Every finding on record at Sunny Hills Post Acute

Based on observation, interview and record review, the facility failed to meet professional standards of quality, for three of three residents (Residents 1, 2, and 3), by failing to ensure:1. Licensed nurses thoroughly assessed Resident 1 after a change of condition (COC) and while pending transfer to the General Acute Care Hospital (GACH).2. Resident 1's stool softeners were held (not given) and the Primary Care Physician (PCP) was consulted when Resident 1 had loose stools.3. Resident 1, 2, and 3's care plans were followed by documenting/recording daily bowel movements (BM). 4. Residents 2 and 3 were offered as needed (PRN) stool softeners as ordered by the PCP when Residents 2 and 3 did not have a BM for three days.These failures had the potential for staff to not identify life threatening conditions that required urgent interventions for Resident 1, worsening of Resident 1's symptoms and condition, and Resident 1, 2 and 3 to experience complications from constipation such as nausea, pain and bowel obstruction (blockage in the small or large intestine that stops food, liquids, gas, and stool from moving through the digestive system normally). Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 2's diagnoses included atrial fibrillation ([AFib], a type of irregular and very fast heart rhythm) and urinary tract infection ([UTI], an infection in the bladder/urinary tract).During a review of Resident 1's History and Physical (H&P) dated 8/11/2026, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool), dated 6/12/2026, the MDS indicated Resident 1 had moderate cognitive impairment (problems with the ability to think, remember, and solve problems). The MDS indicated Resident 1 was dependent (helper does less than half the effort) on staff for Activities of Daily Living (ADLs) such as toileting hygiene and required substantial/maximal assistance (helper does more than half the effort) to perform movements such as rolling left and right.During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE]. The admission Record indicated Resident 2's diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (when a blood blot or blockage cuts off blood and oxygen to the brain, causing brain tissue to die) affecting the left non-dominant (the side that is less powerful or used) side.During a review of Resident 2's H&P dated 12/26/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions.During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 was cognitively intact (no problems with the ability to think, remember, and solve problems). The MDS indicated Resident 2 required partial/moderate assistance (helper does less than half the effort) with ADLs such as showering/bathing self and required supervision or touching assistance (helper does verbal cues and/or/touching/steadying and/or contact guard assistance as resident completes activity) to transfer from chair to bed.During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 3's diagnoses included respiratory failure (when the lungs cannot exchange gases properly) with hypercapnia (having too much carbon dioxide in the blood) and AFib.During a review of Resident 3's H&P dated 6/26/2026, the H&P indicated Resident 3 had the capacity to understand and make decisions.During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 cognitively intact. The MDS indicated Resident 3 was dependent on staff for ADLs such as toileting hygiene and required substantial/maximal assistance to perform movements such as rolling left and right.During a review of Resident 1's Hospital Transfer form (a form used when a resident is transferred out of the facility), dated 8/5/2026, the Hospital Transfer form indicated Resident 1 was noted with abdominal discomfort and was transferred to a GACH for further evaluation.During a review of Resident 1's progress notes, dated 8/5/2026, the progress notes did not indicate a full assessment of Resident 1 was completed prior to Resident 1 being transferred to the GACH.During an interview and record review on 8/21/2026 at 1:47 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 1's Progress Notes, Hospital Transfer Form, and vital signs, dated 8/5/2026, were reviewed. LVN 1 stated if a resident had a COC, licensed nurses should immediately assess the resident. LVN 1 stated Resident 1's Hospital Transfer form and progress notes, dated 8/5/2026, did not indicate a full assessment of Resident 1 was completed nor were vital signs recorded upon the resident's COC on 8/5/2026. During an interview and record review on 8/21/2026 at 3:03 p.m., with the Quality Assurance Nurse (QA Nurse), Resident 1's Progress Notes and Hospital Transfer Form, dated 8/5/2026 and vital signs, dated 8/2026, were reviewed. The QA Nurse stated there were no vital signs nor full assessments documented for Resident 1 during his COC. There should have been an assessment and vital signs documented for Resident 1 to indicate that Resident 1 was stable.During a review of Resident 1's ADL Bowel Elimination Task Sheet, dated 7/2026, the ADL Bowel Elimination Task Sheet, indicated Resident 1 had loose stools for three consecutive shifts on 7/5/2026 (day shift 7:00 a.m.- 3:00 p.m., evening shift 3:00 p.m.-11:00 p.m., night shift 11:00 p.m.- 7:00 a.m.). During a review of Resident 1's Medication Administration Record (MAR), dated 7/2026, the MAR indicated Resident 1 had an order to administer Senna Oral Tablet (medication to treat constipation) 8.6 milligrams ([mg], metric unit of measurement, used for medication dosage and/or amount), one tablet by mouth one time a day to Resident 1 for bowel management and hold for loose stools. The MAR indicated Resident 1 received a dose of Senna Oral Tablet on 7/5/2026 and 7/6/2026.During a concurrent interview and record review on 8/21/2026 at 1:47 p.m., with LVN 1, Resident 1's ADL Bowel Elimination Task Sheet and MAR, dated 7/2026, were reviewed. LVN 1 stated the nurses should have held Resident 1's stool softener and consulted with the PCP because the resident had loose stools. If the resident was given stool softener with loose stools, it could cause skin problems and could indicate that the resident might be experiencing a side effect from the medication.During a review of Resident 1's care plan titled, At risk for constipation related to (r/t) diminished appetite, use/side effects of medication - antidepressants, dated 8/11/2025, the care plan indicated to record bowel movement pattern each day and to describe size and consistency.During a review of Resident 1's ADL Bowel Elimination task sheets, dated 7/2026 and 8/2026, the ADL Bowel Elimination Task Sheets did not indicate that BMs were documented for Resident 1 during the following shifts:- On 7/24/2026, 7/26/2026, and 8/2/2026 during the day shifts - On 8/11/2026 during the evening shift - On 7/8/2026 and 7/31/2026 during the night shifts During a review of Resident 2's care plan titled, At risk for constipation r/t decreased mobility, use/side effects of medication - Norco (medication used to treat pain), dated 10/16/2025, the care plan indicated to record bowel movement pattern each day and describe size and consistency.During a review of Resident 2's ADL Bowel Elimination task sheets, dated 7/2026 and 8/2026, the ADL Bowel Elimination Task Sheets did not indicate that BMs were documented for Resident 2 on 7/25/2026 during the day shift, on 8/18/2026 during the evening shift, on 7/28/2026, 7/31/2026, and 8/3/2026 during the night shift. During a review of Resident 3's care plan titled, The resident is at risk for constipation r/t decreased mobility, use/side effects of medication - hydrocodone (a strong pain killer), dated 4/1/2024, the care plan indicated to record bowel movement pattern each day and describe size and consistency.During a review of Resident 3's ADL Bowel Elimination task sheets, dated 7/2026 and 8/2026, the ADL Bowel Elimination Task Sheets did not indicate that BMs were documented for Resident 3 on 8/10/2026 during the day shift and on 7/4/2026, 7/5/2026, 7/17/2026, 7/21/2026, 8/10/2026, and 8/15/2026 during the evening shift.During a concurrent interview and record review on 8/21/2026 at 1:47 p.m., with LVN 1, the following were reviewed:-Resident 1's care plan titled, At risk for constipation r/t diminished appetite, use/side effects of medication - antidepressants, dated 8/11/2025,-Resident 2's care plan titled, At risk for constipation r/t decreased mobility, use/side effects of medication - Norco (a painkiller used to treat severe pain), dated 10/16/2025,-Resident 3's care plan titled, The resident is at risk for constipation r/t decreased mobility, use/side effects of medication - hydrocodone, dated 4/1/2024,-Resident 1, 2, and 3's ADL Bowel Elimination task sheets, dated 7/2026 and 8/2026,-Resident 1, 2, and 3's census, dated 8/21/2026.LVN 1 stated staff did not document bowel patterns for Residents 1, 2 and 3 on all for the months of 7/2026 and 8/2026. Nurses should have documented the bowel patterns for Resident 1, 2, and 3 for these months based on their care plans due to residents' risk for constipation. LVN 1 stated the facility did not follow Resident 1, 2 and 3's Care Plans. During a review of Resident 2's ADL Bowel Elimination Task Sheet, dated 7/2026, the ADL Bowel Elimination Task Sheet indicated Resident 2 did not have a bowel movement on 7/17/2026 - 7/19/2026.During a review of Resident 2's Order Summary Report, dated 7/20/2026, the Order Summary Report indicated Resident 2 had an order placed on 12/7/2025, to administer Dulcolax ([Bisacodyl], a medication used to treat constipation and help promote a BM) Suppository (medication that is inserted into the body through the rectum), 10 mg rectally every 24 hours PRN for Bowel Management, administer if no BM in 3 days.During a review of Resident 2's MAR, dated 7/2026, the MAR did not indicate Resident 2 was given the PRN order for Dulcolax during the month of 7/2026.During a review of Resident 2's Progress Notes, dated 7/17/2026 - 7/19/2026, the Progress Notes did not indicate that Resident 2 was offered a PRN for Dulcolax to help promote BM.During a concurrent interview and record review on 8/21/2026 at 1:47 p.m., with LVN 1, Resident 2's ADL Bowel Elimination Task Sheet and MAR, dated 7/2026, and progress notes dated 7/30/2026, were reviewed. LVN 1 stated staff should have offered a suppository for Resident 2 on 7/30/2026 to promote a BM because it is important to have a BM. LVN 1 stated the progress notes and MAR did not indicate a PRN suppository was offered to Resident 2 on 7/30/2026.During a review of Resident 3's ADL Bowel Elimination Task Sheet, dated 7/2026, the ADL Bowel Elimination Task Sheet indicated Resident 3 did not have a BM on 7/28/2026 - 7/30/2026.During a review of Resident 3's MAR, dated 7/2026, the MAR indicated Resident 3 had an order for Magnesium Hydroxide (a medication used to help relieve constipation) Oral Suspension (a liquid medicine that contains small drug particles mixed with a liquid base meant to be swallowed by the mouth) 400 mg/milliliters ([ML], a small unit used to measure liquid volume), give 30 ml by mouth every 24 hours PRN for Bowel Management. The MAR did not indicate Resident 3 was given a PRN dose on 7/30/2026.During a review of Resident 3's Progress Notes, dated 7/30/2026, the Progress Notes did not indicate Magnesium Hydroxide was offered to Resident 3.During a concurrent interview and record review on 8/21/2026 at 3:03 p.m., with the QA Nurse, Resident 3's ADL Bowel Elimination Task Sheet and MAR, dated 7/2026, and Progress Notes, dated 7/19/2026, were reviewed. The QA Nurse stated Resident 3 should have been offered a PRN dose of Magnesium Hydroxide because he did not have a BM for 3 days. There was no progress note on 7/19/2026 to indicate that Resident 3 was offered a PRN dose after not having a BM for 3 days. The QA Nurse stated if a resident did not have a BM for more than 3 days, it could cause constipation or bowel obstruction (a serious medical emergency where food, fluid, and gas cannot move through the small or large intestine).During a concurrent interview and record review on 8/21/2026 at 3:56 p.m., with the Director of Nursing (DON), the following were reviewed:-Resident 1's vital signs, dated 8/5/2026,-Resident 1's Progress Notes, dated 8/5/2026,-Resident 1's care plan titled, At risk for constipation r/t diminished appetite, use/side effects of medication - antidepressants, dated 8/11/2025,-Resident 2's care plan titled, At risk for constipation r/t decreased mobility, use/side effects of medication - Norco (a painkiller used to treat severe pain), dated 10/16/2025,-Resident 3's care plan titled, The resident is at risk for constipation r/t decreased mobility, use/side effects of medication - hydrocodone, dated 4/1/2024,-Resident 1, 2, and 3's ADL Bowel Elimination task sheets, dated 7/2026 and 8/2026,-Resident 1, 2, and 3's census, dated 8/21/2026.The DON stated licensed nurses should have obtained vital signs and completed an assessment during a resident COC as part of the nursing process. The DON stated care plans were used to identify and address the residents' problems. Staff should have been informed of residents having loose stools and had not had a BM in three days. The DON stated loose stools could indicate bowel issues or a side effect from the medication. The PCP should have been notified if there were multiple episodes and to discuss regarding holding stool softeners. The DON stated vital signs and a complete assessment should have been done during Resident 1's COC and there were no documented vital signs nor assessments for the resident. The DON stated staff should have held Resident 1's stool softener and informed the PCP when Resident 1 had multiple loose stools. The DON stated staff should have offered a PRN medication as ordered to Residents 2 and 3 when the residents did not have a bowel movement for 3 days. During a review of facility's policy and procedures (P&P) titled, Documentation in Medical Record, dated 12/19/2022, the P&P indicated, Licensed Staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. The P&P also indicated, Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care.During a review of facility's P&P titled, Medication Administration dated 12/19/2022, the P&P indicated, Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters.During a review of facility's P&P titled, Notification of Changes, dated 12/19/2022, the P&P indicated, the purpose of this policy is to ensure the facility promptly consults the resident's physician, when there is a change requiring notification. The P&P indicated circumstances that require notification included, need to alter treatment. The P&P also indicated that this could include discontinuation of current treatment due to adverse (harmful) consequences.During a review of facility's P&P titled, Comprehensive Care Plans, dated 12/19/2022, the P&P indicated, it is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet the resident's medical and nursing needs. The comprehensive care plan will describe, at a minimum, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview and record review, the facility failed to ensure a medicine was not left at the resident's bedside and ensure one of three sampled residents (Resident 2), drunk the scheduled medication.This failure resulted in the medication not being taken timely. Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 2's diagnoses included acute respiratory failure (sudden, life-threatening condition where the lungs cannot give enough oxygen into the blood) with hypoxia (a medical condition where your body's tissues and organs do not get enough oxygen to work properly). During a review of Resident 2's History and Physical (H&P), dated 6/30/2026, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set ([MDS], a resident assessment tool), dated 7/6/2026, the MDS indicated Resident 2 had moderate (not severe or extreme) cognitive impairment (problems with the ability to think, learn, use judgement, and make decisions). Resident 2 required substantial/maximal assistance (helper does more than half the effort) to perform Activities of Daily Living (ADLs) such as toileting hygiene and showering/bathing self. Resident 2 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) to perform movements such as rolling left and right and required partial/moderate assistance (helper does less than half the effort) to change positions from sitting to lying. During a review of Resident 2's Order Summary Report, dated 7/1/2026, the Order Summary Report indicated Multiple Vitamins-Minerals Tablet, one tablet by mouth one time a day for wound management. Resident 2's Order Summary Report did not indicate that Resident 2 had orders to self-administer medication. During an observation on 7/16/2026 at 12:43 p.m., in Resident 2's room, a small, round, orange pill was observed inside a medication cup at Resident 2's bedside table. During a concurrent observation and interview on 7/16/2026 at 12:51 p.m., with Licensed Vocational Nurse (LVN) 2, at Resident 2's bedside, LVN 2 stated Resident 2's bedside table had a small, round, orange pill. LVN 2 stated the pill was Resident 2's multivitamin from the morning medications. LVN 2 stated nurses should observe that residents swallow their medications before leaving. LVN 2 stated, leaving Resident 2's medication unattended at the bedside should be avoided. During an interview on 7/16/2026 at 3:40 p.m., the Quality Assurance (QA) Nurse stated there were no residents currently with orders to self-administer medication. During a review of the facility's policy and procedure (P&P) titled, Resident Self-Administration of Medication, dated 12/19/2022, the P&P indicated a resident may only self-administer medications after the facility's IDT (Interdisciplinary Team - a group of healthcare professionals, including physician, nurses, resident/ resident representative, working together to develop a plan of care for the residents) has determined which medications may be administered safely. During a review of facility's P&P titled, Medication Administration, dated 12/19/2022, the P&P indicated, medications should be administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician. The P&P indicated that compliance guidelines included to observe resident consumption of medication.

Based on interview and record review, the facility failed to ensure the prescribed therapeutic diet of one of three sampled residents (Resident 1) was followed.This failure placed Resident 1 at risk for elevated blood sugar levels.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included Chronic Obstructive Pulmonary Disease ([COPD], a chronic lung disease causing difficulty in breathing) with (Acute [sudden or quick]) Exacerbation (a sudden worsening of symptoms) and Type 2 Diabetes Mellitus ([DM], a disorder characterized by difficulty in blood sugar control and wound healing) with Diabetic Peripheral Angiopathy without Gangrene (high blood sugar which causes narrowing of blood vessels in the arms or legs, reducing blood flow, with no tissues dying or turning black). During a review of Resident 1's History and Physical (H&P), dated 1/30/2026, 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 4/23/2026, the MDS indicated Resident 1 had moderate (not severe or extreme) cognitive impairment (problems with the ability to think, learn, use judgement, and make decisions). Resident 1 required substantial/maximal assistance (helper does more than half the effort) to perform Activities of Daily Living (ADLs) such as eating and oral hygiene. Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) to perform movements such as rolling left and right and was dependent (helper does all the effort) to change positions from sitting to standing. During a review of Resident 1's Order Summary Report, dated 7/7/2026, the Order Summary Report indicated an order of Consistent Carbohydrate Diet (CCHO), No Added Salt (NAS) minced and moist ([MM5], Level 5 International Dysphagia Diet Standardization Initiative [IDDSI], a global framework that helps classify the thickness of drinks and texture of foods for people with swallowing difficulties), thin (TN0) consistency (liquids such as water, tea, or clear broth). During a review of Resident 1's dietary slip, dated 7/16/2026, the dietary slip indicated Resident 1 had large portions. During an interview on 7/16/2026 at 1:48 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 had large portions indicated on his dietary slip. During an interview on 7/16/2026 at 3:02 p.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated large portions would be an order that needed to come from the physician. During a concurrent interview and record review on 7/16/2026 at 3:18 p.m., with the Dietary Supervisor (DS), Resident 1's diet order and dietary slip, dated 7/16/2026, were reviewed. DS stated Resident 1 previously had an order for large portions during their previous admission. DS stated Resident 1's current diet order did not indicate that Resident 1 be given large portions. DS stated they had printed large portions on Resident 1's dietary slip because it was a note that was carried over from Resident 1's previous diet orders prior to Resident 1's current admission to the facility. DS stated they should have verified that Resident 1's diet slip matched Resident 1's current diet orders before the dietary slip was printed. DS stated Resident 1 having large portions could have increased their blood sugar levels and declined their health. During an interview on 7/22/2026 at 2:31 p.m., with Registered Nurse (RN) 1, RN 1 stated all diet orders from the physician should be followed and verified because only the physician can determine what orders to continue or discontinue once a resident is readmitted to the facility. During a review of facility's policy and procedure (P&P) titled, Therapeutic Diet Orders, dated 5/17/2023, the P&P indicated, the facility should provide all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician. The P&P indicated that dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed.

