiene. A review of the Physician ' s Orders for Resident 1, dated [DATE] at 1:47 p.m., indicated to place Resident 1 on a T-bar (T-shaped tubing connected to an endotracheal tube [a small, usually plastic tube inserted into the trachea through the mouth or nose to maintain an unobstructed passageway especially to deliver oxygen to the lungs] used to deliver oxygen therapy in an intubated patient who does not require mechanical ventilation [a type of therapy that helps the patient/resident breathe or breathes when the patient/resident cannot breathe]) as tolerated ,d+[DATE] (24 hours a day, seven days a week) on oxygen, every shift. A review of Resident 1 ' s Respiratory Daily Notes entered by RT 2, dated [DATE] at 11:36 p.m., indicated Resident 1 was on a T-bar, at 5 liters of oxygen per minute (LPM-unit of measurement), with thick white sputum (a mixture of saliva and mucus coughed up from the respiratory tract), and bilateral rhonchi (large airway sounds, are continuous gurgling or bubbling sounds typically heard during both inhalation [breathe in] and exhalation [breathe out]). The notes indicated Resident 1 ' s tracheal tube was midline (refers to the imaginary line that divides the body into symmetrical left and right halves) and intact, airway was patent (open) and secured. During a review of Resident 1 ' s Tracheostomy Tube Change form, dated [DATE] at 3:32 a.m. and an interview with RT 2, RT 2 stated on [DATE], at 3:32 a.m. Resident 1 ' s original tracheal tube was the Bivona 75HA60 (type of tracheal tube) which was 7.5 mm in size, and it was decannulated outside of Resident 1 ' s stoma (an opening made during surgery). RT 2 stated It appeared that Resident 1 was on his (Resident 1 ' s) side and his position may have caused his Bivona to come out of his stoma. RT 2 stated the Portex 7 mm (a type of tracheal tube) uncuffed (not cuffed) was not successfully inserted. RT 2 stated a Portex 6 mm uncuffed was inserted and a catheter (a flexible tube) was able to pass through Resident 1 ' s tracheostomy with little resistance. RT 2 stated Resident 1 ' s breath sounds were diminished with minimal airflow noted from the airway. RT 2 stated RT 2 recommended/endorsed RN 1 to obtain an order from MD 1 for an x-ray (a type of medical imaging that creates pictures of the bones and soft tissues) to confirm Resident 1 ' s new tracheal tube (Portex 6 mm) placement. The Tracheostomy Tube Change form indicated for staff (in general) to notify the physician (MD 1) if a smaller size tracheal tube was used. A review of Resident 1 ' s Change of Condition notes entered by RN 1, dated [DATE] at 5:14 a.m., indicated Resident 1 expired (died ). The notes indicated (on [DATE]), at 4 a.m., during rounds, charge nurse (LVN 2) noted that Resident 1 ' s tracheal tube was not fully secured (not attached firmly so that it cannot be moved). RT 2 and RN 1 were notified immediately. Vital signs checked after RT 2 replaced Resident 1 ' s displaced tracheal tube. The notes indicated (on [DATE]), at around 5:55 a.m. Resident 1 was noted with breathing difficulty, Resident 1 ' s vital signs were unappreciated (unrecognized), and MD 1 was notified. The notes indicated on ([DATE]) at 6:08 a.m., the paramedics arrived and took over the care and the paramedics pronounced Resident 1 expired at 6:13 a.m. A review of the Los Angeles Fire Department (LAFD) Care Report for Resident 1, dated [DATE], at 6:01 a.m., indicated LAFD received dispatch notification (on [DATE]), at 6:01 a.m. with dispatch complaint as cardiac arrest (occurs when the heart suddenly and unexpectedly stops pumping). The report indicated the paramedics arrived on scene (at the facility) at 6:08 a.m. and at 6:12 a.m., exam indicated Resident 1 was unresponsive, pale, with bilateral eyes fixed (did not react to light) and dilated (became wider/larger). The report indicated Resident 1 was lying in hospital bed of nursing home obviously dead. The report indicated Resident 1 had rigor and lividity. Resident 1 was determined dead at 6:13 a.m. During an interview on [DATE] at 2:29 p.m., RN 1 stated that (on [DATE]) at around 4 a.m. LVN 2 and RT 2 told RN 1 that Resident 1 ' s tracheostomy tube was partially displaced, and RT 2 replaced Resident 1 ' s tracheostomy tube. RN 1 stated at 5:55 a.m. LVN 2 and RN 1 walked into Resident 1 ' s room and saw Resident 1 was gasping for air like he (Resident 1) could not breathe. RN 1 stated he (RN 1) yelled for help. RN 1 stated RT 3 who was close by arrived and asked RN 1 to call code blue, (generally used to indicate a patient requiring resuscitation or otherwise in need of immediate medical attention, most often as the result of a respiratory or cardiac arrest [occurs when the heart suddenly and unexpectedly stops pumping]) and RT 3 came into Resident 1 ' s room and started cardiopulmonary resuscitation (CPR- an emergency procedure used to restart a person's heartbeat and breathing after one or both have stopped). During an interview on [DATE] at 3 p.m., LVN 2 stated (on [DATE]) at 4 a.m., she (LVN 2) found Resident 1 ' s tracheostomy tube was out (displaced) and called RT 2. LVN 2 stated RT 2 placed Resident 1 ' s tracheal tube, and Resident 1 ' s vital signs were taken and were within normal ranges (the results were normal, and no further investigation or treatment is needed). LVN 2 stated (on [DATE]), at 5:55 a.m. RN 1 called LVN 2 for help when RN 1 saw Resident 1 was having difficulty breathing/labored breathing (breathing that requires observed effort or an increased amount of energy). LVN 2 stated she (LVN 2) tried to obtain Resident 1 ' s vital signs but she was not able to get the vital signs reading. LVN 2 stated Resident 1 started to turn blue. LVN 2 stated RN 1 called the code blue and RT 3 then got inside Resident 1 ' s room. LVN 2 stated Resident 1 lost consciousness and RT 3 started CPR on Resident 1. LVN 2 stated the paramedics arrived at the facility (on [DATE]) at around 6:08 a.m., and the paramedics took over Resident 1 ' s care. During an interview on [DATE] at 3:30 p.m., RT 2 stated that (on ,d+[DATE]) at around 3:30 a.m. Resident 1 ' s tracheostomy tube came out (displaced) while Resident 1 was lying on Resident 1 ' s side (did not indicate which side). RT 2 stated when he (RT 2) asked Resident 1 how long the tracheostomy tube had been out Resident 1 stated he (Resident 1) did not know. RT 2 stated he (RT 2) then did an emergency tracheostomy tube change. RT 2 stated emergency tracheostomy tube change meaning he must insert a new tracheal tube. RT 2 stated Resident 1 ' s tracheal tube was a size 7.5 mm and he tried to insert a size 7 mm, but it (the new tracheal tube size 7 mm) did not go through. RT 2 stated he then inserted a smaller tracheostomy tube size 6 mm and Resident 1 ' s oxygen saturations (the amount of oxygen being carried by red blood cells and normal level is usually 95% or higher) went from 95% to 98%. RT 2 stated he informed RN 1 to get an x-ray to confirm the new tracheal tube placement. RT 2 stated Resident 1 ' s breath sounds were diminished with minimal airflow due to a smaller size of the new tracheal tube. During an interview on [DATE] at 4:30 p.m., RN 1 stated RT 2 did ask RN 1 to obtain an order for an x-ray on Resident 1 to confirm the new tracheal tube placement, but RT 2 said Resident 1 was okay. RN 1 stated RT 2 mentioned it casually and he (RN 1) did not call MD 1 to obtain a new order for the x-ray to confirm Resident 1 ' s new tracheal tube placement as requested by RT 2. RN 1 stated he (RN 1) informed MD 1 when Resident 1 was having distress on [DATE] at 5:55 a.m. RN 1 stated there were no prior notifications made to MD 1. During a concurrent interview with RT 5 and a review of Resident 1 ' s Tracheostomy Tube Change form, dated [DATE], on [DATE] at 10:33 a.m., RT 5 stated that when RT 2 was unable to insert the current size (same size) tracheal tube, RT 2 must notify the doctor and get a new order for the new size of the tracheal tube. RT 5 stated when RT 2 noticed Resident 1 had diminished breath sounds as indicated on RT 2 ' s notes, RT 2 needed to send Resident 1 to a General Acute Care Hospital (GACH) for further evaluation. RT 5 stated Resident 1 ' s minimal airflow was not a good thing. RT 5 stated it would be a concern when Resident 1 ' s diminished breath sounds was a new onset. RT 5 stated on [DATE] at around 5:58 a.m., RN 2 called her in Resident 1 ' s room. RT 5 stated RT 3 and RT 6 were already performing chest compressions on Resident 1. RT 5 stated Resident 1 was lying flat in bed, pulseless (without a heart rate), and Resident 1 ' s nail beds were pale. During an interview on [DATE] at 11:39 a. m., RN 2 stated on [DATE] at around 5:50 a.m., while getting a report from RN 1, RN 1 stated Resident 1 needed a follow up due to prior issue with tracheostomy. RN 2 stated he (RN 2) did an initial round and saw Resident 1 was pale in color. RN 2 stated he yelled, I need help here. RN 2 stated Resident 1 was still breathing but he (Resident 