Based on observation, interview, and record review, the facility failed to ensure one out of three sampled residents' (Resident 2) low air loss (LAL) mattress pump (a small electric machine that constantly blows air into a medical air bed to prevent a pressure ulcer/injury [localized damage to the skin and/or underlying tissue usually over a bony prominence]) from developing or worsening) was set according to Resident 2's weight.This failure placed Resident 2's current pressure ulcers to worsen and had the potential to develop further pressure injuries. Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included acute respiratory failure (sudden, life-threatening condition where the lungs cannot give enough oxygen into the blood) with hypoxia (a medical condition where your body's tissues and organs do not get enough oxygen to work properly). During a review of Resident 2's History and Physical (H&P), dated 6/30/2026, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set ([MDS], a resident assessment tool), dated 7/6/2026, the MDS indicated Resident 2 had moderate cognitive impairment (problems with the ability to think, learn, use judgement, and make decisions). Resident 2 required substantial/maximal assistance (helper does more than half the effort) to perform Activities of Daily Living (ADLs) such as toileting hygiene and showering/bathing self. Resident 2 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) to perform movements such as rolling left and right and required partial/moderate assistance (helper does less than half the effort) to change positions from sitting to lying. During a review of Resident 2's Skin Check, dated 6/30/2026, the Skin Check indicated Resident 2 was admitted to the facility with a pressure ulcer to the sacrum (large, triangle-shaped bone at the base of the spine) and with another pressure ulcer to the right buttock. During a review of Resident 2's Order Summary Report, dated 7/1/2026, the Order Summary Report indicated Resident 2 had an order for, LAL Mattress for wound management. Set to resident's weight/comfort. During a review of Resident 2's weight summary, dated 7/16/2026, the weight summary indicated Resident 2 weighed 180 pounds (lbs.) as of 7/13/2026. During an observation on 7/15/2026 at 2:53 p.m., Resident 2's LAL mattress pump (labeled Protekt Aire 4000DX/5000DX ) was observed to be set at 400 lbs. During a concurrent observation, interview and record review on 7/15/2026 at 3:28 p.m., with Treatment Licensed Vocational Nurse (LVN) 1, Resident 2's LAL mattress pump was observed and Resident 2's weight, dated 7/13/2026, was reviewed. Resident 2 weighed 180 lbs. and not 400 lbs. Treatment LVN 1 stated Resident 2's pump was set to 400 lbs. Treatment LVN 1 stated Resident 2's LAL mattress pump should have been set to Resident 2's weight of 180 lbs. and comfort. Treatment LVN 1 stated incorrect LAL mattress pump setting could cause Resident 2's wound to decline and possibly allow for more (wounds) to develop. During an interview on 7/16/2026 at 8:55 a.m., with Registered Nurse (RN) 1, RN 1 stated licensed staff should have checked the LAL mattress pump at least once a shift to ensure that the settings were correct. During a review of the facility's policy and procedure (P&P) titled, Pressure Injury Prevention and Management, dated 5/18/2026, the P&P indicated, the facility was committed to provide treatment and services to heal the pressure ulcer/injury, prevent infection, and the development of additional pressure ulcers/injuries. The P&P indicated that basic or routine care interventions could include but are not limited to redistribute pressure (such as repositioning, protecting, and/or offloading heels, etc.). During a review of the facility's P&P titled, Pressure Injury Prevention Guidelines, dated 11/27/2023, the P&P indicated, interventions will be implemented in accordance with physician orders, including the type of prevention devices to be used and, tasks, the frequency of performance. The P&P indicated prevention devices should be utilized in accordance with manufacturer recommendations (e.g., heel flotation devices, cushions, mattresses). During a review of facility's operation manual titled, Proactive Medical Products, Operation Manual for Protekt Aire 4000DX/4600DX/5000DX, the operation manual indicated, users should adjust air mattress to a desired firmness according to the resident's weight or the suggestion from a health care professional.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), medications was available, and were administered to the resident, and, ensure the medication brought to the facility by a family member (FM) was verified, order obtained to administer, according to its policy and procedure (P&P) titled, Medication Ordering and Receiving From Pharmacy. These failures placed Resident 1 at risk for complications when medications were received or not received as ordered, which could lead to hospitalizations.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included unspecified (unknown) fracture (broken bone) of sacrum (tailbone), subsequent encounter (follow-up or routine aftercare) for fracture with routine healing. During a review of Resident 1's Order Summary report dated 3/27/2026, the order summary report indicated to apply Buprenorphine Transdermal (through the skin) Patch (a controlled [regulated] pain medication for the management of severe, persistent, and chronic pain) weekly 7.5 micrograms ([mcg], unit of weight in the metric system equal to one-millionth of a gram)/hour (hr), 1 patch transdermal every Monday (Mon) for pain and change patch every week, start date of 4/1/2026. The Order Summary Report dated 3/26/2026, indicated to inject Ozempic 0.5 milligrams (mg., a unit of measurement) subcutaneously (under the skin) weekly, every Monday for diabetes (abnormal blood sugar levels) management. During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool) dated, 4/2/2026, the MDS indicated Resident 1 had moderate cognitive impairment (problems with the ability to think, remember, and solve problems). The MDS indicated Resident 1 required setup or clean-up assistance (helper sets up or cleans up) for Activities of Daily Living (ADLs) such personal hygiene and required substantial/maximal assistance (helper does more than half the effort) for ADLs such as showering/bathing self. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) to perform movements such as rolling left and right and transferring from bed to chair. During a review of Resident 1's Medication Administration Record (MAR), for the month of 4/2026, the MAR did not indicate Resident 1 received the Buprenorphine Transdermal Patch on 4/8/2026 and 4/15/2026. The MAR did not indicate Resident 1 received Ozempic on 4/6/2026, 4/13/2026, 4/20/2026, and 4/27/2026. During a review of Resident 1's Progress Notes, dated 4/6/2026, 4/8/2026, 4/13/2026, 4/15/2026, 4/20/2026, and 4/27/2026, the progress notes indicated Resident 1 did not receive the prescribed Ozempic and the Buprenorphine Transdermal Patch because the medications were on order. During a concurrent interview and record review on 5/27/2026 at 2:23 p.m., with the Licensed Vocational Nurse (LVN) 1, Resident 1's MAR, for the month of 4/2026, and the progress notes, dated 4/6/2026, 4/8/2026, 4/13/2026, 4/15/2026, 4/20/2026, and 4/27/2026, were reviewed. LVN 1 stated the MAR did not indicate Resident 1 received the Buprenorphine patch on 4/8/2026 and 4/15/2026 because the medications were on order. LVN 1 stated it placed Resident 1 at risk for pain. LVN 1 stated staff should have followed up the ordered missing medications from the pharmacy. LVN 1 stated Resident 1's progress notes did not indicate what further actions were done when Resident 1 did not receive Ozempic medications on 4/6/2026, 4/13/2026, 4/20/2026, and 4/27/2026. LVN 1 stated not receiving the Ozempic doses placed Resident 1 at risk for issues with controlling blood sugar levels. During a concurrent interview and record review on 5/27/2026 at 4:35 p.m., with the Director of Nursing (DON), Resident 1's MAR, for the month of 4/2026, was reviewed. The DON stated the facility did not receive the required high-cost form to sign and was not aware that Resident 1 was needing authorization for Ozempic medication. The DON stated not receiving Buprenorphine Patch on 4/8/2026 and 4/15/2026, placed Resident 1 at risk for unresolved pain. The DON stated staff did not follow up Resident 1's Ozempic and Buprenorphine Patch with the pharmacy. During an interview on 5/28/2026 at 11:16 a.m., with Pharmacist (Pharm) 1, Pharm 1 stated Resident 1's Ozempic was never dispensed to the facility because it was a high-cost medication requiring facility authorization and documentation. Pharm 1 stated the high-cost form was never received from the facility. During an interview on 5/28/2026 at 12:27 p.m., with Pharm 2, Pharm 2 stated Resident 1's Buprenorphine patch was never dispensed to the facility because it required the PCP's signature. Pharm 2 stated the pharmacy did not receive the Primary Care Physician (PCP) signature and authorization from the facility. During a concurrent interview and record review on 5/28/2026 at 2:13 p.m., with LVN 4, Resident 1's MAR for Buprenorphine Patch, dated 4/22/2026 and 4/29/2026, and Progress Note, dated 4/22/2026, were reviewed. LVN 4 stated to a the box of Buprenorphine Patches were brought by Resident 1's FM to the facility (date unknown). LVN 4 stated the progress notes on 4/22/2026 did not indicate LVN 4 obtained Resident 1's PCP's approval to use Resident 1's Buprenorphine Patches brought from home at the facility. During a concurrent interview and record review on 6/1/2026 at 2:18 p.m., with the DON, Resident 1's MAR for Ozempic, dated 3/30/2026, the MAR for Buprenorphine Patch, dated 4/1/2026, 4/22/2026 and 4/29/2026, the facility's policy and procedures (P&P), titled Medication Ordering and Receiving from Pharmacy, dated 8/2014, and Resident 1's Progress Notes, dated 4/2026, were reviewed. The DON stated both Ozempic on 3/30/2026 and Buprenorphine Transdermal Patch on 4/1/2026, 4/22/2026 and 4/29/2026 should not have been marked off as given, because the medications were never delivered by the pharmacy. The nurses should have followed up with pharmacy. The DON stated she was aware that Resident 1 did not receive the Buprenorphine Patch, and FM brought in two doses from home (date not specified). The DON stated medications brought from home which are to be continued at the facility should be verified by the pharmacist or physician according to the facility's P&P titled Medication Ordering and Receiving from Pharmacy. The DON stated Resident 1's progress notes did not indicate the Buprenorphine patches brought by the resident's FM was verified from the resident's PCP if approved to continue taking the medicine (Buprenorphine patch). During a review of facility's P&P titled, Medication Administration, dated 12/19/2022, the P&P indicated to sign MAR after medications is administered, correct any discrepancies and report to nurse manager. During a review of facility's P&P titled, Medication Ordering and Receiving From Pharmacy, dated 8/2014, the P&P indicated, the use of medications brought to the facility by a family member from home is allowed only when the physical description of the medication have been verified by a pharmacist or physician.

Based on interview and record review, the facility failed to ensure one of three sampled residents' (Resident 1), pain level was reassessed timely, after the pain medication was administered.This failure placed Resident 1's pain level unresolved and the potential to affect in maintaining the resident's highest practicable physical, mental and psychosocial wellbeing.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included unspecified (unknown) fracture (broken bone) of sacrum (tailbone), subsequent encounter (follow-up or routine aftercare) for fracture with routine healing. During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool) dated, 4/2/2026, the MDS indicated Resident 1 had moderate cognitive impairment (problems with the ability to think, remember, and solve problems). The MDS indicated Resident 1 required setup or clean-up assistance (helper sets up or cleans up) for Activities of Daily Living (ADLs) such personal hygiene and required substantial/maximal assistance (helper does more than half the effort) for ADLs such as showering/bathing self. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) to perform movements such as rolling left and right and transferring from bed to chair. During a review of Resident 1's Order Summary report, Resident 1's physician's order, dated 3/30/2026, indicated, Hydromorphone (also known as Dilaudid, a powerful, prescription-only pain medication used to treat severe pain) 4 milligrams ([mg], metric unit of measurement) one tablet by mouth every four (4) hours, as needed (PRN) for (7/10) severe pain (a numerical pain scale used in a facility with 0 no pain, 1-3 mild pain, 4-6 moderate pain, 7-8 severe pain, 9-10 worst pain possible) and Hydrochloric Acid (HCl) Oral Tablet 4 mg, 1 tablet by mouth every 4 hours PRN for 7-10 pain. During a review of Resident 1's Medication Administration Record (MAR), for the month of 4/2026, the MAR indicated that on 4/8/2026 at 8:49 p.m., Resident 1 received Hydromorphone HCl 4 mg tablet for 9/10 (severe pain) pain level and 10/10 (severe pain) on 4/10/2026 at 7:52 p.m. During a review of Resident 1's progress notes dated 4/8/2026 at 10:18 p.m., the progress notes indicated Resident 1's pain level was reassessed, and the level was 2/10 (mild pain). The progress notes dated 4/10/2026 at 11:27 p.m., indicated Resident 1's pain level was reassessed, and the level was 1/10 (mild pain). During a concurrent interview and record review on 5/27/2026 at 4:03 p.m., with Licensed Vocational Nurse (LVN) 3, Resident 1's MAR, dated 4/8/2026 and 4/10/2026, and progress notes dated 4/8/2026 and 4/10/2026 were reviewed. LVN 3 stated after the pain medications were administered to Resident 1 on 4/8/2026 and 4/10/2026, the facility staff should have reassessed the resident's pain level after an hour, to determine if the resident's pain has improved or not. LVN 3 stated Resident 1's progress notes indicated that on 4/8/2026 and 4/10/2026, Resident 1's pain level was reassessed more than an hour after the pain medication was administered. LVN 3 stated it was important to reassess the resident's pain level and document the reassessment to ensure that the resident's pain was managed timely. During an interview on 6/1/2026 at 2:18 p.m., with the Director of Nursing (DON), the DON stated it was not acceptable to reassess Resident 1's pain level more than one hour after the pain medications were administered as the resident's pain level could have been unmanaged. During a review of facility's policy and procedure (P&P) titled, Pain Management, dated 3/17/2025, the P&P indicated, the facility must ensure that pain management is provided to residents in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences.

Based on interview and record review, the facility failed to notify one of three sampled residents' (Resident 1) primary care physician (PCP), when the resident did not receive prescribed Buprenorphine (a controlled [regulated] pain medication for the management of severe, persistent, and chronic pain) and Ozempic (medication to lower blood sugar).This failure placed the resident at risk for potential complications such as increased need of pain medication, poor pain management, and complications from diabetes such as diabetic ketoacidosis (a life-threatening complication that can occur if blood glucose levels are high) leading to hospitalization.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included unspecified (unknown) fracture (broken bone) of sacrum (tailbone), subsequent encounter (follow-up or routine aftercare) for fracture with routine healing. During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool) dated, 4/2/2026, the MDS indicated Resident 1 had moderate cognitive impairment (problems with the ability to think, remember, and solve problems). The MDS indicated Resident 1 required setup or clean-up assistance (helper sets up or cleans up) for Activities of Daily Living (ADLs) such personal hygiene and required substantial/maximal assistance (helper does more than half the effort) for ADLs such as showering/bathing self. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) to perform movements such as rolling left and right and transferring from bed to chair. During a review of Resident 1's Order Summary report, dated 3/27/2026, the Order Summary Report indicated, Buprenorphine Transdermal (through the skin) Patch Weekly 7.5 micrograms ([mcg], unit of weight in the metric system equal to one-millionth of a gram)/hour (hr.), apply 1 patch transdermal every Monday (Mon) for pain, change patch every week. The start date was dated 4/1/2026. During a review of Resident 1's Medication Administration Record (MAR), for the month of 4/2026, the MAR indicated Resident 1 did not receive the prescribed Buprenorphine medication on 4/8/2026 and 4/15/2026 and Ozempic on 4/6/2026, 4/13/2026, 4/20/2026, and 4/27/2026. During a review of Resident 1's Nursing progress notes, dated 4/8/2026 to 4/27/2026, the progress notes indicated, meds on order. The progress notes did not indicate Resident 1's PCP was notified about the missed doses of Buprenorphine medication on 4/8/2026 and 4/15/2026, and Ozempic on 4/6/2026, 4/13/2026, 4/20/2026, and 4/27/2026. During a concurrent interview and record review on 5/27/2026 at 2:33 p.m., with Licensed Vocational Nurse (LVN) 1, the following were reviewed:Resident 1's MAR for Buprenorphine, for the month of 4/2026.Resident 1's MAR for Ozempic, for the month of 4/2026.Resident 1's Progress notes, dated 4/6/2026, 4/8/2026, 4/13/2026, 4/15/2026, 4/20/2026, and 4/27/2026.LVN 1 stated that on 4/8/2026 and 4/15/2026, the MAR did not indicate that Resident 1 received the Buprenorphine medicine, and the Ozempic on 4/6/2026, 4/13/2026, 4/20/2026, and 4/27/2026. During interview on 5/27/2026 at 4:35 p.m., with the Director of Nursing (DON), the DON stated if the Buprenorphine and Ozempic were not given, Resident 1's blood sugar and pain could not be managed effectively. During an interview on 6/1/2026 at 2:18 p.m., with the DON, the DON stated Resident 1's progress notes did not indicate that the PCP was notified about the missed doses of Buprenorphine and Ozempic. During a review of facility's policy and procedure (P&P) titled, Notification of Changes, dated 12/19/2022, the P&P indicated, the facility must consult with the resident's physician when there is a change requiring notification. The P&P indicated. circumstance requiring notification include circumstances that require a need to alter treatment.

Based on observation, interview and record review, the facility failed to ensure the at risk for fall care plan for 1 of 3 residents, (Resident 1), who was non-compliant (uncooperative) in maintaining the height of bed to its lowest position, was revised, as indicated in its policy and procedure (P&P) titled Fall Prevention Program. This failure placed the resident at risk for falls, severe injuries, including hospitalization. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 1's diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction (stroke), syncope (a temporary loss of consciousness and muscle tone caused by insufficient blood flow to the brain) and collapse (fall to the ground, which may be caused by syncope or other non-cardiac issues), and other abnormalities of gait and mobility. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 1/13/2026, the MDS indicated Resident 1 had clear speech, usually understood and understands. The MDS indicated Resident 1required substantial/maximal assistance (helper does more than half the effort) with toileting, shower/bathe self and lower body dressing. During a review of Resident 1's care plan, no title, dated 1/20/2025, the care plan indicated Resident 1 was at risk for falls related to gait/balance problems and fall at home on 1/10/2025. The care plan interventions included to anticipate and meet needs, place call light within reach and encourage to use the call light for assistance as needed. Resident 1 needs a safe environment with even floors free from spills and/or clutter; adequate glare-free light, and the bed in low position at night. The care plan did not indicate Resident 1 was non-complaint with keeping the height of bed in low position nor education was provided regarding safety precautions. During a review of Resident 1's Fall Risk assessment, dated 2/9/2025, the Fall Risk assessment indicated Resident 1 was at risk for falls. The Fall Risk assessment indicated Resident 1 had intermittent confusion. During a review of Resident 1's progress notes, dated 4/6/2026, at 2:52 p.m., the progress notes indicated Resident 1's bed was observed elevated. The bed was lowered and Resident 1 raised the bed again. During a concurrent observation and interview on 4/6/2026 at 11:30 am with the Director of Nursing (DON), at Resident 1's bedside, Resident 1's bed height was observed at approximately 30 inches high from the floor. The DON stated the height of the bed was too high. If Resident 1 was at high risk for falls, the resident could fall. The DON stated Resident 1 was non-compliant with following instructions to maintain the height of bed at the lowest position. During an interview 4/6/2026 at 12:15 p.m., with the Charge Nurse, the Charge Nurse stated Resident 1 was not compliant with following staff instructions and education to maintain the bed to its lowest position to reduce the risk of falling. The Charge Nurse stated if the bed height was high, it placed Resident 1 at an increased risk of falling. During a review of the facility's policy and procedure (P&P) titled, Fall Prevention Program, dated 12/28/2023, The P&P indicated each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. The P&P indicated the nurse and /or interdisciplinary team will initiate interventions on the resident's care plan, in accordance with the resident's level of risk. The P&P indicated each resident's risk factors and environmental hazards will be evaluated when developing the residents comprehensive plan of care. Interventions will be monitored for effectiveness, and the plan of care will be revised as needed.