1) was struggling to breathe. RN 2 stated when RT 2 downsized Resident 1 ' s tracheal tube, and RT 2 endorsed to RN 1 to notify MD 1 then RN 1 must notify MD 1. RN 2 stated RT 2 can also communicate to the doctor (MD 1). During an interview on [DATE] at 1:07 p.m., RT 2 stated RNs (any RN) must notify the doctor when RTs (any RT) downsized the resident ' s tracheal tube. RT 2 stated RNs must update the doctor because it is a new airway and RNs must obtain new orders for the new tracheal tube size. During an interview on [DATE] at 1:17 p.m., RT 3 stated that on [DATE] at 5:55 a.m. he (RT 3) was close by when RN 1 called to help Resident 1. RT 3 stated he ran into Resident 1 ' s room and he (RT 3) was the first staff assessing Resident 1. RT 3 stated Resident 1 was not breathing, the resident had no pulse, and the resident ' s color was dark. RT 3 stated he (RT 3) checked and saw Resident 1 ' s tracheostomy tie was loose, and Resident 1 was not breathing. RT 3 stated the canula (a small tube that is inserted into a body cavity for medical purposes) was still in and he tightened the tracheostomy tie. RT 3 stated when there is a need to downsize the tracheal tube due to decannulation, one must notify the doctor and ask for a new order for the new tracheal tube size. During an interview on [DATE] at 4:30 p.m., MD 1 stated he (MD 1) was notified of Resident 1 ' s change in condition only when Resident 1 required emergency services on [DATE], at 5:55 a.m. During an interview on [DATE] at 9:32 a.m., RN 1 stated if RT 2 had told RN 1 that Resident 1 had diminished equal breath sounds and minimal airflow, he (RN 1) would monitor Resident 1. RN 1 stated he would do a COC but would have not reported to MD 1 at 4 a.m. because MD 1 would have not responded to his (RN 1 ' s) call at that time (4 a.m.). RN 1 stated he would have waited until the morning (unspecified time) to inform MD 1. During a concurrent review of Resident 1 ' s Trach tube change document, dated [DATE] and interview with the DON on [DATE] at 10:11 a.m., the DON stated, tracheal tube decannulation is not expected but it can happen. The DON reviewed Resident 1 ' s Trach tube change document, and stated staff (in general) needed to notify the physician when a smaller tracheal tube is used. The DON stated MD 1 was not notified when RT 2 downsized Resident 1 ' s tracheal tube. The DON stated the start of the COC for Resident 1 was when Resident 1 ' s tracheal tube decannulation occurred. The DON stated when there was a COC, the resident ' s family member and doctor must be notified. The DON stated RN 1 should have called MD 1 when Resident 1 was not stable. The DON stated that based on Resident 1 ' s Trach tube change notes written by RT 2, Resident 1 was not stable when Resident 1 had diminished bilateral breath sounds with minimal airflow. During a concurrent review of Resident 1 ' s Tracheostomy Notes and interview with the DON on [DATE] at 10:55 a.m., the DON stated Resident 1 ' s Tracheostomy notes, dated [DATE] indicated that Resident 1 had been rhonchi throughout his (Resident 1 ' s) stay then after the tracheostomy tube changed on [DATE] due to the tracheal tube decannulation, Resident 1 had diminished bilateral breath sounds with minimal airflow. The DON stated, it was a new change of condition. A review of the current facility-provided P&P titled, Change of Condition, last revised on [DATE], indicated ensure proper assessment and follow-through for any resident with a change of condition. c. Upon a change in condition for any reason, nursing staff member are to take the following actions. Physician shall be called promptly. If for some reason physician cannot be reached, alternative physician shall be contacted. If alternate cannot be reached, Medical Director is to be contacted. All contacts or attempt to contact shall be documented and include the correct time of the activity. If no physician is available, arrangements are to be made for physician services that may include transfer to ER (emergency room ) for appropriate care.

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) received tracheostomy (an opening surgically created through the neck into the trachea to allow air to fill the lungs) care when on [DATE] at 4 a.m., Resident 1 ' s tracheal tube (trach tube, a catheter that is inserted into the trachea for the primary purpose of establishing and maintaining an open airway) was partially (not completely) displaced (removed from the usual or proper place). Respiratory Therapist 2 (RT 2) was unable to replace the tracheal tube with the same size (7.5 millimeter [mm, a metric unit of length equal to one thousandth of a meter]) but was able to replace it (the trach tube) with a smaller-sized tube (6 mm) and RT 2 noted Resident 1 had bilateral (both lungs) diminished (decreased) breath sound and minimal airflow from airway. As a result, on [DATE] at 5:55 a.m., Registered Nurse 1 (RN 1) and Licensed Vocational Nurse 2 (LVN 2) found Resident 1 with breathing difficulty, vital signs (clinical measurements, specifically pulse rate/heart rate, temperature, respiration rate [number of breaths a person takes per minute], and blood pressure [the force of the blood pushing against the walls of the arteries], that indicate the state of a patient ' s essential body functions) unappreciated (not located, felt, or heard), and Resident 1 starting to turn blue. The paramedics (health professionals certified to perform advanced life support procedures) arrived at the facility at 6:08 a.m. The paramedic found Resident 1 lying in bed with rigor (stiffening of the body muscles due to chemical changes after death) and lividity (the bluish-purple discoloration of skin after death) and pronounced Resident 1 dead on [DATE], at 6:13 a.m. On [DATE] at 2:02 p.m., while onsite at the facility, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility ' s failure to provide Resident 1 with tracheostomy care under 42 CFR S483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. On [DATE] at 12:12 p.m., the ADM and DON submitted an IJ Removal Plan (a detailed plan to address the IJ findings). While onsite at the facility, the SSA verified the IJ situation was no longer present and confirmed the facility ' s implementation of the IJ Removal Plan through observations, interviews, and record reviews, the SSA accepted the IJ Removal Plan and removed the IJ situation in the presence of the ADM and DON on [DATE], at 3:30 p.m. The acceptable IJ Removal Plan included the following summarized actions: 1. On [DATE], the DON provided one on one (1:1, one staff to one staff) in-service education and COC competency to RN 1 regarding the proper procedures for assessing, identifying, and addressing a resident ' s COC, monitoring for any change of condition, and prompt notification of the physician to request for appropriate interventions for a COC. 2. On [DATE], the DON and the Sub-Acute Unit (unit with patients/residents who required lesser degree than acute care) RN 1 initiated in-service/education for all interdisciplinary (IDT- a group of healthcare professional from different discipline who participate in the care of the residents) staff (Nursing, Respiratory, Environmental, Dietary, Activities, Medical Records, Social Services, and Rehab Services) regarding the proper procedures for identifying a resident ' s COC, reporting a COC, monitoring for any COC, and prompt notification of the physician to request for appropriate interventions for a COC. All decannulations (removal of the tracheostomy tube) or trach changes that require a smaller tracheal tube will be reported to the physician promptly for interventions. 3. On [DATE], the DON and RN (unidentified) reviewed 15 residents ' medical records with a change of condition in the last 72 hours. All documentation reflected that the physician was notified promptly regarding the change of condition as required. 4. On [DATE], the DON and the Quality Assurance (QA) Consultant created a new COC Validation Competency which included recognizing signs and symptoms of respiratory distress (a condition where the body needs more oxygen), identifying a COC, notifying the physician regarding a COC immediately and documenting in the resident's medical record. 5. On [DATE], all 43 residents with tracheostomy tubes were assessed by the respiratory therapist and no other residents were identified with abnormal findings. All residents had the proper trach size as ordered by the physician and no issues with tracheal tube placement. There were no residents with decannulation in the last 72 hours. 6. The DON/ Designee will randomly review at least 10 residents ' medical records with COC charts per month for 3 months and then quarterly thereafter. 7. On [DATE], The Director of Staff Development (DSD) reviewed all RNs competencies to ensure completion. No other RNs were affected. 8. RN 1 will receive and pass competency training monthly for 3 months and then annually thereafter. The DON/DSD/ Designee will repeat in-service training monthly for 3 months and then quarterly and as needed regarding the proper procedures for identifying a resident's change of condition, reporting a change of condition, monitoring for any change of condition, and prompt notification of the physician to request for appropriate interventions for a change of condition, calling the paramedics in a timely manner during an emergency, and contacting the medical director if a physician does not answer. 9. The DON/Designee will complete 10 competencies per month for IDT staff using the COC Competency and Validation form. 10. Any negative findings of the residents ' medical records audit will be reported by the Medical Records Director/ Designee to the Quality Assurance Committee monthly for 3 months and then quarterly thereafter for review and further action as needed. Cross Reference: F580 and F726 Findings: A review of Resident 1 ' s Admission Record indicated the facility admitted the resident on [DATE] with diagnoses that included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), tracheostomy (an opening surgically created through the neck into the trachea to allow air to fill the lungs), dysphagia (swallowing difficulties), encephalopathy (a group of conditions that cause brain dysfunction ), and respiratory (pertaining to the lungs) failure. A review of Resident 1 ' s Care Plan titled, Tracheostomy tube care with risk for accidental decannulation and associated respiratory distress, developed on [DATE], indicated Resident 1 needed special treatments for tracheal tube care with risk for accidental decannulation and associated respiratory distress. The approached interventions included when decannulation occurs RT (any RT) or RN (any RN) to replace the tracheostomy tube with the same size or smaller size ASAP (right away), observe and monitor vital signs, notify physician and responsible party of change of condition, and keep extra trach tubes with the same size or smaller size at the resident ' s bedside with other tracheostomy supplies. A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated [DATE] indicated Resident 1 had the ability to be understood and had the ability to understand. The MDS indicated Resident 1 was dependent on staff on oral care, toileting, showering, upper and lower body dressing, putting on and taking off footwear and personal hygiene. A review of the Physician ' s Orders for Resident 1, dated [DATE] at 1:47 p.m., indicated to place Resident 1 on a T-bar (T-shaped tubing connected to an endotracheal tube [a small, usually plastic tube inserted into the trachea through the mouth or nose to maintain an unobstructed passageway especially to deliver oxygen to the lungs] used to deliver oxygen therapy in an intubated patient who does not require mechanical ventilation [a type of therapy that helps the patient/resident breathe or breathes when the patient/resident cannot breathe]) as tolerated ,d+[DATE] (24 hours a day, seven days a week) on oxygen, every shift. A review of Resident 1 ' s Respiratory Daily Notes entered by RT 2, dated [DATE] at 11:36 p.m., indicated Resident 1 was on a T-bar, at 5 liters of oxygen per minute (LPM-unit of measurement), with thick white sputum (a mixture of saliva and mucus coughed up from the respiratory tract), and bilateral rhonchi (large airway sounds, are continuous gurgling or bubbling sounds typically heard during both inhalation [breathe in] and exhalation [breathe out]). The notes indicated Resident 1 ' s tracheal tube was midline (refers to the imaginary line that divides the body into symmetrical left and right halves) and intact, airway was patent (open) and secured. During a review of Resident 1 ' s Tracheostomy Tube Change form, dated [DATE] at 3:32 a.m. and an interview with RT 2, RT 2 stated on [DATE], at 3:32 a.m. Resident 1 ' s original tracheal tube was the Bivona 75HA60 (type of tracheal tube) which was 7.5 mm in size, and it was decannulated outside of Resident 1 ' s stoma (an opening made during surgery). RT 2 stated It appeared that Resident 1 was on his (Resident 1 ' s) side and his position may have caused his Bivona to come out of his stoma. RT 2 stated the Portex 7 mm (a type of tracheal tube) uncuffed (not cuffed) was not successfully inserted. RT 2 stated a Portex 6 mm uncuffed was inserted and a catheter (a flexible tube) was able to pass through Resident 1 ' s tracheostomy with little resistance. RT 2 stated Resident 1 ' s breath sounds were diminished with minimal airflow noted from the airway. RT 2 stated RT 2 recommended/endorsed RN 1 to obtain an order from MD 1 for an x-ray (a type of medical imaging that creates pictures of the bones and soft tissues) to confirm Resident 1 ' s new tracheal tube (Portex 6 mm) placement. The Tracheostomy Tube Change form indicated for staff (in general) to notify the physician (MD 1) if a smaller size tracheal tube was used. A review of Resident 1 ' s Change of Condition notes entered by RN 1, dated [DATE] at 5:14 a.m., indicated Resident 1 expired (died ). The notes indicated (on [DATE]), at 4 a.m., during rounds, charge nurse (LVN 2) noted that Resident 1 ' s tracheal tube was not fully secured (not attached firmly so that it cannot be moved). RT 2 and RN 1 were notified immediately. Vital signs checked after RT 2 replaced Resident 1 ' s displaced tracheal tube. The notes indicated (on [DATE]), at around 5:55 a.m. Resident 1 was noted with breathing difficulty, Resident 1 ' s vital signs were unappreciated (unrecognized), and MD 1 was notified. The notes indicated on ([DATE]) at 6:08 a.m., the paramedics arrived and took over the care and the paramedics pronounced Resident 1 expired at 6:13 a.m. A review of the Los Angeles Fire Department (LAFD) Care Report for Resident 1, dated [DATE], at 6:01 a.m., indicated LAFD received dispatch notification (on [DATE]), at 6:01 a.m. with dispatch complaint as cardiac arrest (occurs when the heart suddenly and unexpectedly stops pumping). The report indicated the paramedics arrived on scene (at the facility) at 6:08 a.m. and at 6:12 a.m., exam indicated Resident 1 was unresponsive, pale, with bilateral eyes fixed (did not react to light) and dilated (became wider/larger). The report indicated Resident 1 was lying in hospital bed of nursing home obviously dead. The report indicated Resident 1 had rigor and lividity. Resident 1 was determined dead at 6:13 a.m. During an interview on [DATE] at 2:29 p.m., RN 1 stated that (on [DATE]) at around 4 a.m. LVN 2 and RT 2 told RN 1 that Resident 1 ' s tracheostomy tube was partially displaced, and RT 2 replaced Resident 1 ' s tracheostomy tube. RN 1 stated at 5:55 a.m. LVN 2 and RN 1 walked into Resident 1 ' s room and saw Resident 1 was gasping for air like he (Resident 1) could not breathe. RN 1 stated he (RN 1) yelled for help. RN 1 stated RT 3 who was close by arrived and asked RN 1 to call code blue, (generally used to indicate a patient requiring resuscitation or otherwise in need of immediate medical attention, most often as the result of a respiratory or cardiac arrest [occurs when the heart suddenly and unexpectedly stops pumping]) and RT 3 came into Resident 1 ' s room and started cardiopulmonary resuscitation, (CPR- an emergency procedure used to restart a person's heartbeat and breathing after one or both have stopped). RN 1 stated the crash cart (a wheeled container carrying medicine and equipment for use in emergency resuscitations) was nearby and it (the crash cart) was pulled into Resident 1 ' s room. RN 1 stated there was a phone on top of the crash cart and he (RN 1) called 911. RN 1 stated RT 3 checked Resident 1 ' s tracheostomy tube and changed the oxygen via artificial manual breathing unit (ambu bag - a type of device known as a bag valve mask, which is used to provide respiratory support to patients) to a full-face mask. RN 1 stated he did not assist with the CPR as it was all done by RT 3. During an interview on [DATE] at 3 p.m., LVN 2 stated (on [DATE]) at 4 a.m., she (LVN 2) found Resident 1 ' s tracheostomy tube was out (displaced) and called RT 2. LVN 2 stated RT 2 placed Resident 1 ' s tracheal tube, and Resident 1 ' s vital signs were taken and were within normal ranges (the results were normal, and no further investigation or treatment is needed). LVN 2 stated (on [DATE]), at 5:55 a.m. RN 1 called LVN 2 for help when RN 1 saw Resident 1 was having difficulty breathing/labored breathing (breathing that requires observed effort or an increased amount of energy). LVN 2 stated she (LVN 2) tried to obtain Resident 1 ' s vital signs but she was not able to get the vital signs reading. LVN 2 stated Resident 1 started to turn blue. LVN 2 stated RN 1 called the code blue and RT 3 then got inside Resident 1 ' s room. LVN 2 stated Resident 1 lost consciousness and RT 3 started CPR on Resident 1. LVN 2 stated the paramedics arrived at the facility (on [DATE]) at around 6:08 a.m., and the paramedics took over Resident 1 ' s care. During an interview on [DATE] at 3:30 p.m., RT 2 stated