Based on observation, interview, and record review, the facility failed to ensure the call light was within reach and/or not a proper call light for five of 18 sampled residents (Resident 31, Resident 44, Resident 95, Resident 48 and Resident 99). This deficient practice had the potential to negatively impact Residents 31, 44, 95, 48, and 99's psychosocial well-being and result in delayed provision of care and services. Findings: a. During a review of Resident 31's admission Record, the admission Record indicated Resident 31 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), and depression (a medical illness causing feelings of sadness, or loss of interest in activities). During a review of Resident 31's Minimum Data Set (MDS - a resident assessment tool), dated 1/24/2026, the MDS indicated Resident 31's cognitive skills for daily decision making (the ability to think and process information) was moderately impaired. The MDS indicated Resident 31 required moderate (helper does less than half the effort) assistance from staff for 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 31's care plan titled The resident has a communication problem related to difficulty hearing and Alzheimer's disease, dated 1/27/2026, the care plan indicated to provide a safe environment, including having the call light in reach. During an observation on 2/23/2026 at 9:20 a.m., at Resident 31's bedside, Resident 31 was observed lying in bed. The call light was located behind Resident 31's bed and not within reach. During a concurrent observation and interview on 2/23/2026 at 12:31 p.m., with Resident 31, at Resident 31's bedside, Resident 31 was observed sitting in bed visibly upset trying to reach the call light. Resident 31's call light was attached to the back side of her bed, not within reach. Resident 31 stated she needed assistance with using the restroom but was unable to call the nurse because she was not able to reach her call light. During a concurrent observation and interview on 2/23/2026 at 12:45 p.m., with Certified Nursing Assistant (CNA) 2, at Resident 31's bedside, Resident 31's call light was attached to the back of the resident's bed. CNA 2 stated the call light was not within reach. CNA 2 stated the call light should always be placed within Resident 31's reach so she could call for help when needed. CNA 1 stated not having the call light within reach placed Resident 31 at risk for unmet care needs, delayed assistance, increased risk for falls, and potential injury. During an interview on 2/26/2026 at 7:56 a.m., with the Director of Nursing (DON), the DON stated resident's call lights must be placed within the resident's reach at the bedside. The DON stated the call light was important for residents to be able to communicate their needs to staff. The DON stated licensed staff were responsible for ensuring residents' call lights were checked and positioned within reach at the bedside. The DON stated when a call light was not within reach, the resident would not be able to call for help, which was a safety issue. The DON stated this placed residents at risk for delayed care needs, and avoidable harm. b. During a review of Resident 44's admission Record, the admission Record indicated Resident 44 was admitted to the facility on [DATE]. Resident 44' diagnoses included difficulty walking, dementia (a progressive state of decline in mental abilities), hypertensive heart disease (a heart disease caused by long-term high blood pressure) with heart failure (a condition in which the heart does not pump blood effectively to meet the body's needs), acute kidney failure (a sudden loss of kidney function in which the kidneys are unable to properly filter waste and fluids from the blood), stable burst fracture of the first lumbar vertebra (a broken bone in the lower spine caused by compression or pressure), unspecified fracture of T11-T12 vertebra (broken bones in the middle portion of the spine), and unspecified fracture of second lumbar vertebra (a broken bone in the lower spine). During a review of Resident 44's MDS, dated [DATE], the MDS indicated Resident 44's cognitive skills for daily decision making (ability to think, remember, and reason) was severely impaired. The MDS indicated Resident 44 required moderate assistance with toileting and bathing. The MDS indicated Resident 44 required maximal assistance (helper does more than half the effort) for transferring to and from bed and toilet and walking 10 feet and 50 feet. The MDS further indicated Resident 44 had a one fall since admission. During a review of Resident 44's History and Physical (H&P), dated 2/6/2026, the H&P indicated Resident 44 did not have the capacity to understand and make decisions. The H&P further indicated Resident 44 was identified as at risk for falls. During a review of Resident 44's Fall Risk assessment dated [DATE], the assessment indicated Resident 44 was at risk for falls. During a review of Resident 44's care plan titled Risk for falls, revised 2/5/2026, the care plan indicated to place Resident 44's call light within reach and encourage the resident to use for assistance as needed. During a concurrent observation and interview on 2/23/2026 at 9:58 a.m. with CNA 1, Resident 44's call light was observed hanging from a wall hook. CNA 1 stated the call light was not within reach. CNA 1 stated it was important for Resident 44 to have the call light accessible in case of an emergency. CNA 1 stated if the call light was not within reach, Resident 44 could attempt to get up without assistance and fall. During an interview on 2/25/2026 at 11:41 a.m., with Licensed Vocational Nurse (LVN) 5, LVN 5 stated Resident 44 was on fall precautions and should have the call light within reach at all times. LVN 5 stated Resident 44 could attempt to reach for something and fall without a way to contact staff for assistance. c. During a review of Resident 95's admission Record, the admission Record indicated Resident 95 was admitted to the facility on [DATE]. Resident 95's diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke – caused by a blockage that stops blood flow to part of the brain), aphasia (a disorder that makes it difficult to speak), apraxia (difficulty coordinating movements), anxiety disorder (a condition causing excessive worry, fear, or nervousness), and dysphagia (difficulty swallowing).During a review of Resident 95's MDS, dated [DATE], the MDS indicated Resident 95's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 95 required maximal assistance for eating and was dependent (staff does all the effort) for toileting, bathing, dressing, and personal hygiene. During a review of Resident 95's H&P, dated 2/16/2026, the H&P indicated Resident 95 did not have the capacity to make decisions. During a review of Resident 95's care plan titled Risk for falls, revised 1/26/2026, the care plan indicated to place Resident 95's call light within reach and encourage the resident to use for assistance as needed. During a concurrent observation and interview on 2/23/2026 at 10:51 a.m. with Resident 95, Resident 95 was observed in bed, awake and alert. Resident 95 attempted to speak but was unable to articulate understandable words. Resident 95 pointed to the picture call nurse on her communication board. The call light was observed hanging behind the resident's head on the bedpost. When asked if she was able to reach the call light, Resident 95 shook her head, indicating no. During a concurrent observation and interview on 2/23/2026 at 11:02 a.m. with CNA 3, in Resident 95's room, the call light was observed hanging on the bedpost behind the resident. CNA 3 stated the call light should have been within reach at all times so she could call for help if she was in pain, needed assistance, or during an emergency. CNA 3 stated she forgot to return the call light to the resident after checking on her earlier. During an interview on 2/25/2026 at 11:34 a.m. with LVN 5, LVN 5 stated it was important for Resident 95 to have the call light within reach for emergencies or when assistance was needed. LVN 5 stated residents could fall or experience an emergency and would not be able to summon help if the call light was not accessible. LVN 5 stated Resident 95 could not verbalize her needs, which made it more important for the call light to remain within reach. d. During a review of Resident 48's admission Record, the admission Record indicated Resident 48 was initially admitted to the facility on [DATE]. Resident 48's diagnoses included contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion) of the left and right elbow and wrist, functional quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), dysphagia (difficulty swallowing), and adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity). During a review of Resident 48's MDS, dated [DATE], the MDS indicated Resident 48's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 48 had functional range of motion (ROM, the measure of the full, natural movement potential of a joint, such as how far it can bend or stretch) limitations to his upper and lower extremities (arm, legs). The MDS indicated Resident 48 was entirely dependent on staff for ADLs. During a review of Resident 48's care plan titled, At Risk for Falls, initiated 11/21/2024, the care plan indicated to keep the call light within reach, and ensure a safe environment with a working and reachable call light. During a concurrent observation and interview on 2/23/2026 at 1:50 p.m. with Resident 48, in Resident 48's room, Resident 48 was observed in bed with both wrists and elbows in a fixed, flexed (bent) position. A push button call light was observed. Resident 48 attempted to activate the call light but was unable to do so due to limited ROM in her elbows and wrists. Resident 48 stated she could not push the button. During an observation on 2/24/2026 at 12:09 p.m., in Resident 48's room, observed a push button call light at Resident 48's bedside. During a concurrent interview and record review on 2/24/2026 at 12:20 p.m. with Registered Nurse (RN) 1, a photo of Resident 48's call light, dated 2/24/2026 and timed at 12:09 p.m., was reviewed. RN 1 stated Resident 48 was capable of verbalizing her needs. RN 1 stated Resident 48's call light was not the most appropriate call light because she was unable to call or ask for help when needed. RN 1 stated Resident 48 would have benefitted from a call pad due to her presence of contractures to the wrist and elbows. RN 1 stated the incorrect call light placed Resident 48 at risk for delayed response to emergent or non-emergent care needs. e. During a review of Resident 99's admission Record, the admission Record indicated Resident 99 was admitted to the facility on [DATE]. Resident 99 diagnoses included diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), Alzheimer's (a disease characterized by a progressive decline in mental abilities), dysphagia, schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) and contractures of the right and left knees and ankles. During a review of Resident 99's H&P, dated 9/2/2025, the H&P indicated Resident 99 did not have the mental capacity to make decisions. During a review of Resident 99's MDS, dated [DATE], the MDS indicated Resident 99 cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 99 was dependent for ADLs. During an observation on 2/23/2026 at 10:39 a.m., at Resident 99's bedside, Resident 39 was observed lying in bed. The call light was on the floor under the bed. During an interview on 2/24/2026 at 2:02 p.m., with LVN 6, LVN 6 stated the the call light must always be kept within the resident's reach while the resident was in bed or seated. LVN 6 stated that the call light should never be placed on the floor or underneath the resident's bed. LVN 6 stated staff were responsible for ensuring the call light was accessible after providing care, repositioning the resident, or leaving the room. LVN 6 stated that maintaining the call light within reach was a basic safety measure and an expectation for all nursing staff to ensure resident safety and timely assistance. During an interview on 2/26/2026 at 10:23 a.m., with the DON, the DON stated the facility policy required call lights to be within all residents' reach at all times. The DON stated that it was the responsibility of nursing staff to ensure the call light was properly placed before exiting the residents' room. The DON stated that placing the call light on the floor or under the bed was not an acceptable practice and did not meet the facility's safety standards. The DON indicated that failure to maintain the call light within reach could prevent residents from summoning assistance in a timely manner and could increase the risk of falls, injury, or delayed care. During a review of the facility's policy and procedures (P&P) titled Call Lights: Accessibility and Timely Response, dated 12/19/2022, the P&P indicated the facility staff will ensure the call light is within reach of resident and secured. The P&P indicated the call system would be accessible to residents while in their bed or other sleeping accommodations within the resident's room. The P&P indicated each resident should, as much as possible, be evaluated for unique needs and preferences to determine any special accommodations that may be needed in order for the resident to utilize the call system. The P&P further indicated special accommodations would be identified on the residents' person-centered plan of care and provided accordingly (examples include touch pads, larger buttons, bright colors, etc.).

Based on observation, interview, and record review, the facility failed to ensure staff provided necessary assistance with activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) for one of eight sampled residents (Resident 22), who required assistance with transfers (help from one or more staff members to safely move a resident between two positions, such as from a bed to a chair, a chair to a wheelchair, or standing up) and dressing.This deficient practice had the potential to result in decline in mobility (ability to move freely), muscle weakness, development of pressure injuries (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence), and decreased psychosocial well-being from remaining in bed for prolonged periods. Findings:During a review of Resident 22's admission Record, the admission Record indicated Resident 22 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 22's diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke - caused by a blockage that stops blood flow to part of the brain), muscle weakness, history of falling, and Stage 2 pressure ulcer (partial-thickness loss of skin, presenting as a shallow open sore or wound) of the sacral region (lower back). During a review of Resident 22's History and Physical (H&P), dated 9/22/2025, the H&P indicated Resident 22 had the capacity to make decisions. During a review of Resident 22's Minimum Data Set (MDS - a resident assessment tool), dated 1/13/2026, the MDS indicated Resident 22's cognitive skills for daily decision making (ability to think, remember, and reason) were moderately impaired. The MDS indicated Resident 22 required set up and clean up assistance for eating, oral hygiene, and personal hygiene. The MDS indicated Resident 22 required maximal assistance (helper does more than half the effort) for toileting, bathing, and dressing and required moderate assistance (helper does less than half the effort) for transferring to and from bed and toilet. The MDS indicated Resident 22 was at risk for pressure ulcers.During a review of Resident 22's care plan titled, Restorative Nursing Program: passive range of motion (PROM, the movement of a joint through its full range by an external force without any muscle contraction or effort from the patient), assistive range of motion (AAROM, the maximum distance and direction a joint can move voluntarily using an individual's own muscle strength, without any outside assistance), revised 1/23/2026, the care plan indicated Resident 22 had potential for decline in range of motion (ROM, the amount of movement that a particular joint or series of joints can achieve in a specific direction) and functional activity tolerance related to cerebrovascular accident (CVA - stroke, loss of blood flow to a part of the brain). The care plan indicated Resident 22 would be able to adapt and adjust to living as independently and safely as possible; enable good hygiene and promote functional mobility; decrease risk for skin breakdown; and improve posture and enable the resident to sit up in a wheelchair for meals and activities, as needed. The interventions included to monitor Resident 22 for any changes and refer to nursing and/or rehabilitation as indicated; provide PROM exercises to bilateral lower extremities (legs) five times per week or as tolerated; provide AAROM exercises to bilateral upper extremities (arms); and promote mobility and positioning to support functional activity.During a review of Resident 22's care plan titled, Limited Physical Mobility related to weakness, bilateral knee pain, revised 1/23/2026, the care plan indicated Resident 22 had limited physical mobility related to weakness and bilateral knee pain. The goals indicated Resident 22 would remain free of complications related to immobility, including contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion), thrombus formation (blood clot development), skin breakdown, and fall-related injury through the next review date; and would minimize contracture formation, skin breakdown, and fall-related injury. The interventions included monitoring for signs and symptoms of pain associated with mobility and attempting non-pharmacological interventions; inviting the resident to activity programs that encourage physical mobility; providing gentle range of motion as tolerated with daily care; providing supportive care and assistance with mobility as needed; and documenting assistance provided; and initiating physical therapy (PT) and occupational therapy (OT) referrals, as needed.During a review of Resident 22's ADLs Transfer Flow Sheet dated 1/26/2026 through 2/26/2026, the ADL Transfer Flow Sheet indicated Not Applicable for transfers on 2/23/2026, 2/24/2026, 2/25/2026, and 2/26/2026.During a concurrent observation and interview on 2/23/2026 at 11:13 a.m., in Resident 22's room, Resident 22 was observed lying in bed awake and alert. The low air loss mattress (LALM - a therapeutic mattress used to reduce pressure and prevent skin breakdown) was set at 240. Resident 22 was dressed in a gown and covered with a jacket while lying in bed. Resident 22 stated staff did not get her out of bed. Resident 22 stated staff told her the nurses were female and unable to get her up. Resident 22 stated she had to wait for two male staff to assist her with getting out of bed. Resident 22 stated she had been in bed for approximately five months and had only been out of bed twice. Resident 22 stated when she was receiving physical therapy she was getting out of bed and felt she was getting stronger. Resident 22 stated after therapy ended, staff attempted to get her up out of bed with a Hoyer lift (a mechanical device used to lift and/or transfer a person from place to place). Resident 22 stated staff used the Hoyer lift incorrectly, which caused her pain, and since that time staff had not attempted to get her up again except on two occasions when male staff were available. Resident 22 stated when she asked staff to get her out of bed, staff told her she must wait for two male staff because the female staff were not strong enough to assist her out of bed. Resident 22 stated her physician told staff she needed to get out of bed and that there were special staff who could assist with getting her up. Resident 22 stated she remained in bed every day and did not get dressed. Resident 22 stated she wore a gown and covered herself with a jacket while lying in bed. Resident 22 stated she wanted to get up and go to activities, including the Sunshine Room, but staff would not get her out of bed. Resident 22 stated staff provided exercises to her legs while in bed but did not get her out of bed for activities.During observations on 2/23/2026 at 11:13 a.m., 2/24/2026 at 9:26 a.m., 12:35 p.m., and 4:25 p.m., 2/25/2026 at 9:30 a.m. and 11:45 a.m., and 2/26/2026 at 9:26 a.m., Resident 22 was observed lying in bed wearing a hospital gown and covered with a jacket.During a concurrent observation and interview on 2/24/2026 at 12:35 p.m., with Resident 22, Resident 22 was observed lying in bed awake and alert. Resident 22 stated she wanted to get out of bed, but staff told her the female staff were unable to lift her, and she needed to wait for male staff to assist her out of bed.During an interview on 2/26/2026 at 9:40 a.m. with Certified Nursing Assistant (CNA) 3, CNA 3 stated it was her responsibility to wake residents in the morning, assist with dressing, and assist residents out of bed in preparation for breakfast. CNA 3 acknowledged Resident 22 did not get out of bed from 2/23/2026 through 2/26/2026. CNA 3 stated Resident 22 complained the Hoyer lift hurt her leg the last time staff attempted to get her up, and since that time Resident 22 had refused to get out of bed and get dressed. CNA 3 stated she had been documenting Not Applicable instead of Resident Refused on the ADL Flow Sheet. CNA 3 acknowledged refusals should have been documented as Resident Refused so there would be a record of the resident's refusal to get out of bed. CNA 3 further acknowledged she had not reported the refusals to get out of bed to the charge nurse. CNA 3 stated it was important for Resident 22 to get dressed and participate in activities and maintain mental well-being. CNA 3 stated residents generally felt presentable and happier when they were dressed and out of bed. CNA 3 stated she had not personally assisted Resident 22 out of bed but would use the Hoyer lift with two staff if the resident requested assistance.During an interview on 2/26/2026 at 9:40 a.m. with Licensed Vocational Nurse (LVN) 5, LVN 5 stated Resident 22 typically only got out of bed when two male staff assisted her because the resident reported the Hoyer lift caused her pain. LVN 5 stated Resident 22 reported experiencing pain when staff attempted to transfer her using the Hoyer lift. LVN 5 stated mobility and ADLs should have been addressed daily. LVN 5 acknowledged she did not get the resident out of bed the previous day and did not administer pain medication prior to attempting a transfer. LVN 5 stated staffing should not have been a reason a resident remained in bed throughout the day. LVN 5 stated Resident 22 was weight-bearing, could pivot during transfers, and required a two-person assist. LVN 5 stated Resident 22 was not bedbound and there was no clinical reason for the resident to remain in bed throughout the day. LVN 5 stated if a resident refused to get out of bed, the refusal should have been documented, addressed in the care plan, and the physician and responsible party should have been notified so alternate methods of assisting the resident out of bed could have been explored. LVN 5 stated the charge nurse, and CNAs were responsible for ensuring care plans addressing mobility were followed to promote activity. LVN 5 stated remaining in bed throughout the day could place the resident at risk for pressure ulcers, depression, and loss of mobility, which could negatively impact the resident's quality of life. LVN 5 stated there were no orders for bedrest or mobility restrictions for Resident 22. During an interview on 2/26/2026 at 11:10 a.m., with Director of Nursing (DON), the DON stated she was aware Resident 22 reported discomfort when using the Hoyer lift. The DON stated if a resident experienced discomfort with a transfer method, staff should have explored alternative methods to assist the resident out of bed. The DON stated if a resident refused care, the refusal should have been documented in the progress notes and addressed through the care plan and interdisciplinary team (IDT - a group of healthcare staff from different departments who work together to plan and coordinate a resident's care). The DON stated if a resident was not receiving care related to mobility, the lack of care and any refusals should have been documented. The DON stated remaining in bed for extended periods could place Resident 22 at risk for contractures, pressure ulcers, and decline in well-being.During a review of the facility's policy and procedure (P&P) titled ADL Care of Dementia Unit Residents, dated 12/19/2022, the P&P indicated the facility will provide appropriate treatment and services related to ADLs to ensure residents' ADL needs are met while attaining or maintaining the resident's highest practicable physical, mental, and psychosocial well-being. The P&P indicated each resident's physical functioning will be assessed in accordance with the facility's assessment procedures, the level of assistance needed for ADL activities will be included in the resident's plan of care, and care plan interventions will be monitored on an ongoing basis for effectiveness and revised as necessary. The P&P further indicated referrals may be made if current interventions are ineffective or if the resident shows a decline in physical functioning.During a review of the facility's P&P titled Safe Resident Handling/Transfers, dated 12/19/2022, the P&P indicated the facility will ensure residents are handled and transferred safely to prevent or minimize the risk of injury and to provide a safe and comfortable experience for residents while keeping employees safe in accordance with current standards and guidelines. The P&P indicated the IDT, or designee will evaluate and assess each resident's individual mobility needs. The P&P indicated mechanical lifting equipment or other approved transferring aids will be used based on the resident's needs to prevent manual lifting except in medical emergencies. The P&P further indicated two staff members must be utilized when transferring residents using mechanical lifts and resident lifting and transferring will be performed according to the resident's individual plan of care.