that (on ,d+[DATE]) at around 3:30 a.m. Resident 1 ' s tracheostomy tube came out (displaced) while Resident 1 was lying on Resident 1 ' s side (did not indicate which side). RT 2 stated when he (RT 2) asked Resident 1 how long the tracheostomy tube had been out Resident 1 stated he (Resident 1) did not know. RT 2 stated he (RT 2) then did an emergency tracheostomy tube change. RT 2 stated emergency tracheostomy tube change meaning he must insert a new tracheal tube. RT 2 stated Resident 1 ' s tracheal tube was a size 7.5 mm and he tried to insert a size 7 mm, but it (the new tracheal tube size 7 mm) did not go through. RT 2 stated he then inserted a smaller tracheostomy tube size 6 mm and Resident 1 ' s oxygen saturations (the amount of oxygen being carried by red blood cells and normal level is usually 95% or higher) went from 95% to 98%. RT 2 stated he informed RN 1 to get an x-ray to confirm the new tracheal tube placement. RT 2 stated Resident 1 ' s breath sounds were diminished with minimal airflow due to a smaller size of the new tracheal tube. During an interview on [DATE] at 4:30 p.m., RN 1 stated RT 2 did ask RN 1 to obtain an order for an x-ray on Resident 1 to confirm the new tracheal tube placement, but RT 2 said Resident 1 was okay. RN 1 stated RT 2 mentioned it casually and he (RN 1) did not call MD 1 to obtain a new order for the x-ray to confirm Resident 1 ' s new tracheal tube placement as requested by RT 2. RN 1 stated he (RN 1) informed MD 1 when Resident 1 was having distress on [DATE] at 5:55 a.m. RN 1 stated there were no prior notifications made to MD 1. During a concurrent interview with RT 5 and a review of Resident 1 ' s Tracheostomy Tube Change form, dated [DATE], on [DATE] at 10:33 a.m., RT 5 stated that when RT 2 was unable to insert the current size (same size) tracheal tube, RT 2 must notify the doctor and get a new order for the new size of the tracheal tube. RT 5 stated when RT 2 noticed Resident 1 had diminished breath sounds as indicated on RT 2 ' s notes, RT 2 needed to send Resident 1 to a General Acute Care Hospital (GACH) for further evaluation. RT 5 stated Resident 1 ' s minimal airflow was not a good thing. RT 5 stated it would be a concern when Resident 1 ' s diminished breath sounds was a new onset. RT 5 stated on [DATE] at around 5:58 a.m., RN 2 called her in Resident 1 ' s room. RT 5 stated RT 3 and RT 6 were already performing chest compressions on Resident 1. RT 5 stated Resident 1 was lying flat in bed, pulseless (without a heart rate), and Resident 1 ' s nail beds were pale. During an interview on [DATE] at 11:39 a. m., RN 2 stated on [DATE] at around 5:50 a.m., while getting a report from RN 1, RN 1 stated Resident 1 needed a follow up due to prior issue with tracheostomy. RN 2 stated he (RN 2) did an initial round and saw Resident 1 was pale in color. RN 2 stated he yelled, I need help here. RN 2 stated Resident 1 was still breathing but he (Resident 1) was struggling to breathe. RN 2 stated when RT 2 downsized Resident 1 ' s tracheal tube, and RT 2 endorsed to RN 1 to notify MD 1 then RN 1 must notify MD 1. RN 2 stated RT 2 can also communicate to the doctor (MD 1). During an interview on [DATE] at 1:07 p.m., RT 2 stated RNs (any RN) must notify the doctor when RTs (any RT) downsized the resident ' s tracheal tube. RT 2 stated RNs must update the doctor because it is a new airway and RNs must obtain new orders for the new tracheal tube size. During an interview on [DATE] at 1:17 p.m., RT 3 stated that on [DATE] at 5:55 a.m. he (RT 3) was close by when RN 1 called to help Resident 1. RT 3 stated he ran into Resident 1 ' s room and he (RT 3) was the first staff assessing Resident 1. RT 3 stated Resident 1 was not breathing, the resident had no pulse, and the resident ' s color was dark. RT 3 stated he (RT 3) checked and saw Resident 1 ' s tracheostomy tie was loose, and Resident 1 was not breathing. RT 3 stated the canula (a small tube that is inserted into a body cavity for medical purposes) was still in and he tightened the tracheostomy tie. RT 3 stated when there is a need to downsize the tracheal tube due to decannulation, one must notify the doctor and ask for a new order for the new tracheal tube size. During an interview on [DATE] at 4:30 p.m., MD 1 stated he (MD 1) was notified of Resident 1 ' s change in condition only when Resident 1 required emergency services on [DATE], at 5:55 a.m. During an interview on [DATE] at 9:32 a.m., RN 1 stated if RT 2 had told RN 1 that Resident 1 had diminished equal breath sounds and minimal airflow, he (RN 1) would monitor Resident 1. RN 1 stated he would do a COC but would have not reported to MD 1 at 4 a.m. because MD 1 would have not responded to his (RN 1 ' s) call at that time (4 a.m.). RN 1 stated he would have waited until the morning (unspecified time) to inform MD 1. During a concurrent review of Resident 1 ' s Trach tube change document, dated [DATE] and interview with the DON on [DATE] at 10:11 a.m., the DON stated, tracheal tube decannulation is not expected but it can happen. The DON reviewed Resident 1 ' s Trach tube change document, and stated staff (in general) needed to notify the physician when a smaller tracheal tube is used. The DON stated MD 1 was not notified when RT 2 downsized Resident 1 ' s tracheal tube. The DON stated the start of the COC for Resident 1 was when Resident 1 ' s tracheal tube decannulation occurred. The DON stated when there was a COC, the resident ' s family member and doctor must be notified. The DON stated RN 1 should have called MD 1 when Resident 1 was not stable. The DON stated that based on Resident 1 ' s Trach tube change notes written by RT 2, Resident 1 was not stable when Resident 1 had diminished bilateral breath sounds with minimal airflow. During a concurrent review of Resident 1 ' s Tracheostomy Notes and interview with the DON on [DATE] at 10:55 a.m., the DON stated Resident 1 ' s Tracheostomy notes, dated [DATE] indicated that Resident 1 had been rhonchi throughout his (Resident 1 ' s) stay then after the tracheostomy tube changed on [DATE] due to the tracheal tube decannulation, Resident 1 had diminished bilateral breath sounds with minimal airflow. The DON stated, it was a new change of condition. A review of the current facility-provided policy and procedure (P&P) titled, Change of Condition, last revised on [DATE], indicated, to ensure proper assessment and follow-through for any resident with a change of condition. c. Upon a change in condition for any reason, nursing staff member are to take the following actions. Physician shall be called promptly. If for some reason physician cannot be reached, alternative physician shall be contacted. If alternate cannot be reached, Medical Director is to be contacted. All contacts or attempt to contact shall be documented and include the correct time of the activity. If no physician is available, arrangements are to be made for physician services that may include transfer to ER (emergency room ) for appropriate care. A review of the current facility-provided P&P titled, Reinsertion (putting something back into or inside of something else) of Accidental Extubation (removal) of Trach Tube, undated, indicated sub-acute licensed staff, including RCPs (Respiratory Care Practitioners), RNs, and LVNs, must reinsert trach tubes that have been accidentally extubated. 3. Unsuccessful attempts to reinsert trach tube will be brought to the attention of the RCP or Nurse Manager. 4. Orders to replace extubated trach tube will be included in the physicians ' orders.

Based on observation, interview, and record review, the facility failed to practice infection control measures for Coronavirus Disease-19 (COVID-19, a disease caused by [MEDICAL CONDITION] that can trigger a respiratory tract infection) by failing to: 1. Transfer 40 of 83 residents (Resident 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57) who resided in the green cohort (area designated for residents who have no contact with COVID-19) to the yellow cohort (area designated for residents who have had possible exposure to COVID-19) after exposure to COVID-19 by facility staff, which then lead to a delay in initiating the appropriate transmission based precautions (droplet precaution (prevention of an infection that can be spread to others by speaking, sneezing or coughing) and contact precaution (prevention of infection that can be spread to others by direct or indirect contact)) for COVID-19 exposure. 2. Ensure one of two staff (Certified Nursing Assistant 1 (CNA 1)) disposed of soiled linen in designated soiled linen bin in the yellow cohort. 3. Ensure one of two staff (Licensed Vocational Nurse 1 (LVN 1)) did not drink at two of four nursing stations. 4. Ensure one of one ice cooler that was in the Director of Nursing's (DON) office, was limited to staff access only. 5. Ensure two of two staff (Certified Nursing Assistant 2 (CNA 2) and Certified Nursing Assistant 3 (CNA 3)) properly disposed of their personal protective equipment (PPE, protective clothing, helmets, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection) gowns immediately after use. 6. Ensure one of two staff (Licensed Vocational Nurse 4 (LVN 4)) was wearing the required PPE while working in the facility. 7. Ensure one of two staff (Certified Nursing Assistant 4 (CNA 4)) doffed (removed) their gown properly after caring for a resident in the yellow cohort. 8. Ensure three of 17 staff (Laundry Staff 1 (LS 1), Certified Nursing Assistant 7 (CNA 7), and Housekeeping Staff 1 (HSK 1)) properly wore a N95 mask (a respiratory protective device designed to achieve a very close facial fit and efficient filtration of at least 95% of airborne particles). 9. Ensure one of three staff (CNA 7) demonstrated proper hand hygiene and utilized approved cleaning agent. 10. Ensure one of two staff (CNA 7) performed hand hygiene after donning (putting on) previously used N95 mask. 11. Ensure one of one soiled linen room had a designated bin for soiled gowns used by laundry staff. 12. Ensure one of two staff (LS 1) disposed of used gown in designated soiled linen bin. 13. Ensure one of eight staff (LS 1) was knowledgeable of disinfection procedures and contact time (the length of time the surface needs to remain wet after the disinfectant has been applied). 14. Ensure one of four disinfectant spray bottles not in original containers were properly labeled. These deficient practices had the potential to place residents and staff at an increased risk of contracting and/or spreading COVID-19. These individuals, if infected, can be at higher risk of severe illness and have the potential to expose large numbers of individuals at risk for severe disease, which could then lead to serious adverse outcomes such as a significant decline in physical, mental function and or death due to COVID-19. On 2/5/2021 at 5:22 p.m., the Department of Public Health (Department) called an Immediate Jeopardy situation (IJ-a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM) and Director of Nursing (DON) for the facility's failure to implement measures to prevent infection that threatened the health and safety of the residents and staff. On 2/7/2021 at 10:06 pm., the ADM provided the Department with a Plan of Action (POA) which included the following summarized actions: 1. The facility converted 40 residents (Resident 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57) with COVID-19 exposure from staff who tested positive during the mass testing conducted on 1/26/21 and 1/27/21. The residents' last day of exposure was 1/29/21. These residents will be Polymerase Chain Reaction (PCR-a molecular test to detect genetic material of [MEDICAL CONDITION]) tested on [DATE] and on 2/10/2021 as part of routine mass testing. At the end on the 14-day quarantine period on 2/12/2021 these residents will be retested for COVID-19 via PCR. Residents that remain asymptomatic and negative during testing will be cleared to the green cohort (area designated for residents who have recovered or are clear of COVID-19). Residents that test positive or who develop symptoms consistent with COVID-19 will continue quarantine until COVID-19 is ruled out or if COVID-19 positive will be moved to the Red Cohort (area designated for residents with confirmed COVID-19) until they complete the quarantine period. 2. The soiled linens were properly placed in the soiled linen barrel for further handling on 2/7/2021. 3. The Administrator, Assistant Director of Nursing (ADON), Continuous Care Coordinator (CCC), infection Preventionist (IP) and Maintenance Supervisor provided in-service training for multidisciplinary staff on 2/5/2021-2/6/2021 regarding proper hand hygiene, proper use of disinfecting wipes, and not eating or drinking in patient care areas. The ice chest was immediately taken to the kitchen for disinfection and ice was discarded. Once disinfected, the ice chest was relocated to the closed dining room to ensure it is only accessible to staff. The ice chest was also labeled FOR STAFF USE ONLY. 4. The Certified Nursing Assistant (CNA) immediately removed the reusable gown on 2/7/2021 and placed it in the appropriate soiled linen barrel. 5. 1:1 in-service training was provided to the Licensed Nurse regarding not using cloth masks in the facility. Additional in-service training was provided on 2/4/2021-2/7/2021 for employees regarding proper PPE use including employees with resident contact are not allowed to wear cloth masks while in the facility. 6. The ADON, Director of Staff Development (DSD), IP, Administrator, CCC, and Maintenance Supervisor provided in-service training for multidisciplinary staff on 2/4/2021-2/7/2021 regarding proper donning (putting on) and doffing (taking off) of PPE. Facility staff also viewed the videos Demonstration of donning PPE, Demonstration of Doffing PPE, Keep COVID out, and Clean Hands and signed an attestation on 2/7/2021. 7. Proof of fit testing for employees identified by the surveyor was provided on 2/5/2021 with the employees signed acknowledgment. The ADON reviewed fit testing logs on 2/5/2021, 2/6/2021, 2/7/2021 and did not identify any staff that were not fit tested . The Maintenance Supervisor made rounds on 2/5/2021, 2/6/2021, and 2/7/2021 and did not identify any further laundry staff with improper mask usage. 8. A labeled trash can with lid was provided to the laundry room on 2/6/2021. The facility provided a labeled soiled linen barrel for doffing on 2/6/2021. The Maintenance Supervisor, CCC, IP, ADON, DSD, and Administrator provided in-service training for multidisciplinary staff on 2/5/2021-2/7/2021 regarding not reusing soiled gowns and placing used gowns and gloves in the appropriate areas provided. 9. In-service training was provided by the IP, DSD, Maintenance Supervisor, CCC, and ADON on 2/5/2021-2/7/2021 for multidisciplinary staff regarding disinfectant use including proper kill times (period of time the solution should remain on an object to ensure disinfection from bacteria and or viruses). A kill time cheat sheet was posted in the nurse's station, at the COVID-19 information board, and the break room for reference. 10. A labeled trash can with lid was provided to the laundry room on 2/6/2021. The facility provided a labeled soiled linen barrel for doffing on 2/6/2021. The Maintenance Supervisor, CCC, IP, ADON, DSD, and Administrator provided in-service training for multidisciplinary staff on 2/5/2021-2/7/2021 regarding not reusing soiled gowns and placing used gowns and gloves in the appropriate areas provided. On 2/8/2021 at 2:27 p.m., while onsite and after confirming the facility's implementation of the immediate corrective actions, the Department accepted the POA and removed the Immediate Jeopardy, in the presence of the ADM and the DON. Findings: 1. During an observation and concurrent interview on 2/4/2021 at 1:30 p.m. of the facility's green cohort with the Infection Preventionist Nurse (IP), it was observed that 40 Residents (Resident 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57) were residing in the green cohort. IP verified the observation and stated that the 40 residents were cared for by three Health Care Personnel (Licensed Vocational Nurse 4 (LVN 4), Certified Nursing Assistant 5 (CNA 5), and Certified Nursing Assistant 6 (CNA 6)), who received a positive COVID-19 result on 1/29/2021. IP confirmed that the 40 residents last exposure date from LVN 4, CNA 5, and CNA 6 was on 1/29/2021. When the IP was asked why the 40 residents remained in the green cohort after COVID-19 exposure from staff, IP stated that the facility did not consider the residents as exposed from the three Health Care Personnel. During an interview on 2/4/2021 at 1:32 p.m., the Director of Nursing (DON) explained that the facility did not consider the 40 residents (Resident 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57) exposed to positive Health Care Personnel (HCP) because the staff wore a N95 and face shields. The DON stated that the 40 residents did not need to be quarantined because the staff had been wearing PPE. During an interview on 2/5/2021 at 3:40 p.m., DON stated that the facility verified with Public Health Nurse 1 (PHN 1 - nurses focusing on promoting health for the community) that the 40 residents (Resident 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57) who were cared for by the three HCPs (LVN 4, CNA 5, CNA 6) who tested positive of COVID-19 on 1/29/2021 should have been considered exposed and placed in the yellow cohort. DON stated that because of the delay in moving exposed residents to the yellow cohort, there was an increased risk of COVID-19 exposure to other staff and residents within the green cohort due to not initiating proper transmission (an act of transferring something from one spot to another) based precautions (a measure taken in advance to prevent something dangerous or inconvenient from happening). A review of the facility's COVID-19 Mitigation Plan dated 10/10/2020, indicated that the facility will place residents into three separate cohorts based on COVID-19 test results, accordingly: Positive result (isolation/red cohort) Negative result but exposed within the last 14 days (quarantine/yellow cohort) Negative result without known exposure within the last 14 days (Non-COVID/Regular Unit/green unit) A review of Department of Public Health Guidelines for Preventing and Managing for COVID-19 in Skilled Nursing Facilities, updated 11/24/2020, indicated the following: Yellow Cohort (Mixed quarantine & symptomatic cohort) This cohort is for the following residents: Close contacts to a known COVID-19 case. A close contact is anyone who has been within six feet of a person with confirmed COVID-19 for a cumulative total of 15 minutes within a 24 hour period (e.g. roommate) or who had unprotected direct contact with infectious secretions or excretions of the person with COVID-19. All residents on the unit or wing where a case was identified in a resident or HCP should be considered exposed and placed in quarantine. All exposed residents should remain in their current rooms unless sufficient private rooms are available. Signage indicating appropriate precautions should be placed outside of these residents' rooms. 