Based on observation, interview, and record review, the facility failed to change one of one sampled resident's (Resident 138) peripherally inserted central catheter (PICC, a thin, flexible tube inserted into the vein in the upper arm and guided into a large vein near the heart) line dressing and securement device (a sterile tool to hold the PICC in place on the skin) in accordance with the physician's orders.These deficient practices resulted in Resident 138's PICC line dressing and securement device remaining unchanged for 11 days which had the potential to result in avoidable bloodstream infection.Findings:During a review of Resident 138's admission Record, the admission Record indicated Resident 138 was admitted to the facility on [DATE] with diagnoses that included osteomyelitis of the vertebra in the lumbar region (infection in the spinal bones of the lower back), discitis in the lumbar region (infection of the disc space between the spinal bones), and spondylosis (age-related wear and tear of the spine).During a review of Resident 138's History and Physical (H&P), dated 2/20/2026, the H&P indicated Resident 138 had the capacity to understand and make decisions.During a review of Resident 138's Order Summary Report, active on 2/25/2026, the Order Summary Report indicated to:1. Change Resident 138's peripherally inserted central catheter (PICC, a thin, flexible tube inserted into the vein in the upper arm and guided into a large vein near the heart) line securement device (a sterile tool to hold the PICC in place on the skin) upon admission and every seven days during the evening shift.2. Change Resident 138's PICC line transparent dressing (a clear, sticky bandage placed over the PICC line insertion site), per sterile technique, upon admission and every seven days during the evening shift.During a concurrent observation and interview on 2/23/2025 at 9:56 a.m., with Resident 138, in Resident 138's room, Resident 138 was observed with a PICC line to the right upper arm. The dressing was dated 2/13/2026. Resident 138 stated the PICC line was inserted during his admission at the general acute care hospital (GACH) for antibiotic treatment (medication administered to treat an infection). Resident 138 stated the facility had not changed his PICC line dressing since his admission on [DATE].During an interview on 2/24/2026 at 8:50 a.m., with Registered Nurse (RN) 3, RN 3 stated, on 2/19/2026, Resident 138 was admitted to the facility with a PICC line inserted to his right upper arm. RN 3 stated Resident 138's PICC line dressing and securement device should have been changed upon his admission. RN 3 stated Resident 138's PICC line dressing and securement device were last changed on 2/13/2026 and the longest they should be in place was seven days. RN 3 stated Resident 138's PICC line dressing and securement device were present on Resident 138 for 11 days. RN 3 stated changing Resident 138's PICC line dressing and securement device was important to ensure the licensed nurses were aware of the last change date and to trust the facility's licensed nurses changed the dressing and securement device competently. RN 3 stated while Resident 138 was admitted to the facility, Resident 138 was under their care and the facility was responsible for ensuring the dressing and securement device change were done correctly. RN 3 stated due to Resident 138's dressing and securement device being unchanged for 11 days, Resident 138 was at risk for bloodstream infection. During a concurrent interview and record review on 2/24/2026 at 3:46 p.m., with RN 2, Resident 138's IV Administration Report, dated 2/1/2026 through 2/28/2026, was reviewed. The IV Administration Report indicated securement device change on 2/20/2026 and 2/23/2026, and PICC line transparent dressing change on 2/20/2026, 2/22/2026, and 2/23/2026. RN 2 stated checkmarks on the IV Administration Report indicated the order was completed. RN 2 stated, on 2/22/2026 and 2/23/2026, she documented Resident 138's PICC line transparent dressing was changed, and on 2/23/2026, she documented Resident 138's PICC line securement device was changed. RN 2 stated she was confused and thought the order was to assess the PICC line dressing and securement device to see if they needed to be changed. RN 2 stated on 2/22/2026 and 2/23/2026, she did not change Resident 138's PICC line dressing and securement device. RN 2 stated Resident 138's PICC line dressing and securement device were not changed upon admission.During an interview on 2/25/2026 at 2:24 p.m., with the Director of Nursing (DON), the DON stated Resident 138's PICC line dressing and securement device should have been changed upon his admission to the facility. The DON stated having the PICC line dressing and securement on for 11 days would allow the adhesive to begin to peel off and expose the insertion site to air and other bacteria. The DON stated if bacteria were to enter through the PICC insertion site, it would enter the blood and could potentially reach the heart, causing a very serious infection.During a review of the facility's Policy and Procedure (P&P) titled, PICC/Midline/Central Vascular Access Device Dressing Change (CVAD- a tube inserted into a vein or artery to deliver medications and fluids), dated 12/19/2026, the P&P indicated to change PICC, midline, or central venous access device (CVAD) dressing, weekly or if soiled, in a manner to decrease potential for infection and/or cross contamination.

Based on interview and record review, the facility failed to ensure care and services related to urinary Foley catheter (a flexible tube inserted through the urethra [a hollow tube that lets urine leave the body] into the bladder to drain urine into a collection bag) management were provided for one of six sampled residents (Resident 39), who had sediment (matter that settles to the bottom of a liquid), cloudiness and blood in the urine.This deficient practice had the potential to result in urinary catheter obstruction, urinary tract infection (UTI- an infection in the bladder/urinary tract) and a decline in Resident 39's health status.During a review of Resident 39's admission Record, the admission Record indicated Resident 39 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 39's diagnoses included dysphagia (difficulty swallowing), bradycardia (low heart rate), and hepatic encephalopathy (a serious brain dysfunction caused by liver failure) and quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury).During a review of Resident 39's History and Physical (H&P), dated 12/03/2025, the H&P indicated Resident 39 was not able to make medical or financial decisions.During a review of Resident 39's Minimum Data Set (MDS - a resident assessment tool), dated 12/8/2025, the MDS indicated Resident 39's cognitive skills for daily decision making (ability to think, remember, and reason) was moderately impaired. The MDS indicated Resident 39 was dependent for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 39's physician order dated 12/3/2025, the physician order indicated indwelling Foley catheter size 18. Change for blockage, leaking, pulled out, excessive sediment.During an interview on 2/24/2026 at 1:37 p.m., with Licensed Vocational Nurse (LVN) 8, LVN 8 stated that normal urine should be yellow in color, clear, and free from cloudiness, sediment, blood, or foul odor. LVN 8 stated that the particles observed in the urine were most likely sediment. LVN 8 stated that this finding represented a change in condition and that a change-of-condition assessment should have been initiated and the physician notified in accordance with the resident's care plan. LVN 8 stated that the resident was unable to feel sensations below the waist due to a diagnosis of quadriplegia. LVN 8 stated it was important to closely monitor Resident 39 for signs and/or symptoms of a UTI.During an interview on 2/26/2026 at 10:23 a.m., with the Director or Nursing (DON), the DON stated that urine should be clear, yellow in color, and free from sediment, cloudiness, blood, or foul odor. The DON stated that the presence of sediment or cloudy urine indicated an abnormal finding and constituted a change in the resident's condition. The DON stated that nursing staff were required to initiate a change-of-condition assessment and notify the physician per the facility policy. The DON stated that residents with quadriplegia may be unable to feel pain or discomfort related to urinary issues, which placed them at increased risk for an undetected UTI. The DON stated that staff were responsible for closely monitoring such residents for non-verbal signs and symptoms of infection and ensuring timely documentation and physician notification.During a review of the facility's policy and procedure (P&P) titled, Notification of Changes dated 12/19/2022, the P&P indicated The purpose of this policy is to ensure the facility promptly informs the resident, the resident's physician when there is a change requiring notification. Circumstances requiring notification include significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include life-threatening conditions, or Clinical complications.

Based on observation, interview, and record review, the facility failed to ensure the placement of bilateral (pertaining to both) floor mats and padded siderails for two of eight sampled residents (Residents 44 and 37), who were on fall and seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) precautions. These deficient practices had the potential to result in Resident 44 sustaining an injury from a fall, and Resident 37 sustaining an injury during seizure activity. Findings: a. During a review of Resident 44's admission Record, the admission Record indicated Resident 44 was admitted to the facility on [DATE] with diagnoses which included difficulty walking, dementia (a progressive state of decline in mental abilities), stable burst fracture of the first lumbar vertebra (a broken bone in the lower spine caused by compression or pressure), unspecified fracture of the T11-T12 vertebra (broken bones in the middle portion of the spine), and unspecified fracture of the second lumbar vertebra (a broken bone in the lower spine). During a review of Resident 44's Minimum Data Set (MDS - a resident assessment tool), dated 11/6/2025, the MDS indicated Resident 44's cognitive skills for daily decision making (ability to think, remember, and reason) was severely impaired. The MDS indicated Resident 44 required moderate assistance (helper does less than half the effort) for toileting and bathing. The MDS indicated Resident 44 required maximal assistance (helper does more than half the effort) for transferring to and from bed and toilet and walking 10 feet and 50 feet. The MDS further indicated Resident 44 had a one fall with no injury since admission. During a review of Resident 44's History and Physical (H&P), dated 2/6/2026, the H&P indicated Resident 44 did not have the capacity to understand and make decisions. The H&P indicated Resident 44 was identified as at risk for falls. During a review of Resident 44's Fall Risk assessment dated [DATE], the assessment indicated Resident 44 was at risk for falls. During a review of Resident 44's care plan titled Risk for falls, revised 2/5/2026, the care plan indicated Resident 44 was at risk for falls. The interventions indicated to provide bilateral floor mats at the bedside. During a review of Resident 44's Order Summary Report dated 2/26/2026, the Order Summary Report indicated bilateral floor mats. During an observation on 2/23/2026, at 9:55 a.m., while in Resident 44's room, Resident 44 was observed sleeping. A fall mat was observed to the right side of the bed. No fall mat was observed to the left side of the bed. During an interview on 2/23/2026, at 10:15 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 44 was supposed to have two floor mats. CNA 1 stated she confirmed with the charge nurse that Resident 44 required bilateral floor mats. During an interview on 2/25/2026 at 11:41 a.m., with Licensed Vocational Nurse (LVN) 5, LVN 5 stated Resident 44 was on fall precautions. LVN 5 stated Resident 44 should have fall mats on both sides of the bed, and the bed should be in the lowest position and locked. LVN 5 stated having only one fall mat could be an issue because Resident 44 could fall from the opposite side of the bed where no fall mat was in place and there was no way to determine which direction Resident 44 could fall. During a review of the facility's policy and procedure (P&P) titled Fall Prevention Program, revised 12/28/2023, the P&P indicated the nurse and/or interdisciplinary team would initiate interventions on the resident's care plan in accordance with the resident's level of risk. The P&P further indicated fall interventions would be implemented as appropriate and that each resident's risk factors and environmental hazards would be evaluated when developing the resident's comprehensive care plan. The P&P indicated care plan interventions would be monitored for effectiveness and revised as needed. b. During a review of Resident 37's admission Record, the admission Record indicated Resident 37 was admitted to the facility on [DATE] with diagnoses that included epilepsy (a chronic brain disorder characterized by a tendency to have recurrent, unprovoked seizures) and dementia (a progressive state of decline in mental abilities). During a review of Resident 37's MDS, dated [DATE], the MDS indicated Resident 37's cognition was moderately impaired. The MDS indicated Resident 37 required supervision or touching assistance with oral hygiene, upper body dressing, and personal hygiene.During a review of Resident 37's H&P, dated 3/27/2025, the H&P indicated Resident 37 could make his needs known but could not make medical decisions.During observations on 2/23/2026 at 10:08 a.m. and on 2/24/2026 at 8:36 a.m., in Resident 37's room, Resident 37 was observed lying in bed. The grab bars were unpadded. During a concurrent observation and interview on 2/24/2026 at 1:04 p.m., with LVN 2, in Resident 37's room, Resident 37's bed was observed with unpadded bilateral grab bars. LVN 2 stated Resident 37 did not have any padding on his grab bars.During a concurrent interview and record review on 2/24/2026 at 1:05 p.m., with LVN 2, Resident 37's Orders, active on 2/24/2026, were reviewed. The Orders indicated to apply padded grab bars for seizure precautions. LVN 2 stated Resident 37 had a history of seizures and should have had padding added to his grab bars. LVN 2 stated padded grab bars were used as a safety precaution if Resident 37 had a seizure with jerking, involuntary movement. LVN 2 stated without padded grab bars, Resident 37 was at risk for injury during a seizure.During an interview on 2/25/2026 at 1:54 p.m., with the Director of Nursing (DON), the DON stated Resident 37 had a history a seizures and seizure precautions, such as medication treatment and padded side rails, should be in place to prevent seizure occurrence and injury. During a review of the facility's P&P titled, Seizure Precautions, dated 12/19/2022, the P&P indicated, It is the policy of this facility to ensure a resident is protected from injury and managed in the event of a seizure according to current standards of practice.

Based on observation, interview, and record review the facility failed to provide oxygen (a medical gas used to help with breathing) therapy in accordance with the facility policy and physician orders for one of three sampled residents (Resident 137). This deficient practice had the potential to result in hyperoxygenation (too much oxygen) which could result in respiratory failure (sudden onset condition where the lungs cannot bring enough oxygen into the blood). Findings:During a review of Resident 137's admission Record, the admission Record indicated Resident 137 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 137's diagnoses included acute respiratory failure with hypoxia (sudden onset condition where the lungs cannot bring enough oxygen into the blood), pneumonia (an infection/inflammation in the lungs), and chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing).During a review of Resident 137's Minimum Data Set (MDS- a resident assessment tool), dated 2/7/2026, the MDS indicated Resident 137's cognitive skills (process of thinking) for daily decision making was severely impaired. The MDS indicated Resident 137 depended on staff with oral hygiene, toileting, bathing, upper/lower body dressing, and personal hygiene. The MDS indicated Resident 137 received oxygen (a medical gas used to help with breathing) therapy.During a review of Resident 137's History and Physical (H&P), dated 1/10/2026, the H&P indicated Resident 137 did not have the mental capacity to make decisions.During an observation on 2/23/2026 at 9:45 a.m., 2/23/2026 at 1:43 p.m., and 2/24/2026 at 8:54 a.m., in Resident 137's room, Resident 137 was observed lying in bed. Resident 137 was receiving oxygen at 5 liters per minute (LPM, unit of volume measurement) via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen).During a concurrent observation and interview on 2/24/2026 at 12:47 p.m., with Registered Nurse (RN) 1, in Resident 137's room, Resident 137 was observed lying in bed. Oxygen was infusing at 5 LPM via nasal cannula. RN 1 lowered Resident 137's oxygen to 2 LPM and checked his oxygen saturation (measurement of the percentage of oxygen in the blood). RN 1 stated Resident 137's oxygen should not be infusing at 5 LPM.During a concurrent interview and record review on 2/24/2026 at 12:49 p.m., with RN 1, Resident 137's Orders, active on 2/24/2026, were reviewed. The Orders indicated to administer oxygen at 2 LPM via nasal cannula to maintain Resident 137's oxygen saturation above 92 percent (%). RN 1 stated Resident 137's oxygen should not be above 2 LPM based on Resident 137's physician order. RN 1 stated Resident 137 had COPD and his need for oxygen was lower compared to a resident who did not have COPD. RN 1 stated giving Resident 137 too much oxygen could cause the resident to lose his drive to breathe and could cause respiratory failure. During an interview on 2/25/2026 at 1:56 p.m., with the Director of Nursing (DON), the DON stated the licensed nurses were responsible for administering oxygen therapy per the physician's order. The DON stated Resident 137 required oxygen therapy, however, Resident 137 had COPD. The DON stated residents with COPD had a lower oxygen saturation threshold (normal oxygen saturation is between 95 to 100%) and providing too much oxygen would be harmful. The DON stated Resident 137 was at risk of hyperoxygenation which could reduce Resident 137's lung function and cause respiratory failure.During a review of the facility's Policy and Procedure (P&P) titled, Oxygen Administration, dated 12/10/2022, the P&P indicated, Oxygen is administered under orders of a physician.

Based on interview and record review, the facility failed to ensure a resident's consent for the administration of a psychotropic medication (drugs that affects behavior, mood, thoughts, or perception) was obtained from and verified with the resident's representative party (RP) for one out of two sampled residents (Resident 3).This deficient practice had the potential to place Resident 3 at risk for receiving psychotropic medications without the proper authorization and education regarding the risks and the benefits of the prescribed psychotropic medications.Findings:During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 3's diagnoses included hemiplegia and hemiparesis (total paralysis of the arm, leg, and trunk on the same side of the body) following cerebral infarction (loss of blood flow to a part of the brain) affecting the right dominant side, hypertensive heart disease (high blood pressure), heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), atrial fibrillation (irregular heart rhythm) and end stage renal disease (ESRD- irreversible kidney failure).During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool), dated 11/11/2025, the MDS indicated Resident 3's cognitive skills for daily decision making (ability to think and reason) was moderately impaired. The MDS indicated Resident 3 was dependent on staff's assistance with toileting, bathing, and upper/lower body dressing.During a review of Resident 3's History and Physical (H&P), dated 11/11/2025, the H&P indicated Resident 3 did not have the capacity to understand and make medical decisions.During a review of Resident 3's physician order dated 11/18/2025, the order indicated Lorazepam (a psychotropic medication) one milligram (mg, a unit of measurement) every six hours as needed for anxiety (feeling of unease).During a review of Resident 3's Medication Administration Record (MAR), dated 11/2025 through 12/2025, the MAR indicated from 11/18/2025 through 12/10/2025, Resident 3 was administered Risperidone (a psychotropic medication) 0.5 mg three times a day.During a concurrent interview and record review on 2/24/2026 at 12:20 p.m. with Registered Nurse (RN) 1, Resident 3's Psychotropic Consent Forms for Risperidone 0.5 mg and Lorazepam 1 mg, dated 11/16/2025, were reviewed. The consent forms indicated consent was obtained from Resident 3. RN 1 stated she was the nurse responsible for obtaining verification of informed consent for the administration of Resident 3's psychotropic medications. RN 1 stated because Resident 3 was deemed unable to make medical decisions, consent should have been verified with Resident 3's Representative Party and not Resident 3. RN 1 stated Resident 3's RP had the right to make informed, medical decisions on Resident 3's behalf and should have been made aware of the risks and the benefits of both psychotropic medications before their continued use within the facility. RN 1 stated this placed Resident 3 at risk for receiving psychotropic medications without the appropriate authorization, education regarding risks and benefits, and the opportunity for informed decision-making.During a review of the facility's policy and procedure (P&P) titled, Use of Psychotropic Medications, revised 3/17/2025, the P&P indicated prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative would be informed of the benefits, risks, and alternatives for the medication, including any black box warnings for antipsychotic medication advance of such initiation or increase. The P&P indicated the facility would document that the resident or resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options, and the preferred option to accept or decline.

Based on observation, interview, and record review, the facility failed to notify one of one sampled resident's (Resident 138) physician of scattered ecchymosis (bruising) on both of his arms upon his admission to the facility.This deficient practice resulted in Resident 138's ecchymosis being unmonitored and had the potential for worsening bruising and delay in care.Findings:During a review of Resident 138's admission Record, the admission Record indicated Resident 138 was admitted to the facility on [DATE] with diagnoses that included osteomyelitis of the vertebra in the lumbar region (infection in the spinal bones of the lower back), discitis in the lumbar region (infection of the disc space between the spinal bones), and spondylosis (age-related wear and tear of the spine).During a review of Resident 138's History and Physical (H&P), dated 2/20/2026, the H&P indicated Resident 138 had the capacity to understand and make decisions.During a review of Resident 138's physician orders, active on 2/25/2026, the physician orders indicated to inject heparin sodium (anticoagulant medication used to treat blood clots from forming in the blood vessels and the heart) injection solution 1000 units per milliliter (mL, unit of measurement), 0.5 mL subcutaneously (into the fat tissue) two times a day for deep vein thrombosis prophylaxis (method used to stop blood clots from forming in deep veins, usually in the legs, of at-risk individuals). The physician orders did not indicate to monitor Resident 138 for signs of bleeding. During a concurrent observation and interview on 2/23/2026 at 9:56 a.m., with Resident 138, in Resident 138's room, Resident 138 was observed lying in bed with scattered ecchymosis (bruising) on his arms. Resident 138 stated the bruises on his arms developed in the general acute care hospital (GACH) when he started on heparin. Resident 138 stated he did not have any other issues with bleeding.During a concurrent interview and record review, on 2/25/2026 at 9:24 a.m., with Registered Nurse (RN) 1, Resident 138's Skin Check, dated 2/20/2026, was reviewed. The Skin Check indicated Resident 138 had a pressure injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) to his sacrum (area near the bottom of the spine) and an open wound to his left upper arm. The Skin Check did not indicate scattered ecchymosis on Resident 138's arms. RN 1 stated Resident 138 was admitted to the facility with scattered ecchymosis on his arms due to his heparin therapy. RN 1 stated the Skin Check should have indicated the scattered ecchymosis on Resident 138's arms to ensure Resident 138's physician was notified of the assessment.During a concurrent interview and record review, on 2/25/2026 at 9:27 a.m., with RN 1, Resident 138's Progress Notes, dated 2/19/2026 through 2/25/2026, were reviewed. The Progress Notes did not indicate Resident 138's physician was notified of the scattered ecchymosis on his arms. RN 1 stated Resident 138's physician was only notified of the pressure injury and open wound but was not informed of the scattered ecchymosis. RN 1 stated informing Resident 138's physician of the scattered ecchymosis upon admission was important to ensure Resident 138 was monitored for new or worsening ecchymosis on his arms and the rest of his body. RN 1 stated early notification upon admission would inform Resident 138's physician of the existing problem and to allow the physician to evaluate the necessity of the heparin treatment. RN 1 stated this placed Resident 138 at risk of undetected bleeding and delay in treatment.During a review of the facility's policy and procedure (P&P) titled, Notification of Changes, dated 12/19/2022, the P&P indicated the facility would promptly inform the resident's physician of any change requiring notification. The P&P indicated the physician was notified of circumstances that require a need to alter treatment such as a new treatment or discontinuation of current treatment due to adverse consequences or an acute condition.