2. During an observation on 2/7/2021 at 1:38 p.m. in the yellow cohort, CNA 1 was observed providing resident care to Resident 2 in their room. CNA 1 then bagged the soiled linen in a plastic bag. CNA 1 exited Resident 2's room carrying the bagged soiled linen and entered Resident 58's room, also in the yellow cohort. CNA 1 then placed the bag of soiled linen inside Resident 58's restroom. During an interview on 2/7/2021 at 1:42 p.m., CNA 1 confirmed the they placed the soiled linen bag inside Resident 58's restroom. CNA 1 stated that she brought the plastic bag of soiled linen into another resident's room because a soiled linen bin was not available. CNA 1 stated that she should have obtained a soiled linen bin from the laundry area to dispose the bagged soiled linen. During an interview on 2/7/2021 at 1:44 p.m., IP stated that soiled linen should be disposed directly into the soiled linen bin and not placed in another resident's area in order to maintain infection control. A review of the facility's policy titled Handling, Transporting or Processing Isolation Room Linens reviewed and approved on 4/15/2020 indicated that staff double bags and deposits soiled linens in hampers/barrels marked Soiled Linen after changing bed and supplying towels (daily). 3. During an observation and concurrent interview on 2/7/2021 at 1:55 p.m. with the DON, LVN 2 was observed removing her N95 and was drinking in two of four nursing stations. DON confirmed the observation. During an interview on 2/7/2021 at 4:24 p.m., DON stated staff are not supposed to remove their mask at the nursing station and should not drink in resident care areas due to COVID-19 precautions. DON stated there was a designated break room for staff. A review of the facility's policy titled COVID-19 Preparedness dated 9/24/2020, indicated that infection control procedures including administrative rules and engineering controls, environmental hygiene, correct work practices, and appropriate use of personal protective equipment (PPE) are all necessary to prevent infections from spreading during health care delivery. Prompt detection and effective triage and isolation of potentially infectious patients are essential to prevent unnecessary exposures among patients, healthcare personnel, and visitors at the facility. 4. During an observation on 2/7/2021 at 2:00 p.m., Resident 1 from the yellow cohort, was observed getting ice from the ice cooler located by the DON's office. During a concurrent observation and interview on 2/7/2021 at 2:03 p.m., Registered Nurse 1 (RN 1) confirmed the observation of Resident 1 obtaining ice from the ice cooler. RN 1 stated that the ice cooler should only be accessed by staff to maintain infection control. RN 1 stated he will bring the ice cooler down to be disinfected and change the ice contents. A review of the facility's policy titled COVID-19 Preparedness dated 9/24/2020, indicated that infection control procedures including administrative rules and engineering controls, environmental hygiene, correct work practices, and appropriate use of personal protective equipment (PPE) are all necessary to prevent infections from spreading during health care delivery. Prompt detection and effective triage and isolation of potentially infectious patients are essential to prevent unnecessary exposures among patients, healthcare personnel, and visitors at the facility. 5. During an observation and concurrent interview on 2/7/2021 at 4:51 p.m., a disposable gown was observed hanging in the staff break room. LVN 1 confirmed the observation. CNA 2 was then interviewed in the presence of LVN 1. CNA 2 confirmed that the gown hanging in the break room belong to her. CNA 2 stated that she was under the impression that gowns were reusable and meant be used throughout her shift. During an observation and concurrent interview on 2/7/2021 at 4:54 p.m., CNA 3 was observed wearing a gown in the staff break room. CNA 3 stated that she worked in the yellow cohort. CNA 3 stated she forgot to remove her gown after exiting the yellow cohort. During an interview with LVN 1 on 2/7/2021 at 4:58 p.m., LVN 1 stated that after providing resident care, staff should remove their gowns before exiting any resident room. A review of the facility's COVID-19 Mitigation Plan dated 10/10/2020 indicated that trash disposal bins are positioned as near as possible to the exit inside of the resident room to make it easy for staff to discard PPE after removal, prior to exiting the room, or before providing care for another resident in the same room when there are units with separate cohorted spaces for both COVID-19 positive and negative residents. 6. During an observation and concurrent interview on 2/4/2021 at 10:15 a.m. LVN 4 was observed walking out of a resident's room in the green cohort wearing a black cloth mask. LVN 4 confirmed the observation and stated that wearing a cloth mask was appropriate for the green cohort. LVN 4 stated that wearing a N95 respirator is required to enter a room in the yellow cohort. During an interview on 2/4/2021 at 12:30 p.m., IP stated that staff working in the green cohort should wear either a surgical mask or N95 along with face shield/goggles when providing care within six feet (ft-a unit of length) of a resident. IP stated that staff should not wear a cloth mask while working in the facility. A review of the facility's COVID-19 Mitigation Plan dated 10/10/2020 indicated that the facility trained staff on selecting, donning and doffing appropriate PPE and demonstrate competency of such skills during resident care. A review of Department of Public Health Guidelines for Preventing and Managing for COVID-19 in Skilled Nursing Facilities, updated 11/24/2020, indicated HCPs working in green cohort need to have as following: a. Surgical masks or N95 respirators may be worn. b. Goggles/face shields when providing care within six feet of resident. c. Gowns should be used when needed. No re-use. No extended use. 7. During an observation and concurrent interview on 2/4/2021 at 10:46 a.m., Certified Nursing Assistant 4 (CNA 4) was observed exiting a resident's room in the yellow cohort and doffed (removed) their disposable gown placing it in a trash bin in the hallway. Signages were posted for droplet and contact precautions outside the resident's room. CNA 4 was asked why the gown was removed outside of the resident's room. CNA 4 acknowledged that the gown should have been removed inside the room and stated that he forgot to dispose of the gown before exiting the room in the yellow cohort. During an interview on 2/4/2021 at 2:20 p.m., the DON stated that CNA 4 should have removed the gown inside of the room in the yellow cohort before exiting. A review of the facility's COVID-19 Mitigation Plan dated 10/10/2020 indicated that trash disposal bins are positioned as near as possible to the exit inside of the resident room to make it easy for staff to discard PPE after removal, prior to exiting the room, or before providing care for another resident in the same room when there are units with separate cohorted spaces for both COVID-19 positive and negative residents. 