Based on observation, interview, and record review, the facility failed to complete an accurate Minimum Data Set (MDS, a resident assessment tool) assessment for one of six sampled residents (Resident 50) oral and/or dental status.This deficient practice resulted in incorrect data transmitted to the Centers for Medicare and Medicaid Services (CMS, a federal agency within the United States Department of Health and Human Services (HHS) that administers the Medicare program) regarding Resident 50's missing natural teeth, and had the potential to negatively affect Resident 50s' plan of care and delivery of necessary care and services.Findings:During a review of Resident 50's admission Record, the admission Record indicated Resident 50 was originally admitted to the facility on [DATE] and re admitted on [DATE]. Resident 50's diagnoses included dysphagia (difficulty swallowing), chronic obstructive pulmonary disease ([COPD]- a chronic lung disease causing difficulty in breathing), and depression (a medical illness causing feelings of sadness, or loss of interest in activities). During a review of Resident 50's History and Physical (H&P), dated 1/8/2026, the H&P indicated Resident 50 had the capacity to understand and make decisions. During a review of Resident 50's MDS, dated [DATE], the MDS indicated Resident 50's cognitive skills for daily decision making (the ability to think and process information) was intact. The MDS indicated Resident 50 required supervision or touching (helper provides verbal cues and/or touching assistance as resident completes activity) assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS did not indicate Resident 50 was assessed as not having any oral and/or dental issues. During a concurrent observation and interview on 2/24/2026 at 1:10 p.m., at Resident 50's bedside, with Resident 50, Resident 50 was observed eating lunch. Resident 50 stated she did not have her upper and bottom natural teeth. During a concurrent interview and record review on 2/24/2026 at 3:30 p.m., with the MDS Nurse (MDSN), Resident 50's MDS, dated [DATE], section oral/dental status was reviewed. The MDS did not indicate Resident 50 was assessed as not having any oral and/or dental issues. The MDSN stated Resident 50's MDS oral/dental status assessment was coded incorrectly, as it did not reflect the resident's actual oral and/or dental status. The MDSN stated that because Resident 50 did not have her natural teeth, the MDS should have been coded to reflect that the resident was edentulous (toothless). The MDSN stated accuracy of the MDS assessment was important not only for outcome measures and quality indicators, but also for developing and individualizing a care plan based on the resident's actual needs. The MDSN stated inaccuracy of the MDS assessment had the potential to negatively impact the care provided, leading to inappropriate care planning and not meeting the residents' needs and services.During a review of the facility's policy and procedures (P&P) titled Resident Assessment-RAI, dated 12/19/2022, the P&P indicated the facility will conduct a comprehensive and accurate assessment of each resident's needs and health conditions, including dental status.During a review the facility's P&P titled MDS/CRC Coordinator-Job Description, undated, the P&P indicated the MDS coordinator was responsible for accurate completion of all MDS assessments.

Based on interview and record review, the facility failed to ensure an accurate Preadmission Screening and Resident Review (PASARR - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) Level I screening was completed for one of eight sampled residents (Resident 11).This deficient practice resulted in Resident 11 not receiving a PASARR Level II evaluation, and had the potential to result in Resident 11 not receiving the specialized services needed to address serious mental illness while residing in the nursing facility.Findings:During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 11's diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), schizophrenia (a mental illness that is characterized by disturbances in thought), dementia (a progressive state of decline in mental abilities), anxiety disorder (a mental health condition involving persistent and excessive worry that interferes with daily activities), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), and unspecified psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with reality).During a review of Resident 11's History and Physical (H&P), dated 12/7/2025, the H&P indicated Resident 11 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 1/19/2026, the MDS indicated Resident 11's cognitive skills for daily decision making (ability to think, remember, and reason) were severely impaired. The MDS indicated Resident 11 was dependent (helper does all the effort) for toileting, bathing, dressing and personal hygiene. During a review of Resident 11's care plan report titled PASARR, revised 8/19/2025, the care plan indicated Resident 11's diagnoses included schizophrenia, bipolar disorder, psychosis, Parkinson's, and dementia. The interventions indicated to arrange referrals as indicated by PASRR Level II findings.During a review of Resident 11's PASARR Level I Screening, dated 7/24/2024, the PASARR Level I Screening indicated Resident 11 was screened as negative for serious mental illness or intellectual or developmental disability. The PASARR Level I Screening indicated a PASRR Level II evaluation (a more detailed assessment used to determine whether a resident requires specialized mental health or developmental disability services) was not required.During an interview on 2/25/2026 at 11:45 a.m., with the Social Services Director (SSD), the SSD stated the Social Services Department was not responsible for PASARR screenings. The SSD stated PASARR screenings were completed by the Admissions Department.During an interview on 2/25/2026 at 11:50 a.m. with the Admissions Coordinator (AC), the AC stated when a resident was admitted to the facility, the Admissions Department requested the PASARR from the hospital and uploaded the PASARR document into the resident's medical record. The AC stated the Admissions Department was not responsible for following up on the PASARR screening and only uploaded the document into the resident's medical file. The AC stated she was unsure which department was responsible for ensuring the PASARR screening was completed or followed through after admission.During an interview on 2/25/2026 at 12 p.m., with the Director of Nursing (DON), The DON stated upon admission the facility obtained the PASARR from the hospital . The Admissions Department uploaded the PASARR into the resident's medical record. The DON stated the PASARR remained part of the resident's medical record, and she reviewed the PASARR after admission to ensure the information was correct. The DON acknowledged Resident 11's PASARR did not indicate the resident had a serious mental illness; however, the resident's diagnosis report indicated diagnoses including schizoaffective disorder, bipolar type, bipolar disorder, and schizophrenia. The DON stated Resident 11's PASARR should have indicated the presence of serious mental illness based on the resident's diagnoses. The DON stated because the PASARR was coded incorrectly, Resident 11 did not receive an evaluation for services related to the resident's mental health needs. The DON stated Social Services was not involved in reviewing the PASARR. The DON acknowledged the facility policy indicated Social Services was responsible for PASARR review and stated she was unaware of that requirement.During a review of the facility's policy and procedure (P&P) titled Resident Assessment - Coordination with PASARR Program, revised 12/18/2023, the P&P indicated all applicants to the facility will be screened for serious mental disorders or intellectual disabilities through a PASARR Level I screening prior to admission. The P&P indicated a positive PASARR Level I screening requires a PASARR Level II evaluation by the state-designated authority to determine appropriate placement and specialized services. The P&P indicated the Social Services Director, or designee is responsible for maintaining each resident's PASARR screening status and referring residents to the appropriate authority when a serious mental disorder, intellectual disability, or related condition is identified.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for two of 12 sampled residents (Resident 50 and Resident 31), by failing to:1. Develop a care plan to address Resident 50's oral status and lack of teeth. 2. Implement interventions related to Resident 31's indwelling catheter (a flexible tube inserted into the bladder to drain urine into a bag), including monitoring and documenting urinary output.These deficient practices placed Residents 50 and 31 at risk for delayed care, nutrition risks and needs, continuity of care, and overall health status. Findings:a. During a review of Resident 50's admission Record, the admission Record indicated Resident 50 was originally admitted to the facility on [DATE] and re admitted on [DATE]. Resident 50's diagnoses included dysphagia (difficulty swallowing), chronic obstructive pulmonary disease ([COPD]- a chronic lung disease causing difficulty in breathing), and depression (a medical illness causing feelings of sadness, or loss of interest in activities). During a review of Resident 50's History and Physical (H&P), dated 1/8/2026, the H&P indicated Resident 50 had the capacity to understand and make decisions.During a review of Resident 50's Minimum Data Set (MDS - a resident assessment tool), dated 1/10/2026, the MDS indicated Resident 50's cognitive skills for daily decision making (the ability to think and process information) was intact. The MDS indicated Resident 50 required supervision or touching (helper provides verbal cues and/or touching assistance as resident completes activity) assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a concurrent observation and interview on 2/24/2026 at 1:10 a.m., with Resident 50, at Resident 50's bedside, the resident was observed sitting in bed eating lunch. Resident 50 stated she did not have her upper and lower natural teeth. During a concurrent interview and record review on 2/24/2026 at 3:30 p.m., with the MDS Nurse (MDSN), Resident 50's medical records were reviewed. The medical records did not indicate a care plan related to Resident 50's edentulous (having no teeth) status. The MDSN stated a care plan for missing natural teeth should have been developed to indicate specific interventions, including nutritional needs, safe eating, oral health needs, and monitoring Resident 50 for complications related to her edentulous status. During an interview on 2/26/2026 at 7:56 a.m., with the Director of Nursing (DON), the DON stated residents without natural teeth should have an individualized care plan to ensure the residents' needs were addressed, communicated and coordinated with staff for continuity of care and services. b. During a review of Resident 31's admission Record, the admission Record indicated Resident 31 was admitted to the facility on [DATE] with diagnoses included obstructive and reflux uropathy (a blockage in the urinary tract preventing proper urine flow, urinary retention), 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 31's MDS, dated [DATE], the MDS indicated Resident 31's cognitive skills for daily decision making was moderately impaired. The MDS indicated Resident 31 required moderate (helper does less than half the effort) assistance from staff for ADLs. During a review of Resident 31's care plan titled The resident has indwelling catheter ., the dated 1/22/2026, the care plan indicated to monitor and document Resident 31's intake and output. During a concurrent interview and record review on 2/24/2026 at 2:01 p.m., with Licensed Vocational Nurse (LVN) 3, Resident 31's care plan titled The resident has indwelling catheter . dated 1/22/2026, and Electronic Medical Record (EMR) titled Monitor Record, dated 1/22/2026 through 2/24/2026, were reviewed. The EMR did not indicate documented evidence that Resident 31's intake and out was monitored as indicated in the care plan. LVN 3 stated there was no urinary output recorded from 1/22/2026 through 2/24/2026. LVN 3 stated urinary output was required for residents with indwelling catheter to assess urinary function and identify potential complications such as decreased output, pain, and/or signs of infection. During an interview on 2/26/2026 at 7:59 a.m., with the Director of Nursing (DON), the DON stated indwelling catheter monitoring and documenting intake and output was a required intervention as indicated in the care plan. The DON stated Resident 31's care plan interventions were not implemented. The DON stated urinary output monitoring was necessary to ensure resident safety and timely medical intervention. During a review of the facility's policy and procedures (P&P) titled Comprehensive Care Plans, dated 1/19/2022, the P&P indicated the facility would develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.

Based on observation, interview, and record review, the facility failed to revise the comprehensive fall prevention care plan following a resident's fourth fall for one out of six sampled residents (Resident 74).This deficient practice had the potential to result in additional falls and bodily injury for Resident 74.Findings:During a review of Resident 74's admission Record, the admission Record indicated Resident 74 was initially admitted to the facility on [DATE] and readmitted [DATE]. Resident 74's diagnoses included muscle weakness, diabetes (poor blood sugar control), hypertensive (high blood pressure) heart disease, and urinary tract infection (UTI- an infection in the bladder/urinary tract).During a review of Resident 74's Minimum Data Set ([MDS], a resident assessment tool), dated 12/19/2025, the MDS indicated Resident 74's cognitive skills (ability to think and reason) for daily decision making were severely impaired. The MDS indicated Resident 74 required maximal assistance (helper does more than half of the effort) for showering, dressing and taking off footwear and moderate assistance (helper does less than half the effort) for toileting.During a review of Resident 74's Interdisciplinary Notes (IDT, group of different disciplines working together towards a common goal of a resident), dated 9/22/2025, 1/5/2026, and 2/10/2026, the IDT Notes indicated Resident 74 had three unwitnessed falls on 9/19/2025, 1/5/2026, and 2/9/2026.During an observation on 2/23/2026 at 9:23 a.m., in Resident 74's room, Resident 74 was observed in bed without fall mats on either side of the bed.During a concurrent interview and record review on 2/24/2026 at 3:29 p.m. with Registered Nurse (RN) 2, Resident 74's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) Note, dated 2/19/2026, and all of Resident 74's care plans, dated in 2026, were reviewed. The SBAR indicated Resident 74 had an unwitnessed fall on 2/19/2026. There were no care plan intervention revisions to Resident 74's fall care plan since his fall on 2/19/2026. RN 2 stated she was the assigned RN during Resident 74's fall on 2/19/2026. RN 2 stated that the normal process following a fall was to assess the resident, notify the physician, and modify the care plan to implement different or additional interventions to prevent reoccurrence. RN 2 stated Resident 74's care plans were not modified after the fall and the lack of revision, especially given Resident 74's history of frequent falls, placed Resident 74 at risk for another fall.During a concurrent interview and record review on 2/25/2026 at 3:43 p.m. with the Director of Nursing (DON), all of Resident 74's care plans, dated in 2026, were reviewed.The care plans indicated no revisions to the interventions after Resident 74's latest fall on 2/19/2026. The DON stated the care plan should have been reviewed and revised to evaluate the effectiveness of current interventions and to implement additional measures. The DON stated that if the care plan had been revised, floor mats would have been added as an intervention. The DON stated the lack of revisions to the interventions placed Resident 74 at risk for another fall.During a review of the facility's policy and procedure (P&P) titled, Care Plan Revisions Upon Status Change, revised 12/19/2022, the P&P indicated the comprehensive care plan would be reviewed and revised as necessary, when a resident experiences a status change.During a review of the facility's P&P titled, Fall Prevention Program revised 12/28/2023, the P&P indicated the comprehensive care plan would be reviewed, and revised as necessary, when a resident experiences a status change.