8. During an observation and concurrent interview with the Maintenance/Housekeeping/Laundry Supervisor (MS) on 2/5/2021, at 10:05 a.m., in the laundry room washer area, LS 1 was observed wearing a N95 with spaces around the bridge of the nose. MS confirmed the observation. MS stated that her mask was not fitting and there should be no spaces around the mask. During an observation and concurrent interview on 2/5/2021 at 2:10 p.m. with LVN 3, CNA 7 was observed wearing a N95 and a face shield while in the yellow cohort area. CNA 7's N95 was observed with bends on the sides. LVN 3 confirmed the observation. LVN 3 stated that CNA 7's mask was not properly sealed. During an observation and concurrent interview on 2/5/2021, at 2:28 p.m., in the yellow cohort area, HSK 1 was observed wearing her N95 mask with the bottom portion noted to be folded inward. HSK 1 confirmed the observation by looking at her reflection on the glass door. HSK 1 then fixed her mask. A review of facility's policy titled COVID-19 Preparedness dated 9/24/2020, indicated that the facility was to follow Use of PPE based on CDC and Public Health guidance. A review of Centers for Disease Control and Prevention's (CDC) document titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic dated 12/14/2020, indicated the following: Filtering Facepiece Respirators (FFR) including N95 Respirators: To work properly, FFRs must be worn throughout the period of exposure and be specially fitted for each person who wears one. FFR users should also perform a user seal (a procedure that is performed to confirm that a tight-fitting respirator is adequately sealed where no air should escape around the edges of the mask). 9. During an observation and concurrent interview on 2/5/2021, at 2:03 p.m., in the yellow cohort area, CNA 7 was asked about how she conducts hand hygiene. CNA 7 explained that she uses wipes. CNA 7 was then observed pointing to the Lysol Disinfecting Wipes stored on top of a PPE cart. CNA 7 added that she uses the wipes to disinfect the timecard machine. CNA 7 stated, I use this for my hands too. During an interview on 2/5/2021, at 2:10 p.m., LVN 3 stated that staff should use hand sanitizer to disinfect hands. LVN 3 stated that disinfectant wipes should not be used for hand hygiene. A review of the facility's Handwashing policy (undated) indicated that Handwashing is a vigorous, brief rubbing together of all surfaces of lathered hands with soap, followed by rinsing under a stream of water. A review of the CDC's document titled Handwashing: Clean Hands Save Lives subtitled Frequent Questions About Hand Hygiene dated 10/14/2020, indicated that Disinfecting wipes are designed to kill germs on surfaces. Do not use disinfecting wipes to clean your skin because they may cause irritation. Always read and follow the directions on the label to use these products safely. A review of Centers for Disease Control and Prevention's (CDC) document titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic dated 12/14/2020, indicated the following: Hand Hygiene: HCP should perform hand hygiene by using alcohol-based hand sanitizer (ABHS) with 60-95% alcohol or washing hands with soap and water for at least 20 seconds. If hands are visibly soiled, use soap and water before returning to ABHS. 10. During an observation and concurrent interview on 2/5/2021, at 2:03 p.m., CNA 7 was observed wearing a N95 mask and a face shield in the hallway of the yellow cohort area. CNA 7 then removed her mask and drank from a water bottle, then donned her mask. CNA 7 did not perform hand hygiene after touching her mask. CNA 7 confirmed that she did not perform hand hygiene after touching her mask and drinking from a water bottle. During an interview on 2/5/2021, at 2:10 p.m., LVN 3 stated that hand washing should be performed before you put on and after you take off your mask. During an interview on 2/8/2021, at 2:20 p.m., IP confirmed that staff should perform hand hygiene before putting on and after taking off their mask. A review of facility's policy titled PPE reuse and conservation strategies for the protection of the healthcare workers during the onset of an outbreak dated 9/24/2020, indicated that Hand hygiene should be performed after removing and donning during reuse of PPE. 11. During an observation and concurrent interview with MS on 2/5/2021 at 9:57 a.m., there were no designated bins observed for used gowns noted in the soiled linen room. MS confirmed the observation. MS stated that after use, the laundry staff is supposed to discard used gowns in a designated bin in the soiled linen room. During an interview on 2/5/2021, at 3:06 p.m., ADM stated that the laundry soiled linen room should have a designated bin for soiled linens. A review of facility's policy titled, Laundry & Linen Purpose and Policies, reviewed and approved on April 15, 2020, indicated that This facility shall use maximum precautions when handling, transporting, or processing linens used in isolation rooms and by any resident with a diagnosed infectious disease. All required safety and infection control techniques shall be used to prevent cross-contamination of linen and to protect against the spread of infection. The document also indicated procedures for facilities with in-house laundry which includes wearing of rubber gloves and gown prior to handling soiled linen, to remove and disinfect rubber gloves after use, to remove gown and launder after each individual use, and to wash hands. 12. During a concurrent interview and observation with LS 1 in the soiled linen room on 2/5/2021, at 10:44 a.m., LS 1 stated that she reuses her gown. LS 1 stated that after she uses her gown, she hangs the gown on the wall to be used again later. LS 1 then was observed pulling out a gown, pointing to where she would hang it, and then rolling up the gown. LS 1 then placed the rolled-up gown sitting on top of a cleaning machine. During an interview on 2/5/2021, at 10:48 a.m., MS stated that LS 1 is not supposed to reuse the same gown. MS stated that LS 1 is supposed to use separate gowns after each use, and once she is done, put it in a designated used bin. A review of facility's document titled, Laundry & Linen Purpose and Policies, reviewed and approved on April 15, 2020, indicated that This facility shall use maximum precautions when handling, transporting, or processing linens used in isolation rooms and by any resident with a diagnosed infectious disease. All required safety and infection control techniques shall be used to prevent cross-contamination of linen and to protect against the spread of infection. The document also indicated procedures for facilities with in-house laundry which includes wearing of rubber gloves and gown prior to handling soiled linen, to remove and disinfect rubber gloves after use, to remove gown and launder after each individual use, and to wash hands. 13. During a concurrent interview and observation on 2/5/2021, at 10:05 a.m., in the laundry room washer area, LS 1 stated that she disinfects high touch surfaces (surfaces that are handled frequently throughout the day by numerous people) including the outside of the washing machines every two hours. LS 1 pointed to the bottle of Micro-Kill Bleach observed stored on a cart. When asked if LS 1 knows the contact time for the disinfectant used, LS 1 stated she doesn't know the contact time. LS 1 stated that she doesn't remember when the last time she received training for proper use of disinfectant. LS 1 added that she received training when she first came to work which was around March of last year. A review of the product information label titled, Micro-Kill Bleach indicated EPA Reg. No. -1 with contact time of 30 seconds to kill all bacteria [MEDICAL CONDITION]. A review of the CDC's document titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic dated 12/14/2020, indicated for facilities to ensure that environmental cleaning and disinfection procedures are followed consistently and correctly. Routine cleaning and disinfection procedures (e.g., using cleaners and water to pre-clean surfaces prior to applying an EPA-registered, hospital-grade disinfectant to frequently touched surfaces or objects for appropriate contact times as indicated on the product's label) are appropriate for [DIAGNOSES REDACTED]-CoV-2 in healthcare settings, including those patient-care areas in which aerosol generating procedures are performed. 14. During a concurrent observation and interview with MS on 2/5/2021, at 10:37 a.m., an unlabeled spray bottle containing a clear solution was observed stored in the break area outside the COVID-19 unit. MS confirmed the observation and stated that the spray is used to disinfect surfaces. MS stated that the bottle should have been labeled. MS stated that it should be labeled with Strike Bac 2 ounce (oz-unit of measure). A review of the product information label titled, Strike Bac Germicidal Cleaner 2 oz. indicated EPA Reg. No. 1839-169- with contact time of 10 minutes to disinfect surfaces. A review of facility's policy titled CHEMICALS: SURFACES, PPE, DILUTION and CONTACT TIME, reviewed and approved on April 15, 2020, indicated to Ensure all lids and caps on chemicals are closed and containers are fully labeled and legible. Replace missing and/or illegible labels immediately.

Based on observation, review of clinical records and facility documents and staff interviews, the facility failed to ensure that one of one randomly selected resident (Resident 26) maintained acceptable weight when it failed to provide the diet as ordered by the physician. As a result Resident 26, had a slow, gradual, unplanned weight gain and a progression of prediabetes to a [DIAGNOSES REDACTED].) of 6.7 % (normal Hgb A1C is less than 5.7%, prediabetes 5.7% to 6.4%), and to such an extent the resident required medication to treat diabetes. Findings: A review of clinical record showed that Resident 26 was readmitted to the facility in September 2014, with [DIAGNOSES REDACTED]. According to documentation in the clinical record, Resident 26 lacked the capacity to make decisions due to Alzheimer's [DIAGNOSES REDACTED]. decisions. On admission, Resident 26 was 5 feet 2 inches tall, and weighed 149 pounds. The resident's ideal body weight range was 106 - 130 pounds, therefore was 19 pounds or 114 % above his ideal body weight (IBW) range. This weight resulted in a body mass index (BMI) of 27.7, therefore, the resident was classified as overweight. (Normal BMI is 18.5 - 24.9; BMI of 25 - 29.9 is classified as overweight.) BMI measures the degree of fatness and it is correlated to the development of many diseases including diabetes. Between September 2014 and December 2014, Resident 26 had gained a total weight of 15 pounds in three months. Resident 26 would gain and lose 1 to 2 pounds throughout 2015. In January 2016, Resident 26 weighed 164 pounds, but would gain 1 to 2 pounds every month except March 2016, when he lost 1 pound and in May when he did not gain any weight. By August 2016, Resident 26's weight reached 170 lbs. and was 40 pounds above his IBW or 130% of his IBW with a BMI of 30, classified as obese. According to the nutritional assessment conducted on February 18, 2015, by a Registered Dietitian (RD 1), Resident 26 was 138% above IBW, weighing 163 pounds. Resident 26's assessed need was 1410 to 1645 calories per day but the regular diet ordered by the physician, provided the resident with 2200 -2600 calories per day. This is 1000 calories above the resident's assessed need. RD 1 noted weight gain may be related to good po (per os - oral or by mouth) 100%, (intake of all food). RD1 recommended continuing the diet with a sandwich at 2 PM, but only discontinued the 4 ounces high protein supplement. It was not clear after the resident had gained 14 pounds in five months, why RD 1 did not discontinue all the supplements. On March 14, 2015, after Resident 26 gained another pound, RD 1 recommended decreasing the sandwich to half and provide 4 ounces nonfat milk for two meals. RD 1 no longer worked at the facility and could not be interviewed. On August 18, 2015, the dietary staff added to Resident 26's physician ordered regular diet, 8 ounces of juice for all three meals and 4 ounces ice cream every day. However, the food added was in error, as the order was not meant for Resident 26, but for another resident who was in his room. This error was not identified until it was brought to the attention of the Food Service Director (FSD) on November 16, 2016. Eight ounces of juice for all three meals and 4 ounces ice cream was erroneously added to the resident's diet for over one year. An observation of the meal tray on November 8, and 9, 2016, showed that Resident 26 continued to receive an incorrect diet, resulting in providing more calories to the resident than was ordered. On November 8, 2016 at 12:30 p.m., during trayline observation, Resident 26 received a regular sized portion of a controlled carbohydrate (CCHO) diet, which is 1900 to 2000 calories per day. The resident was served baked chicken with [MEDICATION NAME] sauce, boiled parslied potatoes, seasoned peas, cornbread and ice cream. In addition, Resident 26 was served 8 ounces cranberry juice and 4 ounces ice cream, (instead of 1/3 cup listed on the menu) with his lunch tray. On November 9, 2016 at 12:39 p.m., Resident 26 was served regular portion noodles with beef burgundy, spinach, tossed green salad, ½ dutch apple cake, 8 ounces orange juice, 4 ounces chocolate ice cream and 4 ounces nonfat milk. Based on the items provided, Resident 26 received more than 400 additional calories per day than was ordered. If Resident 26 consistently received at least 250 extra calories per day every day for a month, it would result in weight gain of approximately 2 pounds a month, based on the fact that 3500 calories equals one pound of weight gain. According to the facility's Acting Director of Nursing (ADON) in an interview on November 15, 2016 at 6:20 p.m., Resident 26 had been prediabetic since 2014. Laboratory values from September 2015, indicated that Resident 26's Blood Glucose (sugar) was 140 (Normal 74-106) Hgb A1C 6.1 %. (normal Hgb A1C is less than 5.7%, prediabetes 5.7% to 6.4%) A person with prediabetes has a blood sugar level higher than normal, but not high enough for a [DIAGNOSES REDACTED]. According to the American Diabetes Association, research shows a weight loss of approximately 7 % or even 10 to 15 pounds, could prevent the progression of prediabetes to full blown diabetes. The facility was aware of Resident 26's [DIAGNOSES REDACTED]. Resident 26's nutrition care plans did not include weight management that was necessary to prevent the prediabetes from becoming diabetes. There were several Interdisciplinary Team Conferences from June 2015 through March 2016, but no recommended changes were made to Resident 26's plan of care, despite the gradual unplanned weight gain. None of these team conferences included the registered dietitian. (cross refer F281) On March 1, 2016, RD 1 assessed Resident 26 and recommended a change in diet from regular to CCHO secondary to high [MEDICATION NAME] (a simple form of protein ) and Hgb A1C. There was a note by the Food Service Director (FSD) on the same day indicating change diet as ordered to CCHO, subsequent notes from the FSD in July and August 2016, indicated Resident 26 was on a regular diet, not the CCHO diet as was recommended in March 2016. There was no documented evidence why this recommendation/order was discontinued, or if it was ever initiated. This would as such represent a four month delay in medical nutrition therapy that may have benefited the resident. The physician plan in the progress notes of July 12, 2016, indicated 1800 calorie American Diabetic Association (ADA) diet and [MEDICATION NAME], an oral medication for diabetes. Based on the Order Summary Report dated July 29, 2016, Resident 26 was still receiving more calories than was planned by the physician. It showed Resident 26 was receiving a mechanical soft (made up of foods that are easy to chew and swallow), 1800 calorie ADA with thin liquids and ½ a sandwich in the afternoon. (This did not include the juice and ice cream that was erroneously added to the resident's diet.) It appeared the diet order was not placed until July 28, 2016, sixteen days after the diet was written in the physician's plan. On July 12, 2016, Resident 26's physician documented in the Physicians Progress Note was found prediabetic with elevated random glucose (a blood test for sugar done without fasting) 160 and elevated Hgb A1C 6.7. There was no documentation of prediabetes in the physician's progress note prior to July 2016. Hgb A1C or glycated hemoglobin test is an important blood test that provides an average of a person's blood sugar control over a two to three month period. (webmd.com). Normal Hgb A1C is below 5.7%. Laboratory symptom/definition of diabetes is Hgb A1C of 6.5% and above. laboratory results dated [DATE] showed Resident 26's Hgb A1C level as 6.7%, on September 15, 2016, Hgb A1C level was 6.5% and classified as provisional diabetes based on American Diabetes Association definition. RD 2 noted in the multidisciplinary (involving several academic disciplines), progress record on August 16, 2016, that weight gain was not desirable and recommended discontinuing half sandwich to prevent further weight gain. RD 2 documented glucose WNL (within normal limits but failed to identify that Hgb AIC was above normal limits or the fact that Resident 26 was now on a medication to control diabetes and had progressed from prediabetes to diabetes. There was limited intervention by the IDT and RDs when there was evidence of insidious (proceeding in a gradual, subtle way, but with harmful effects), weight gain. In an interview with RD 2 on November 9, 2016 at 2:30 p.m., she described that she only assessed residents annually and when they had significant weight changes. Instead, quarterly assessments which the facility refers to as updates were completed by the Food Service Director for October 2015, January 2016, April 2016, July 2016, with consistent notation of will continue to monitor. It was noted in July and August 2016, Resident 26 was aware of his weight status but no evidence that a plan of care to control the weight gain was ever discussed with him. According to the American Diabetes Association, research shows a weight loss of approximately 7 % or even 10 to 15 pounds, could prevent the progression of prediabetes to full blown diabetes. Resident 26 had a slow unplanned weight gain instead of weight loss. Cross refer F281