Based on observation, interview, and record review, the facility failed to provide supervision to one of two sampled residents (Resident 1) identified as an elopement (the act of leaving a facility unsupervised and without prior authorization) risk by failing to: 1. Follow its policy and procedures (P&P) titled Accidents and Supervision, which indicated the facility will implement interventions to prevent injury to residents. 2. Follow its P&P titled Elopements and Wandering Residents, which indicated residents with a risk for elopement would receive supervision to prevent accidents. 3. Utilize a systematic approach to monitoring and managing Resident 1 to prevent the resident from leaving the facility unsupervised. 4. Ensure door locks/alarms were in place to prevent Resident 1 from eloping. 5. Ensure the facility's exit doors were monitored to prevent Resident 1 from leaving the facility unsupervised. These deficient practices resulted in Resident 1 eloping from the facility, falling and sustaining fractures (broken bone) to the nose, mandible (jawbone), 6th to 8th right ribs, a lip laceration (cut), a bump on the right side of the head, an injured right knee, and broken upper dentures and lower teeth implants. On 4/22/2025 at 3:47 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation caused, or was likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of the Administrator (Admin) due to the facility's failure to provide supervision to Resident 1, in-servicing staff on supervision for residents with elopements risks and complying with rules and regulations to prevent accidents and elopements. On 4/24/2025 at 4:09 p.m., the facility submitted an acceptable IJ Removal Plan (IJRP). After verification of the IJRP implementation through observation, interview, and record review, the IJ was removed onsite on 4/24/2025 at 4:19 p.m., in the presence of the Admin. The IJPR included the following immediate actions: 1. Resident 1 was transferred to the hospital for evaluation and assessment. Resident 1 returned to the facility on [DATE] and was placed on 1:1 supervision (staff member providing continuous and constant observation to a single resident). 1:1 staff was provided supervision education. Resident 1 will be on 1:1 indefinitely until a safe plan can be put in place or the interdisciplinary team (IDT, group of different disciplines working together towards a common goal of a resident) has determined 1:1 supervision is no longer indicated. 2. On 4/6/2025, the Admin provided in-service education to the weekend and evening receptionist regarding not leaving their post unattended. 3. On 4/5/2025, the Director of Staff Development (DSD) and Admin provided in-service regarding the monitoring/supervision, wandering and elopement policy to the receptionist and facility staff who were on shift such as: licensed nurses, certified nursing assistants (CNAs), therapists, environmental services, social services, activities, dietary services, and administrative personnel. 4. On 4/5/2025, facility doors were checked for appropriate function by the Maintenance Director. 5. On 4/5/2025, a head count was initiated of in-house residents by the Admin and found that all residents totaling 132 were accounted for. 6. Elopement assessments were completed on all residents by the Director of Nursing (DON)/designee on 4/5/2025, and 4/6/2025. 7. Two residents identified to be at risk for elopement were reviewed by the DON/designee for appropriate care plan interventions initiated on 4/5/2025. 8. An in-service education regarding wandering and elopement was provided by Administrator/ DON/ Designee to facility staff: facility licensed nurses, CNAs, therapists, environmental services, social services, activities, dietary services, and administrative personnel was initiated on 4/5/2025. Staff who are on leave or as needed (PRN) will be in-serviced on their next scheduled shift. 9. On 4/6/2025, an IDT meeting was conducted for the two residents who are identified as at risk for elopement. 10. The DON or designee will audit new admissions with elopement risks and ensure appropriate interventions are in place for three months or until substantial compliance is achieved. 11. Weekly, the Social Services Director (SSD) or designee will review all new admissions to ensure an elopement risk assessment has been completed, and those residents identified at risk are updated in the Elopement binder. Audits will be conducted for three months or until substantial compliance is achieved. 12. New hires will receive education on wandering, elopement, and resident safety by the DON, SSD, or designee(s) upon hire and annually thereafter. Facility will continue to perform on going in-service trainings regarding wandering, elopement, resident safety, and resident monitoring/supervision to facility staff monthly for 3 months. 13. Elopement risk binders were reviewed by the DON and Administrator on 4/6/2025 and were up to date. Elopement risk binders are available at each nursing station and at the reception area. Elopement binders are updated by the SSD Monthly and PRN with oversite by the DON. 14. Elopement code drills were initiated on all shifts starting on 4/6/2025 and will continue to perform drills monthly for three months; then quarterly thereafter by Administrator/DON and/or DSD. 15. An ongoing weekly check of facility doors and alarms were performed by the Maintenance Department to ensure function and securement. An increase to twice weekly frequency of facility door and alarm checks were initiated on 4/6/2025. 16. An ongoing twice weekly check of facility doors and alarms will be performed by the Maintenance Department to ensure function and securement for three months or until substantial compliance has been achieved. Any findings will be corrected immediately and trends reported to the Quality Assurance/Quality Assurance and Performance Improvement (QA/QAPI- a data driven proactive approach to improvement used to ensure services are meeting quality standards) Committee for further recommendations. 17. The QAPI Committee will review and discuss elopement and supervision for all residents during the monthly QAPI meetings to determine the effectiveness of the facility's efforts and to provide feedback and program modification for a minimum of three months or until pattern of compliance is maintained. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including 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 1's History and Physical (H&P) dated 11/19/2024, 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 2/11/2025, the MDS indicated Resident 1's cognitive skills for daily decision making (ability to think, remember and reason) were impaired. The MDS indicated Resident 1 required moderate assistance (helper does less than half) for toileting hygiene, dressing, and personal hygiene. The MDS indicated Resident 1 required supervision for oral hygiene and putting on/taking off footwear. The MDS indicated Resident 1 required set up or clean up assistance for eating. The MDS indicated Resident 1 required moderate assistance to walk 50 feet with two turns. The MDS indicated Resident 1 used a manual wheelchair for mobility. The MDS indicated Resident 1 had the ability to wheel herself at least 150 feet. During a review of Resident 1's Care Plan titled, Risk for elopement, dated 2/5/2024, the care plan indicated the goal was for Resident 1 to remain in the facility with no episodes of elopement. The interventions indicated to anticipate Resident 1's needs, encourage daily activity participation, and frequent visual checks for needs and safety. During a review of Resident 1's Elopement Risk assessment, dated 8/29/2024, the elopement risk assessment indicated Resident 1 had wandering behaviors and a history of attempting to leave the facility without informing staff. During a review of Resident 1's Situation, Background, Assessment, and Recommendation form ([SBAR], used for information transfer, especially when discussing critical situations or changes in a patient's condition), dated 4/5/2025, the SBAR indicated on 4/5/2025, Resident 1 had a fall in the street. The SBAR indicated Resident 1 stated she fell from the wheelchair and landed on her face. The SBAR indicated Resident 1 had right forehead swelling, a cut to the right lower lip, and blood noted. During a review of Resident 1's General Acute Care Hospital (GACH) H&P Report dated 4/5/2025 at 5:29 p.m., the report indicated Resident 1 had a ground level fall and sustained a right jawbone and nasal (nose) bone fractures and was admitted to the GACH for syncope (a brief loss of consciousness caused by a temporary decrease in blood flow to the brain) and fall. During a review of Resident 1's GACH Computed Tomography ([CT], non-invasive imaging technique that uses X-rays [electromagnetic radiation that can penetrate through objects and create images on film] to create cross-sectional images of the body) results of the face dated 4/5/2025, the CT results indicated Resident 1 had nondisplaced (a break in a bone where the bone fragments remain aligned) lateral (a side part of something) and inferior (a break or crack in the bones surrounding the left maxillary sinus on the lateral and inferior sides) wall fractures of the left maxillary sinus (one of two paranasal sinuses [a hollow space in the bones around the nose], located in the maxillary bone, which is part of the upper jaw, on the left side of the face), a nondisplaced left nasal bone fracture, and right facial and scalp soft tissue injury (damage to the non-bony structures of the body, such as muscles, ligaments, tendons, and nerves). During a review of Resident 1's GACH Discharge Summary dated 4/6/2025 at 11:34 a.m., the discharge summary indicated Resident 1's diagnosis were facial fractures and rib fractures. The discharge summary indicated blood was noted on Resident 1's nose and lower lip and a right parietal hematoma (scalp hematoma [a localized collection of blood outside of blood vessels, typically caused by injury or trauma] outside of the brain). The discharge summary indicated Resident 1 had an acute buckle fracture (one side of a bone bulges out, or buckles, without breaking through the entire bone) at the anterolateral (both anterior and lateral) right 6 - 8th ribs. During an interview on 4/18/2025 at 10:00 a.m. with Resident 1, Resident 1 stated on 4/5/2025, (time unknown) she fell and hurt herself. Resident 1 stated she did not remember where she fell . Resident 1 stated she injured her right knee, and it was very painful. Resident 1 stated after her fall she had bruises on her face and a cut on her right knee. Resident 1 stated her fall caused her dentures and implants to break. During an interview on 4/18/2025 at 10:28 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated on 4/5/2025 at 9:45 a.m., she was notified by Licensed Vocational Nurse (LVN) 1 that Resident 1 wanted to use the restroom. CNA 1 stated she assisted Resident 1 to the commode (a portable toilet, one with a chair like frame), and back on her wheelchair and then she wheeled the resident to the hallway, in front of her room. CNA 1 stated she left Resident 1 sitting on her wheelchair in front of her room and went to assist other residents. CNA 1 stated that was the last time she saw Resident 1. CNA 1 stated at 10:05 a.m., Resident 1 was missing and could not be located. During an interview on 4/18/2025 at 11:10 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 4/5/2025 at 9:30 a.m., she saw CNA 1 wheel Resident 1 outside her room. LVN 1 stated at 9:40 a.m., she saw Resident 1 propel herself down the hallway. LVN 1 stated between 10:00 a.m., and 10:45 a.m., a staff (unnamed) questioned if she had seen Resident 1. LVN 1 stated Resident 1 was found outside by a church parking lot, located adjacent to the facility. LVN 1 stated the CNAs should know to take Resident 1 to the activities or sunshine room (a room where residents watch tv, read, or do activities) to keep Resident 1 busy from wandering behaviors. During an interview on 4/18/2025 at 1:10 p.m. with Resident 1's Responsible Party (RP 1), RP 1 stated on 4/5/2025 at 10:55 a.m., staff informed her Resident 1 left the facility unsupervised. RP 1 stated she was told Resident 1 propelled herself to the adjacent property (church), went down the church's driveway and fell off her wheelchair and landed on the street. RP 1 stated the facility informed her a good Samaritan (someone who gives help to people who need it) who was driving by, stopped and called 911 (Universal Emergency Number, for citizens throughout the United States to request emergency assistance) to assist Resident 1. RP 1 stated Resident 1 sustained fractures to her nose, mandible, three right rib fractures, laceration on the upper lip, and bruising on her face, under the right breast and on her right knee. RP 1 stated she was notified by the emergency medical technician (EMT, a medically trained individual who provides emergency medical care to patients before they are transported to a hospital) that Resident 1 was found in the lane closest to the curb bleeding from her face. RP 1 stated the EMT informed her the good Samaritan blocked incoming traffic with her vehicle and called 911. During an interview 4/18/2025 at 2:15 p.m. with the Director of Staff Development (DSD), the DSD stated on 4/5/2025, CNA 3 asked her (DSD) if she had seen Resident 1 because the resident was missing. The DSD stated she went outside to look for Resident 1 and found the resident on the street near the sidewalk. The DSD stated Resident 1 had fallen out of her wheelchair and had a cut on her lower lip. The DSD stated a civilian stopped her vehicle to help Resident 1 and called 911. The DSD stated she interviewed the facility's Receptionist to determine how and when Resident 1 left the facility unsupervised. The DSD stated the Receptionist told her she did not see Resident 1 leave the facility. The DSD stated the Receptionist stated she left the front desk unattended to use the restroom. The DSD stated Resident 1 was at risk for falls and elopement and should have been always monitored. During an interview on 4/18/2025 at 2:45 p.m. with CNA 2, CNA 2 stated on 4/5/2025 at 10:00 a.m., he was notified by Resident 2 that 20 minutes prior he saw Resident 1 leave through the facility's front doors. CNA 2 stated he began to look for Resident 1 and went outside to the parking lot and then the street where he observed a lady waving him down. CNA 2 stated the lady was standing in the middle of the street and stopped traffic with her vehicle. CNA 2 stated the lady told him not to touch Resident 1 and that she called 911. CNA 2 stated he observed Resident 1 on the ground, in the middle of the street lying on her right side. CNA 2 stated he observed a lot of blood on the ground and on Resident 1's face. CNA 2 stated Resident 1 was not talking. During an interview on 4/18/2025 at 3:30 p.m. with Registered Nurse (RN) 1, RN 1 stated on 4/5/2025 at 10:05 a.m. she heard Resident 1 was missing. RN 1 stated she went outside and saw Resident 1 sitting on the street near the sidewalk. RN 1 stated Resident 1 had blood on her face. RN 1 stated she stayed with Resident 1 until the EMTs transported Resident 1 to the GACH. During an interview on 4/18/2025 at 3:54 p.m., with the Admin, the Admin stated on 4/5/2025 at 10:30 a.m., the DSD notified her Resident 1 left the facility unsupervised and had a fall. The Admin stated Resident 1 should have been supervised every 30 minutes by staff to prevent Resident 1 from elopement, falls, and injuries. The Admin stated the Receptionist walked away from the front desk when Resident 1 eloped from the facility. The Admin stated there was supposed to be a person sitting at the front desk at all times to prevent residents from leaving the facility unattended. The Admin stated the Receptionist should have notified someone to relieve her before leaving the front desk. During an interview on 4/18/2025 at 4:24 p.m., with the DSD, the DSD stated all staff were responsible for monitoring Resident 1. The DSD stated Resident 1 needed to be monitored every hour on her whereabouts. The DSD stated the Receptionist should not leave the front desk unattended. The DSD stated the Receptionist should have notified someone to stay at the front desk to prevent residents from elopement and injuries. During a concurrent observation and interview on 4/21/2025 at 9:35 a.m., with CNA 2, in the facility's adjacent property's parking lot, CNA 2 pointed to the middle of the street as the location where he found Resident 1 on 4/5/2025 laying on her right side. CNA 2 stated he walked out of the facility down the driveway, and to his left he saw a lady flagging him down, waving her arms up and down. During an interview on 4/21/2025 at 12:50 p.m. with the Director of Nursing (DON), the DON stated Resident 1 was an elopement risk. The DON stated an elopement risk meant it was a risk to have Resident 1 alone in an unsupervised area and Resident 1 was not to leave the facility without supervision. The DON stated it was not safe for Resident 1 to be unsupervised in the parking lot because she was confused and could potentially fall and sustain injuries. The DON stated all staff were responsible to supervise Resident 1. The DON stated the reason Resident 1 eloped from the facility and sustained injuries was due to lack of supervision. The DON stated it was important to continuously monitor a resident with an elopement risk for the residents' safety. During an interview on 4/21/2025 at 2:46 p.m. with Resident 2, in Resident 2's room, Resident 2 stated on 4/5/2025 at 9:30 a.m. Resident 1 was sitting at the front lobby and he was sitting out on the patio. Resident 2 stated he saw Resident 1 leave through the facility's front exit door, which was wide open. Resident 2 stated Resident 1 propelled herself out the door and no one noticed her leave. Resident 2 stated he thought Resident 1 was going to come back but she did not. Resident 2 stated he notified the Receptionist that Resident 1 left the facility. Resident 2 stated the Receptionist went outside to look for Resident 1 but did not find her and she came back into the facility to inform staff Resident 1 was missing. Resident 2 stated 20 minutes after Resident 1 left the facility he also notified CNA 2 that Resident 1 exited through the facility's front door and staff started to look for Resident 1. During an interview on 4/24/2025 at 12:21 p.m. with the DON, the DON stated Resident 1 was supposed to be monitored every 5 minutes to prevent the resident from leaving the facility unsupervised. The DON stated there was a lapse in supervision which was the reason why Resident 1 was able to wheel herself out of the facility unnoticed. The DON stated staff were not vigilant in responding to the door alarms in a timely manner. The DON stated there was a delay in staff responding to the front exit door alarm because Resident 1 could have been found right outside the facility. The DON stated the facility's front exit door was not monitored when Resident 1 left the facility. The DON stated all staff should have redirected Resident 1 to another area or involve Resident 1 in activities. The DON stated it was important to follow the facility's monitoring approach in preventing elopement, accidents, and injuries for residents' safety. The DON stated it was important to make sure door alarms were working, monitored, and staff responded to the alarms promptly to prevent elopements and accidents. During a review of the facility's Policy and Procedure (P&P) titled Elopements and Wandering Residents, undated, the P&P indicated the facility would ensure residents who exhibit wandering behavior and/or are at risk for elopement received adequate supervision to prevent accidents. The P&P indicated the facility was equipped with door locks/alarms to help avoid elopements. The P&P indicated staff would be vigilant in responding to alarms in a timely manner. The P&P indicated adequate supervision would be provided to help prevent accidents or elopements. During a review of the facility's P&P titled Accidents and Supervision, dated 12/19/2022, the P&P indicated residents would receive adequate supervision to prevent accidents. The P&P indicated supervision was an intervention and a means of mitigating accident risk. The P&P indicated the facility would establish and utilize a systemic approach to address resident risk and environmental hazards to minimize the likelihood of accidents.

Based on observation, interview and record review, the facility failed to provide the necessary care and services for 6 of 24 sampled residents by failing to: 1. Check Resident 268's blood glucose level (amount of sugar in the blood stream, the normal value between 70 milligrams [mg, unit of measurement] per (/) deciliter [dL, unit of measurement] and 100 mg/dL) prior to administering Insulin Glulisine (a fast-acting medication to lower high blood sugar). 2. Accurately transcribe (copy from one place to another) Resident 268's discharge medication order for Insulin Glargine (a long-acting medication to lower high blood sugar) when readmitted to the facility on [DATE] from a long-term acute care hospital (LTACH). 3. Administer Milk of Magnesia (medication to treat constipation) to Resident 3 who did not have a bowel movement for three days and then for five days. 4. Turn and reposition Resident 30 and Resident 32, both of whom had existing pressure injuries (injury to skin and underlying tissue resulting from prolonged pressure on the skin). 5. Ensure the nasal cannula (a tube with two prongs for the nostrils connected to, and to deliver oxygen to a person with difficulty breathing) was not applied too tightly causing an indentation on the cheeks for two of eight sampled residents (Resident 56 and Resident 94) receiving oxygen therapy. 6. The oxygen nasal cannula was applied in Resident 94 nostrils (external opening of the nose) to supply the amount of oxygen as ordered by the physician. These failures resulted in Resident 268 being administered Insulin Glulisine instead of Insulin Glargine without blood glucose monitoring prior to administration on 10/26/2023 and 10/27/2023. This failure led to Resident 268 having a hypoglycemic (low blood glucose level, below 70 mg/dL) episode, altered mental status (AMS, changes in cognition [process of thinking], mood behavior, and/or arousal) and being transferred on 10/27/2023 to the general acute care hospital (GACH). These failures also resulted in the delay of bowel treatment for Resident 3 and transfer to the general acute care hospital (GACH) and had the potential for the formation of new or worsening of already existing pressure injuries. These failures also had the potential to cause skin breakdown, and the potential for the residents to develop respiratory distress. Findings: 1. During a review of Resident 268's Admission Record (Face Sheet), the Admission Record indicated Resident 268 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included but not limited to metabolic encephalopathy (problem in the brain caused by a chemical imbalance of the blood), sepsis (serious condition resulting from the presence of harmful microorganisms in the blood or other tissues), type 2 diabetes mellitus (condition that results in too much sugar circulating in the blood), anemia (problem of not having enough healthy red blood cells to carry oxygen to the body's tissues), dementia (a condition characterized by progressive or persistent loss of intellectual functioning), and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). During a review of Resident 268's Minimum Data Set (MDS, a standardized assessment and screening tool), dated 8/25/2023, the MDS indicated Resident 268's cognition was severely impaired (ability to think and reason). The MDS indicated Resident 268 did not have the ability to understand and be understood by others. The MDS indicated Resident 268 was totally dependent on staff and required one- person physical assistance for bed mobility, dressing, eating, toilet use, personal hygiene, and bathing. The MDS indicated Resident 268 was receiving insulin. During a review of Resident 268's Order Summary Review, dated 10/27/2023, the Order Summary Review indicated the following orders: 1. Enteral feeding (food delivered through a feeding tube) of Glucerna 1.2 (name of enteral feeding) infused on a feeding pump at 35 milliliters (mL, unit of measurement) per hour for 20 hours. 2. Insulin Glulisine Injection Solution, inject 10 unit (unit of measurement) subcutaneously (injection into the fatty tissue, just under the skin) one time a day, at 9 a.m., for diabetes mellitus management. 3. Insulin Lispro Injection Solution (a fast-acting medication to control high blood sugar), inject per sliding scale (administration of pre-meal insulin dose based on the blood glucose level before the meal) subcutaneously before meals at 6:30 a.m., 11:30 a.m., and 4:30 p.m. and at bedtime, at 9 p.m., for diabetes mellitus management. During a review of Resident 268's Medication Administration Record (MAR), for the month of October 2023, the MAR indicated on 10/27/2023 at 6:30 a.m., Resident 268 had a blood glucose level of 310 mg/dL and was administered 12 units of Insulin Lispro. The MAR indicated Resident 268 was administered Insulin Glulisine 10 units subcutaneously on 10/26/2023 and 10/27/2023 at 9 a.m. During a review of Resident 268's Change in Condition Evaluation (COC), dated 10/27/2023, the COC indicated at 12:20 p.m. on 10/27/2023, Resident 268 had a blood glucose level of 45 mg/dL and sluggish eyes with no eye contact. The COC indicated a code blue was announced and Resident 268 received 1mg of Glucagon (medication to increase blood glucose level) intramuscularly (IM, injection deep in the muscle). The COC indicated paramedics were called and arrived at the facility, and Resident 268 was transferred to the GACH. During a review of the paramedic's Responsive Report, dated 10/27/2023, the Responsive Report indicated Resident 268's chief complaint (statement describing the symptoms, problem, or condition of an individual) was hypoglycemia. The Responsive Report indicated at 12:38 p.m., on 10/27/2023, Resident 268 was administered 125 mL of Dextrose 10% (D10, liquid solution with concentrated level of sugar) intravenously (in the vein). The Responsive Report indicated at 12:39 p.m., Resident 268 had a blood glucose level of 43 mg/dL then at 12:51 p.m., Resident 268 had a blood glucose level of 128 mg/dL. During a review of Resident 268's Emergency Department (ED) Note, dated 10/27/2023, the ED Noted indicated Resident 268 was brought to the ED due to altered mental status and hypoglycemia. The ED Note indicated after Resident 268 arrived in the ED, she was administered 250 mL of D10 intravenously. The ED Note indicated at 1:43 p.m., Resident 268's blood glucose level was 150 mg/dL. The ED Note indicated Resident 268 was admitted to the intensive care unit (ICU, unit in the hospital that provides specialized treatment to patients who require critical medical care) for hypoglycemia, concern for sepsis (a life-threatening complication of an infection), hypothermia (a significant and potentially dangerous drop in body temperature), hydrocephalus (a condition in which fluid builds up in the brain), and possible left-side basilar pneumonia (lung inflammation of the lower left side of the lungs caused by bacteria or viral infection). During an interview on 10/27/2023 at 12:46 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she had gone into Resident 268's room around 12:15 p.m. on 10/27/2023 to check the resident's blood glucose and noticed the resident was foaming at the mouth. When LVN 1 checked Resident 268's blood glucose level it was 45 mg/dL. LVN 1 stated she placed the pulse oximeter (device to check the oxygen level in the blood) on Resident 268's finger and when there was no reading, so LVN 1 announced a code blue. LVN 1 stated once staff arrived to assist, Glucagon was administered. LVN 1 stated Resident 268's blood glucose level was checked after five minutes, and it resulted as 35 mg/dL. LVN 1 stated she last saw Resident 268 at 11 a.m. (on 10/27/2023) before the incident and the resident was okay. During a concurrent interview and record review on 10/27/2023 at 2:39 p.m. with LVN 1, Resident 268's MAR, for the month of October 2023, was reviewed. The MAR indicated Resident 268 had a blood glucose level of 310 mg/dL and was administered 12 units of Insulin Lispro on 10/27/2023 at 6:30 a.m. LVN 1 stated Insulin Lispro was administered during the prior shift, and LVN 1 administered Insulin Glulisine within an hour after the Insulin Lispro was administered. LVN 1 stated Insulin Glulisine was a fast-acting insulin and could decrease the resident's blood glucose level within 30 minutes. LVN 1 stated Resident 268's blood glucose was checked during the prior shift and LVN 1 felt okay giving Insulin Glulisine. LVN 1 stated blood glucose levels should be checked prior to insulin administration. LVN 1 stated Resident 268's enteral feeding was turned off at 9 a.m. per the physician's order. LVN 1 stated after administrating insulin, food was usually given to the resident. LVN 1 stated not checking the blood glucose level prior to insulin administration could cause hypoglycemia that could cause the resident to become nonresponsive or lead to death. LVN 1 stated the combination of the administration of Insulin Lispro, Insulin Glulisine, and the discontinuation of the enteral feeding may have caused Resident 268's hypoglycemic episode. During an interview on 10/27/2023 at 3:30 p.m. with Registered Nurse (RN) 1, RN 1 stated residents who received a rapid-acting insulin needed to have their blood glucose level checked before administration. RN 1 stated Insulin Lispro and Insulin Glulisine were both rapid-acting insulins. RN 1 stated due to the rapid action of both insulins, it was important to check the blood glucose level because the blood glucose level could decrease quickly. RN 1 stated she (RN 1) would have clarified the order for the lack of blood glucose monitoring and the actual order for Insulin Glulisine due to the fact Resident 268 was already receiving Insulin Lispro. RN 1 stated the combination of insulins had the possibility to drop Resident 268's blood glucose level significantly. During an interview on 10/27/2023 at 4:25 p.m. with the Director of Nursing (DON), the DON stated the purpose of administering insulin was to treat hyperglycemia (high blood sugar level) by decreasing the blood glucose level, and the blood glucose level should be checked before administering insulin. The DON stated checking the blood glucose level was important because if the blood glucose level was within the normal range and insulin was administered, that could cause hypoglycemia. The DON stated on10/27/2023, Resident 268 was hard to arouse, had her eyes closed, and did not respond to stimuli (anything that can trigger a physical or behavioral change). The DON stated if staff had not intervened during Resident 268's hypoglycemic episode, the resident could have gotten worse, became more nonresponsive, and had the potential to drift away. 2. During a concurrent interview and record review on 10/27/2023 at 3:40 p.m. with RN 1, Resident 268's LTACH Discharge Medications, dated 10/25/2023, were reviewed. The LTACH Discharge Medications indicated to continue Insulin Glargine, 10 units, subcutaneous injection, daily. RN 1 stated Insulin Glulisine was not on the discharge paperwork from the LTACH. RN 1 stated the action type between Insulin Glulisine and Insulin Glargine were different and had different effects on blood glucose levels. RN 1 stated the RN who admitted Resident 268 to the facility was responsible for transcribing the medication order correctly from the LTACH. RN 1 stated there was a mix up when Resident 268's discharge medications were transcribed incorrectly. During an interview on 10/27/2023 at 3:50 p.m. with Physician 1, Physician 1 stated the normal process was to continue the discharge medications from the LTACH. Physician 1 stated he had not placed the order for Insulin Glulisine. Physician 1 stated the blood glucose level should always be checked prior to administering insulin. Physician 1 stated Resident 268 should not have had two rapid-acting insulins ordered together as this caused Resident 268's hypoglycemic episode. Physician 1 stated there was an error in the discharge medication transcription and the facility should have followed the orders from the LTACH. During an interview on 10/27/2023 at 4:30 p.m. with the DON, the DON stated the normal process was to review the discharge medications from the discharging facility and to input those orders into the system. The DON stated there was a transcription error because Resident 268 was receiving Insulin Glargine at the LTACH and was supposed to be continued at the facility. The DON stated Insulin Glulisine should not have been ordered and Resident 268 should not have received the medication. The DON stated this was a medication error and this affected the resident where her blood glucose level dropped quickly. During a review of the facility's policy and procedure (P&P) titled, Consulting Physician/Practitioner Orders, dated 12/19/2022, the P&P indicated for consulting physician/practitioner orders received in writing or via fax, the nurse in a timely manner will call the attending physician to verify the order . [and] follow the facility procedures for verbal or telephone orders including: noting the order, submitting to pharmacy, and transcribing to medical or treatment administration record, when appropriate. 3. During a review of Resident 3's Admission Record (Face Sheet), the Admission Record indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included but not limited to Parkinson's disease (disorder of the nerves in the body affecting movement of the body), dementia, and type 2 diabetes mellitus. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's cognition was severely impaired. The MDS indicated Resident 3 was totally dependent on staff and required one-person assist when toileting. The MDS indicated Resident 3 had bowel incontinence (inability to control bowel movements that result in involuntary soiling). During a review of Resident 3's Order Summary Report, dated 10/18/2023, the Order Summary Report indicated to administer Milk of Magnesia Oral Suspension (liquid medication to treat constipation) 30 milliliters (ml, unit of measurement) by mouth as needed for constipation, if no bowel movement in two days. During a review of Resident 3's MAR, for the month of October 2023, the MAR indicated Resident 3 received Milk of Magnesia Oral Suspension on 10/12/2023. During an interview on 10/26/2023 at 10:30 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated the CNAs were responsible to chart whether a resident had a bowel movement or not. CNA 1 stated at the end of the shift, she would also report that information to the LVN. During an interview on 10/26/2023 at 10:43 a.m. with LVN 2, LVN 2 stated the licensed nurses were responsible to assess residents' bowel function. LVN 2 stated if a resident was unable to remember their last bowel movement, she would check the resident's electronic health record. LVN 2 stated, in the event a resident did not have any recent bowel movements, she would then look at the resident's orders and see if there are any medications ordered to treat constipation. During a concurrent interview and record review on 10/26/2023 at 10:50 a.m. with LVN 2, Resident 3's Documentation Survey Report (Bowel Elimination), for the month of October 2023 was reviewed. The Documentation Survey Report indicated Resident 3 did not have a bowel movement on 10/3/2023 to 10/5/2023 and 10/7/2023 to 10/11/2023. LVN 2 stated Resident 3 did not have a bowel movement for 3 days on 10/5/2023 and based on her medication orders, she should have been administered the Milk of Magnesia. LVN 2 stated Resident 3 had a bowel movement on 10/6/2023, however did not have a bowel movement for five days afterwards. LVN 2 stated the Milk of Magnesia should have been given to Resident 3 after not having a bowel movement for two days. LVN 2 stated not having a bowel movement could cause discomfort for the resident and there was delay in Resident 3's care. LVN 2 stated Resident 3's lack of bowel movement could have caused the fecal impaction (hardened fecal matter that cannot be pushed out) on 10/18/2023. During an interview on 10/26/2023 at 12:25 p.m. with RN 1, RN 1 stated if a resident did have not a bowel movement in three days, she would assess the resident for abdominal distention (bloating and swelling of the stomach area) and check to see if any medications for constipation could be administered. During a concurrent interview and record review on 10/26/2023 at 12:30 p.m. with RN 1, Resident 3's MAR, for the month of October 2023 was reviewed. The MAR indicated Resident 3 was routinely receiving Docusate Sodium Tablet (stool softener) 100 milligrams (mg, unit of measurement) twice a day and Lactulose Solution (medication to treat constipation) 10 grams per 15mL twice a day for bowel management. RN 1 stated Resident 3 was already on scheduled bowel management medication, it was concerning that she had not a bowel movement for three days and then for five days. RN 1 stated when a resident does not have a bowel movement, this could cause fecal impaction. RN 1 stated although Resident 3 had bowel movements after the administration of Milk of Magnesia, it was possible that the fecal impaction was already present. RN 1 stated there was a delay in Resident 3's care because there were multiple opportunities for her to receive the Milk of Magnesia. During an interview on 10/26/2023 at 12:48 p.m. with the DON, the DON stated she expected her licensed nurses to follow the physician's orders and in Resident 3's situation, to administer the Milk of Magnesia when she did not have a bowel movement after two days. The DON stated, Resident 3 was found to have fecal impaction and not having a bowel movement for multiple days were proof of why she had a fecal impaction. The DON stated Resident 3 was very constipated and had abdominal distention. The DON stated this could have potentially caused Resident 3 to have a bowel obstruction (digested material is prevented from passing normally through the bowel). The DON stated, the possibility of a bowel obstruction could have affected the resident's quality of life negatively. During a review of the facility's P&P titled, PRN Medications, dated 12/19/2023, the P&P indicated 'PRN medication' refers to a medication that is taken 'as needed' for a specific situation. It is not provided routinely, and requires assessment for need and effectiveness . PRN medications are administered by staff who are legally authorized to do so through certification or licensure, in accordance with a physician's order. 4a. During a review of Resident 30's Admission Record, the Admission Record indicated Resident 30 was admitted to the facility 12/25/2018 and had diagnoses of a fracture of the left hip joint (broken hip bone), intervertebral disc (part of the spine that provides cushioning of the bones of the spine) disorders, low back pain, history of falling and chronic pain. During a review of Resident 30's MDS, dated [DATE], the MDS indicated Resident 30's cognition was intact and required extensive assistance with bed mobility, transfers, getting dressed, toileting and maintaining personal hygiene. During an interview, on 10/24/2023, at 9:43 a.m., with Resident 30, Resident 30 stated he had not been repositioned every two hours and needed help to reposition himself. During an interview on 10/24/2023, at 3:20 p.m., with the Treatment Nurse (TN 2), TN 2 stated Resident 30 received treatments for a deep tissue injury and stated he expected Resident 30 to be repositioned every two hours to prevent further skin break down. During an observation, on 10/26/2023, from 7:30 a.m. to 9:30 a.m., Resident 30 was observed positioned on his back side. During an interview, on 10/26/2023, at 9:35 a.m., with Resident 30, Resident 30 stated, They did not turn me yesterday, all day. During a concurrent review and interview on 10/26/2023, at 9:47 a.m., with CNA 8, the charting section titled, Repositioning, was reviewed. CNA 8 was unable to present documentation of repositioning the resident before 4 p.m. on 10/25/2023. CNA 8 stated if it was not charted, it was not done. CNA 8 stated, If we are not repositioning the resident, then the resident has the potential to develop a pressure ulcer. During an interview, on 10/26/2023, at 9:50 a.m. with the Director of Staff Development (DSD), the DSD stated, We do not have a system of charting the repositioning of our residents available for the nurses. We just do a validation method between the LVNs, CNAs and department managers. The DSD stated there was a potential to not know or track how often the residents are turning and stated there was a lack of documentation to prove how often the nurses have repositioned the residents. During an interview with the DON, on 10/26/2023, at 10:20 a.m., the DON stated there was always a potential for residents to develop pressure ulcers. The DON stated there was a lack of documentation to prove that the repositioning was performed and stated there was a possibility that if it was not documented, it may not have been done. During a review of Resident 30's care plan, titled, At risk for pain or discomfort, revised 9/6/2023, the care plan indicated the facility was to reposition Resident 30 every two hours for comfort. 4b. During a review of Resident 32's Admission Record, the Admission Record indicated, Resident 32 was admitted to the facility on [DATE] with diagnoses that included but not limited to acute respiratory failure (condition in which not enough oxygen passes from the lungs into the blood), type 2 diabetes mellitus, and dementia. During a review of Resident 32's MDS, dated [DATE], the MDS indicated Resident 32's cognition was severely impaired. The MDS indicated Resident 32 required extensive assistance in bed mobility and required two-person assist. The MDS indicated Resident 32 has a stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle). During a review of Resident 32's care plan titled, At risk for re-hospitalization , initiated on 6/22/2023, the care plan indicated to turn and reposition every two hours and as needed for circulation and comfort. During a review of Resident 32's Surgical Consult, dated 9/11/2023, the Surgical Consult indicated to continue offloading (relieving pressure on parts of the body) and turn per facility protocol. During an observation on 10/25/2023 at 9:15 a.m., in Resident 32's room, Resident 32 was observed positioned on her right side after her wound care treatment. During an observation on 10/25/2023 at 10:25 a.m., in Resident 32's room, Resident 32 was observed laying on her right side. During an observation on 10/25/2023 at 11:35 a.m., in Resident 32's room, Resident 32 was observed laying on her right side. During a concurrent observation and interview on 10/25/2023 at 11:45 a.m. with TN 1, Resident 32 was observed laying on her right side. TN 1 stated they finished Resident 32's wound treatment at 9:15 a.m. and the resident was placed on her right side. TN 1 stated Resident 32 was in the same position she was in after her treatment. TN 1 stated Resident 32 was supposed to be turned and repositioned every two hours. TN 1 stated residents were turned to promote circulation, prevent skin breakdown, and prevent new pressure injuries from forming. TN 1 stated although Resident 32 was on a specialty mattress, the resident still needed to be turned and repositioned. TN 1 stated residents with existing pressure injuries were prone to developing new ones because they were already compromised. During an interview on 10/25/2023 at 12:45 p.m. with CNA 1, CNA 1 stated residents with pressure injuries and/or bed bound needed to be turned and repositioned to prevent new skin breakdown and to make sure they did not get worse. CNA 1 stated Resident 32 was on her side for two and a half hours and that is too long to be on one side. During an interview on 10/25/2023 at 2:34 p.m. with LVN 8, LVN 8 stated residents in bed were supposed to be turned every two hours or as needed. LVN 8 stated two and a half hours on one side would put a resident at risk for development of a pressure injury. During an interview on 10/26/2023 at 8:36 a.m. with the RN 1, RN 1 stated residents in bed were supposed to be turned every two hours to prevent further pressure injury and other skin issues. During an interview on 10/26/2023 at 8:47 a.m. with the DON stated the normal practice was to turn the residents in bed every two hours. The DON stated when a resident had a pressure injury, the resident would be positioned off that certain area. The DON stated if a resident was left in the same position for a long period of time, there could be the potential that future skin break down could develop. During a review of the facilities P&P titled, Turning and Repositioning, dated 9/12/2023, the P&P indicated residents at risk of, or with existing pressure injuries will be turned and repositioned, unless it is contraindicated due to medical condition. 5. During a review of Residents 56's Admission Records, the admission record indicated Resident 56 was admitted to the facility on [DATE]. Resident 56's diagnoses included respiratory failure, anemia (a low number of red blood cells) and anxiety disorder (persistent and excessive worry that interferes with daily activities). During a review of Resident 56's MDS, dated [DATE], the MDS indicated Resident 56 was unable to complete brief interview for mental status. The MDS indicated Resident 56 required an extensive assistance with two-person physical assist with bed mobility, transfer and one-person physical assist on toilet use, and personal hygiene. The MDS Section O, for Special treatment procedures and program under respiratory treatment indicated Resident 56 was receiving oxygen. During a record review of Resident 56's Oder Summary Report date ordered 5/15/2023, the order summary report indicated oxygen at 2 liters per minute, may titrate (adjust) oxygen to maintain oxygen saturation (concentration of oxygen in the body) greater than 95 percent (%) as needed for shortness of breath. During an interview on 10/24/2023 at 8:19 a.m., in Resident 56's room with CNA 7, CNA 7 stated Resident 56's nasal cannula as being too tight creating an indentation on the resident's face. CNA 7 stated the nasal cannula should have foam protection to prevent pressure injury (localized damage to the skin as well as the underlying soft tissue). During concurrent observation and interview on 10/26/2023 at 8:56 a.m., in Resident 56's room with CNA 9, CNA 9 verified Resident 56 cheeks had indentation markings from the oxygen nasal canula being too tight. CNA 9 further stated when the nasal canula was applied too tight, it would cause pressure injury, redness, possible pain, and discomfort to Resident 56. CNA 9 stated the oxygen needed to be administered properly. CNA 9 stated the nasal canula prongs should be in both nostrils to get the proper amount of oxygen the resident needed. CNA 9 stated the oxygen tubing should not be too tight to protect the residents from skin injury. 6a. During a review of Residents 94's Admission Records, the admission records indicated Resident 94 was admitted to the facility on [DATE]. Resident 94's diagnoses included difficulty in walking, muscle weakness, and obstructive sleep apnea (intermittent airflow blockage during sleep). During a review of Resident 94's MDS, dated [DATE], the MDS indicated Resident 94 had intact cognition for daily decision making. The MDS indicated Resident 94 required an extensive assistance with one-person physical assist with bed mobility, transfer, toilet use, and personal hygiene. The MDS Section O, Special treatment, procedures, and program under respiratory treatment, indicated Resident 94 was receiving oxygen. During a record review of Resident 94's Oder Summary Report date ordered 11/27/2022, the order summary report indicated oxygen at 2 liters per minute continuously via nasal cannula for shortness of breath. During a record review of Resident 94's care plan, initiated 3/14/2023, the care plan indicated oxygen via nasal cannula per MD (medical doctor) order. During a concurrent observation and interview on 10/24/2023 at 8:30 a.m. in Resident 94's room with LVN 3, LVN 3 stated Resident 94's oxygen nasal cannula was too tight, that created an indentation on Resident 94's both cheeks LVN 3 further stated if the canula is applied too tight, there's a possible risk for skin break down. 6b. During concurrent observation and interview on 10/24/2023 at 8:30 a.m. in Resident 94's room with LVN 3, LVN 3 stated Resident 94's nasal canula was not applied properly. One of the nasal canula prong was on the right nares and there was no nasal canula prong on the left nares. LVN 3 further stated both nasal canula prongs should be on both nares to administer the right amount of oxygen Resident 94 needs. During interview on 10/27/2023 at 10:19 a.m., with the Administrator (ADMN), the ADMN stated it was important to administer oxygen according to the physician's order. If the nasal canula was not applied properly, the residents will not get the right amount of oxygen they needed. The nasal cannula should not be too tight, it was a potential for skin beak down if not applied properly. During interview on 10/27/2023 at 10:57 a.m., with the DON, the DON stated oxygen nasal cannula prongs must be on both nostrils (right and left) for the resident to get the right amount of oxygen the resident's needs. The nasal cannula tubing was not supposed to be too tight. If too tight, it could possibly cause redness or skin breakdown. During a review of the facility's P&P titled, Oxygen Administration, revised date 6/5/2023, indicated oxygen is administered to residents who needs it, consistent with professional standards of practice, the comprehensive person -centered care plans, and the resident 's goals and preference. The P&P indicated the equipment needed for oxygen administration will depend on the type of delivery system ordered. Types of delivery system include a nasal cannula - Oxygen was administered through plastic cannula in the nostrils.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was admitted to the facility with no pressure ulcers and/or injuries (damaged skin caused by staying in one position for too long), was turned and repositioned every 2 hours to prevent the development of an unstageable pressure ulcer (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough [yellow/white material consisting of dead cells that accumulate in the wound, contributing to delayed wound healing or eschar [collection of dry, dead tissue within a wound]). This failure resulted in Resident 1 developing an unstageable pressure ulcer on the sacrococcygeal (tail bone) area. Findings: During a review of Residents 1's Admission Records, the admission records indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included difficulty in walking, anemia (lack of healthy red blood cells), and pulmonary hypertension (a type of high blood pressure that affects the arteries in the lungs and the right side of the heart). During a review of Resident 1's Minimum Data Set (MDS, standardized care and screening tool), dated 9/18/2023, the MDS indicated Resident 1 was severely impaired with cognitive skills for daily decision making (ability to think and reason). The MDS indicated Resident 1 required an extensive assistance and one-person physical assist with bed mobility, transfer, personal hygiene, and a two-person physical assist with toilet use. Section M0100S of the MDS indicated Resident 1 was at risk for pressure ulcers and the resident had no skin conditions and/or pressure ulcers upon admission. During a review of Resident 1's Braden Scale for Predicting Pressure Ulcer Risk (tool commonly used in health care to assess and document a resident's risk for developing pressure ulcers), dated 9/13/2023 at 3:28 p.m., the Braden Scale indicated Resident 1 was bedbound and had very limited mobility making position changes to the body or extremities (arms/legs) independently as factors for pressure ulcer development. The Braden Scale indicated Resident 1 had a score of 14, indicating the resident was at moderate risk for developing pressure ulcers. During a review of Resident 1's Braden Scale for Predicting Pressure Ulcer Risk, dated 9/19/2023 at 4:37 p.m., the Braden Scale indicated Resident 1 had a score of 15, indicating moderate risk. During a concurrent interview and record review on 10/7/2023 at 12:52 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 1's Medication Administration Record (MAR), for the month of September 2023, was reviewed. The MAR indicated Resident 1 was not repositioned every 2 hours from 9/11/2023 to 9/24/2023. LVN 1 stated Resident 1 was bed bound upon admission. LVN 1 stated from 9/11/2023 to 9/24/2023, there was no documentation indicating Resident 1 was being repositioned every 2 hours. LVN 1 further stated, If it was not documented, it was not done. During an interview with Family Member 1 (FM 1), on 10/7/2023 at 11:40 a.m., in Resident 1's room, FM 1 stated Resident 1 was not being turned, repositioned every 2 hours upon admission. FM 1 stated the facility started repositioning Resident 1 after the resident acquired an unstageable pressure ulcer on 9/22/2023. During a concurrent observation and interview with Treatment Nurse 1 (TN 1), on 10/7/2023 at 12:40 p.m., in Resident 1's room, Resident 1's unstageable pressure ulcer to the sacrococcygeal was observed. The unstageable pressure ulcer measured 9.0 centimeters (cm, unit of measurement) in length, 6.5 cm in width, and 0.4 cm in depth. The wound bed was observed with 100% slough. TN 1 stated residents that were high risk for pressure ulcer development were to be repositioned every 2 hours. During a concurrent interview and record review with TN 1, on 10/7/2023 at 1:26 p.m., Resident 1's care plans were reviewed. TN 1 stated there was no care plan upon Resident 1's admission addressing the resident's skin integrity. TN 1 stated Resident 1's care plan should have been initiated upon admission. TN 1 stated Resident 1 was unable to reposition herself upon admission and the resident's skin was intact from 9/11/2023 to 9/21/2023. During a record review of Resident 1's document titled Skin Evaluation, the document indicated the following: 9/22/2023 - Resident 1 had an unstageable pressure ulcer to the sacrococcygeal area, measuring 8.0 cm in length, 6.1 cm in width, 80 percent (%) undetermined eschar, and 20 % yellow slough noted to the wound bed. 9/25/2023 -Unstageable pressure ulcer to the sacrococcygeal area measuring 9.0 cm in length, 7.5 cm in width, and 100% necrotic tissue (premature death of cells or tissue from disease or injury) noted to the wound bed. 10/02/2023 - Unstageable pressure ulcer measuring 9.0 cm in length, 6.5 cm in width, 0.4 cm in depth, and 100% yellow slough noted to the wound bed. During a concurrent interview and record review with TN 1, on 10/7/2023 at 6:24 p.m., Resident 1's medical records titled, Physical Therapy (PT) Notes, dated 9/12/2023, was reviewed. The notes indicated Resident 1's bed mobility was maximum assist. TN 1 stated maximum assist meant Resident 1 was unable to move. TN 1 stated if Resident 1 was repositioned every 2 hours there was a possibility Resident 1 would not have developed an unstageable pressure ulcer. TN 1 stated the facility failed to prevent Resident 1's pressure ulcer development. During a concurrent interview and record review with the Administrator, on 10/7/2023 at 7 p.m., Resident 1's MAR for the month of September 2023, the MDS dated [DATE], care plans, Braden Scale dated 9/13/2023 and 9/19/2023, and PT notes dated 9/12/2023 were reviewed. The Administrator verified the following: The MAR indicated the resident was not turned and repositioned every (Q) 2hrs, from 9/11/2023 to 9/24/2023. The MDS indicated Resident 1 was at risk for pressure ulcer development. There was no initial care plan regarding Resident 1's skin integrity and risk for skin breakdown initiated upon admission. A Braden Scale was not initiated until 9/13/2023, and a second Braden Scale dated 9/19/2023, indicated a score of 15 indicating the resident was now at moderate risk for pressure ulcer development. The PT notes indicated Resident 1's baseline was maximum assist with bed mobility. The Administrator stated the facility failed to prevent the development of Resident 1's unstageable pressure ulcer by not repositioning Resident 1 every 2 hours and by not initiating a care plan for skin integrity upon admission. During a record review of the facility's Policy and Procedure (P&P) titled, Pressure injury prevention, revised date 10/2022, the P&P indicated the facility was committed to the prevention of avoidable pressure injuries, unless clinically unavoidable and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcer/injuries. Under Policy Explanation and compliance Guidelines: indicated: 3. Assessment of Pressure Injury Risk a. License nurse would conduct a pressure injury assessment using the Braden scale for predicting pressure ulcer risk, on all residents upon admission /re-admission, weekly times 3 more weeks, then quarterly or when ever the resident's condition changes significantly. b. The tool would be used in conjunction with the other risk factor not captured by the risk assessment tool. Example of risk factors indicated impaired/ decreased mobility and decreased functional ability, cognitive impairment, and exposure of the skin to urine and fecal incontinence (inability to control). 4. Interventions for prevention and to promote healing. a. After completing a thorough assessment/ evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. During a record review of the facility's P&P titled, Turning and Repositioning, revised date 9/12/2023, the P&P indicated it was the facility's policy to implement turning and repositioning as part of our systemic approach to pressure injury prevention and management. This policy establishes responsibilities and protocols for turning and repositioning. Under Policy Explanation and compliance guidelines: 1. Resident at risk of, or with existing pressure injuries, will be turned and repositioned , unless it is contraindicated due to medical condition. In this case, small shifts in repositioning will be employed. 2. Turning and repositioning is a primary responsibility of nursing assistant. However, nursing staff are expected to assist with turning and repositioning. 3. The facility has established routine turning and repositioning schedules consisting of every 2-4 hours, on the even hours, a maximum of thirty minutes before of after the schedule time will be allotted for the compliance with the schedule. 4. The frequency of turning and repositioning will be determined by the resident's: a. Tissue tolerance b. Level of activity and mobility c. Skin condition d. Overall medical condition e. Treatment goal f. Type of pressure distribution support in use(turning and repositioning is still required on specialty surface, but frequency may be reduced) g. Comfort levels

Based on interview and record review, the facility failed to ensure the resident, who was found on the floor unresponsive (lack of response) and pulseless (when the heart stops), and who was a Full Code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation (action or process of reviving someone from unconsciousness or apparent death) procedures will be provided to keep them alive) was provided basic life support ([BLS], care healthcare professionals provide to anyone who's heart stops beating suddenly) including cardiopulmonary resuscitation ([CPR)] an emergency procedure to restart a person's heart (chest compressions) and breathing after one or both have stopped) immediately without a delay and loss of critical time to revive the resident for one of five sampled residents (Resident 1). The facility failed to: 1. Ensure CPR was initiated immediately to Resident 1, who had a Full Code status, when found unresponsive and pulseless per the facility's policy and procedure (P/P) titled Medical Emergency Response, and the American Heart Association (AHA) Guidelines. 2. Ensure the staff were aware and trained in all procedures of administering CPR. 3. Ensure the staff were knowledgeable of the facility's policy and procedure (P/P) regarding initiating CPR when a resident was a full code and unresponsive which require immediate action would occur. These failures resulted in staff's delay in identifying Resident 1 code status and providing CPR when Resident 1 was found unresponsive and pulseless on [DATE] on the floor. The paramedics were called and arrived on [DATE] at 5 a.m. and pronounced Resident 1 deceased (dead/lifeless). According to paramedics' report, the facility staff were not performing CPR to Resident 1 upon the paramedics' arrival. These failures placed other 93 residents, who had Full Code status, not to receive CPR timely. On [DATE] at 2:14 p.m. an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation had cause, or is likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of the Administrator (ADM) due to the facility's failure to ensure basic life support (BLS) was provided to Resident 1, including cardiopulmonary resuscitation (CPR) immediately as per the facility's policy and procedure (P/P) and the American Heart Association (AHA). On [DATE] at 6:34 p.m., the ADM submitted an acceptable IJ removal plan ([IJRP], an intervention to immediately correct the deficient practices). After verification the IJRP was implemented through observation, interview, and record reviews, the IJ was removed while onsite on [DATE] at 6:41 p.m., in the presence of the ADM and the Director of Nursing (DON). The IJRP included the following: 1. The Medical Records Supervisor and licensed staff conducted an initial audit of residents' code status on [DATE], of the 112 in-house residents, 59 were identified as full code. 2. The facility will provide a full code list of residents at each nurses' stations on the two crash carts in a green binder. The facility's clinical staff will identify resident code status by utilizing residents' Advance Directive as identified by the physician's order in the chart/Medication Administration Record (MAR). The facility will update the residents 'code status list based on the POLST (physicians orders for life-sustaining treatment)) and will update the clinical record daily and as needed by the Registered Nurse (RN) Supervisor. 3. The facility's clinical staff was provided re-education by the DON, Director of Staff Development (DSD), and designee initiated on [DATE] related to rapid response to include timely emergency response. 4. Have a system in place for the staff to know the residents with the status of Full Code and the residents with the status of 'Do Not Resuscitate' ([DNR] the person request for no life saving measures in the event they stop breathing and/or heart stops). 5.The facility's RN staff will be in-serviced by the DON/DSD or designee regarding updating the full code list initiated on [DATE]. 6. The facility's crash cart will be taken to the location of the code blue (a medical emergency where the heart stops beating, or the person stops breathing and immediate resuscitation is needed). The green binder will be utilized to attain the code status. A crash cart will be located at each nurse's station. 7. The facility's Medical Director was notified of the resident's (Resident 1) incident on [DATE]. 8. The licensed staff were identified and given 1:1 (one to one individually trained) re-in-service on performing CPR on the full code status residents: Licensed Vocational Nurse (LVN 1) and Registered Nurse (RN 1) on [DATE] and LVN 2 on [DATE]. 9. The facility took the following actions to prevent an adverse outcome from reoccurring by initiating in-services, staff competencies, and mock drills (designed for staff to practice emergency response procedures and to evaluate and improve upon the successfulness of those procedures). The facility's staff were competent in performing emergency response procedures during the mock drills. The systematic change would include ongoing mock code drills and staff competencies (Completion Date: [DATE]). 10. The DON or designee, initiated re-education with the licensed staff on the facility's P/P for initiating CPR on [DATE], on full code status residents who are unconscious and pulseless. The licensed staff who did not finish their in-service were taken off the work schedule and will be reinstated upon completion of the in-service and mock drill competency. 11. The skills competency was initiated on [DATE] to the licensed staff by the` DON or designee on initiating CPR procedures. The skills competency format was from AHA Adult CPR skills testing checklist with return demonstration. Skills competencies will be conducted by the DSD upon hire, annually, and PRN (as needed). 12. A Quality Assurance Performance Improvement (QAPI) of initiation of CPR was implemented. The compliance checks will be conducted by the DON to ensure mock drills and competencies are completed as scheduled twice monthly for three months. 13. The facility initiated a Mock Code drill on 3 p.m. to 11 p.m. shift on [DATE], by the Director of Nursing (DON) and Director of Staff Development (DSD). Certified Nursing Assistants (CNA) and licensed staff were present. The drills will be conducted for subsequence shift until compliance is achieved. The Mock Code drills will continue to be conducted by the DON and DSD two times a month for three months. The RN supervisor will be the designated shift leader, with alternate being an identified licensed staff member in case of an emergency. The shift leader in-services were initiated by the DON/designee on [DATE]. The findings will be reviewed at the monthly Quality Assurance Assessment Committee ([QAA] team responsible for identifying and responding to quality deficiencies that are identified in the facility) meeting. 14. The Medical Records Director (MRD) will conduct weekly audit of the residents' code status by comparing the physician orders with the POLST and findings will be given to DON for follow up. Findings: During a review of Resident 1's Admission Record (AR), dated [DATE], the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including displaced fracture of second cervical vertebra (displaced neck bone), muscle weakness, diabetic retinopathy (an eye condition that can cause vision loss and blindness in people who have diabetes [high blood sugar levels]), dizziness, giddiness (altered sense of balance or place), abnormal posture, and history of falling. During a review of Resident 1's history and physical (H/P), dated [DATE], the H/P indicated Resident 1 had the capacity to make medical decisions. During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated [DATE], the MDS indicated Resident 1 had the ability to understand and be understood by others. The MDS indicated Resident 1 required an extensive assistance for bed mobility, transfer, locomotion off unit (how resident moves to and from distant areas on the floor), dressing, and personal hygiene. According to the MDS, Resident 1 was not steady and only able to stabilize with staff assistance in moving from a seated to standing position, moving on and off the toilet, and transferring to the bed, chair, and or wheelchair. During a review of Resident 1's POLST form, dated [DATE], the POLST indicated if Resident 1 had no pulse and was not breathing to attempt resuscitation/CPR. During a concurrent interview and record review on [DATE] at 10:41 a.m. with the Infection Prevention Nurse ([IP] helps prevent and identify the spread of infections in a healthcare environment) of Resident 1's Nursing Progress Notes (NPN), dated [DATE] and timed at 4:45 a.m., the NPN indicated LVN 1 was called by CNA 1 to come to Resident 1's room. According to the NPN, LVN 1 observed Resident 1 to be faced down on the floor and unresponsive. LVN 1 then called RN 1 to Resident 1's room. RN 1 noted Resident 1 on the floor unresponsive. RN 1 then instructed LVN 1 and LVN 2 to put Resident 1 back to bed. RN 1 noted Resident 1 to be very pale (unusual lightness of skin color) no rise and fall of the chest and unresponsive. RN 1 then went to the nurse's station to check Resident 1's code status and realized Resident 1 was a Full Code and instructed LVN 1 to initiate CPR. The IP stated there was no documentation in Resident 1's medical records to indicate CPR was initiated by CNA 1 when she first saw the resident. The IP stated CPR was not initiated by LVN 1, LVN 2 and/or RN 1 until Resident 1 was placed back to bed. The IP stated CPR should have been initiated while Resident 1 was on the floor, as the floor was the optimal place to perform CPR because it was a hard surface. During an interview on [DATE] at 4:46 p.m. with the DON, the DON stated, If a resident was found on the floor unresponsive, you immediately check for a pulse, if the resident does not have a pulse, then you start chest compressions and call for help. The DON stated you do not put the resident back to bed to initiate CPR, CPR should be initiated wherever the resident was found. During an interview on [DATE] at 5:36 a.m. with RN 1, RN 1 stated CNA 1 and LVN 1 called her to come to Resident 1's room. RN 1 stated LVN 1 told her Resident 1 did not have a pulse and was unresponsive. RN 1 stated, I instructed CNA 1 and LVN 1 to place Resident 1 back in bed. I then assessed Resident 1, who was unresponsive and not breathing. I then left Resident 1's room to check the residents' code status, and I found out Resident 1 was a full code. I instructed CNA 1 and LVN 1 to initiate CPR. RN 1 stated CPR was not initiated by CNA 1 or LVN 1 to Resident 1 prior to her entering the resident's room. During a concurrent interview and record review on [DATE] at 12:18 p.m. with Paramedic 1 ([PM] a healthcare professional who responds to emergency calls to provide emergency medical help outside of a hospital) who was on the scene when Resident 1 was pronounced deceased (dead/lifeless) Resident 1's Emergency Medical Service Response Report (RR), dated [DATE] and timed at 4:53 a.m. was reviewed. The RR indicated Resident 1 was found unresponsive, last seen by facility's staff two hours prior, bilateral eyes fixed and dilated (the black center of the eyes grows larger in size), rigor (stiffening of the joints and muscles of a body) in the jaw, cold at the core (central part of the body), pale, no heart or breath sounds, and in asystole (no heartbeat). PM 1 stated the RR indicated CPR was not provided prior to the paramedics' arrival. The RR indicated Resident 1 was pronounced deceased by the paramedics on [DATE] at 5:05 a.m. PM 1 stated when paramedics entered Resident 1's room, the facility's staff were standing around Resident 1, who was in the bed, and the staff was not performing CPR or touching Resident 1. PM 1 stated she found it strange for the facility staff to not be performing CPR on Resident 1. PM 1 stated the facility staff told paramedics responders Resident 1 was found on the floor, unresponsive, without a pulse, but when paramedics arrived, Resident 1 was in the bed. PM 1 stated rigor in the jaw indicates Resident 1 was most likely deceased for several hours. During an interview on [DATE] at 3:49 p.m. with LVN 1, LVN 1 stated CNA 1 called him to Resident 1's room. LVN 1 stated upon entering Resident 1's room, Resident 1 was found face down on the floor, unresponsive and without a pulse. LVN 1 stated he did not initiate CPR when he found Resident 1 on the floor. LVN 1 stated CPR was not initiated until Resident 1 was placed back to bed and RN 1 notified him of Resident 1's code status. LVN 1 stated CPR should have been initiated immediately while Resident 1 was on the floor. During an interview on [DATE] at 9:27 a.m. with LVN 2, LVN 2 stated he was called to Resident 1's room by CNA 1 to assist CNA 1 and LVN 1 to place Resident 1 back to bed. LVN 2 stated Resident 1 was on the floor without a pulse. LVN 2 stated he did not initiate CPR immediately after Resident 1 was found without a pulse because LVN 1 told him to help place Resident 1 back to bed. LVN 2 stated once he assisted Resident 1 back to bed, he left the room. LVN 2 stated as soon as he found Resident 1 without a pulse, he should have started CPR immediately, while Resident 1 was on the floor. During an interview on [DATE] at 9:12 a.m., with PM 2, PM 2 stated when he entered Resident 1's room, Resident 1 was on the bed and several staff members were standing around Resident 1. PM 2 stated he did not see staff doing anything, they were not doing chest compressions nor giving breaths. PM 2 stated he was wondering why Resident 1 was in the bed when the facility reported to him the resident was found on the floor without a pulse. PM 2 stated the staff should have left Resident 1 on the floor and immediately started CPR. PM 2 stated he assessed Resident 1 and saw obvious signs of death; Resident 1 had rigor at the jaw, there was no apical pulse upon auscultation (listening to heart sounds with a stethoscope), resident did not respond to pain, and her body was cold at the core (cold in abdomen). PM 2 stated he placed Resident 1 on the heart monitor and Resident 1 was in asystole (without heart beats). PM 2 stated cold at core indicates Resident 1's abdomen and chest were cold. During an interview on [DATE] at 10:26 a.m. with CNA 1, CNA 1 stated around 4:10 to 4:15 a.m. she entered Resident 1's room and found Resident 1 on the floor. CNA 1 stated she left Resident 1 unattended to get LVN 1 for help. CNA 1 stated LVN 1 came to Resident 1's room, checked Resident 1's pulse and then called RN 1. CNA 1 stated RN 1 then instructed CNA 1 and LVN 1 to put Resident 1 back to bed. CNA 1 stated she left the room to find LVN 2, who was at Station Two, to assist them with placing Resident 1 back to bed. CNA 1 stated she assisted Resident 1 back to bed with the help of LVN 1 and LVN 2. CNA 1 stated RN 1 went to check Resident 1's code status and then told us to initiate CPR after finding Resident 1 was a full code. CNA 1 stated she did not check Resident 1 for a pulse when she initially found Resident 1 on the floor because she panicked and thought the first thing to do was to go get help. CNA 1 stated I should have checked Resident 1 for a pulse and initiated CPR while the resident was on the floor per the CPR guidelines. During a review of an online article titled, American Heart Association 2020 CPR and Emergency Cardiovascular Care Committee ECC Guidelines, the article indicated the adult basic life support algorithm for healthcare providers indicated to verify for scene safety, check for responsiveness, shout for nearby help, look for no breathing or only gasping and check pulse (simultaneously [at the same time]). The guidelines further indicated if there was no breathing, or only gasping, and pulse not felt, to immediately begin CPR and perform cycles of thirty chest compressions and two breaths. https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines During a review of the facility's policy and procedure (P/P) revised [DATE] and titled, Cardiopulmonary Resuscitation, the P/P indicated if a resident experiences a cardiac arrest, the facility's staff will provide basic life support, including CPR prior to the arrival of emergency medical services. During a review of the facility's P/P revised on [DATE] and titled, Medical Emergency Response, the P/P indicated the employee who first witnesses or is first on site of a medical emergency, that are trained, will initiate immediate action, including CPR.

Based on interview and record review, the facility failed to ensure the resident, who was receiving Zyprexa (an antipsychotic [a medication that works by altering brain chemistry to help reduce psychotic symptoms [including delusions (false beliefs) and hallucinations (seeing or hearing things that others do not see or hear)]medication that can treat several mental health conditions including schizophrenia), received care and services to prevent and manage constipation (condition when stools remain in the colon (large intestine) for too long, and the colon absorbs too much water from the stool, causing them to become hard and dry) as one of Zyprexa side effects for one of two sampled residents (Resident 1). (Cross referenced to F 758) The facility failed to: 1. Ensure the nursing staff monitored Resident 1 for signs and symptoms of constipation in accordance with the care plan titled Risk for constipation related to decreased mobility, use/side effects of medication, and psychoactive medication (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior). 2. Ensure the licensed nurses administered to Resident 1 prescribed Milk of Magnesia ([MOM] a laxative that works by drawing water into the intestines to induce bowel movement), fleets enema (works by increasing water in the intestine to hydrate and soften the stool to help produce a bowel movement) and Dulcolax suppository (inserted into the rectum [the opening at the far end of the digestive tract through which stool leaves the body] stimulates a bowel movement and softens stools to treat constipation) as ordered by the physician to prevent and treat constipation. These deficient practices resulted in Resident 1 experiencing constipation, requiring a transfer to a general acute care hospital (GACH) and diagnosed with a fecal impaction and bowel obstruction. Resident 1 underwent a digital dis-impaction (the use of fingers to manually remove stool from the rectum) and multiple enemas (medication injections of fluid used to cleanse or stimulate the emptying of the intestines). Findings: During a review of Resident 1's Admission Record (AR), the AR indicated the resident was originally admitted to the facility on [DATE] with the diagnosis including schizophrenia (a mental disorder characterized by disruptions in thought process, perceptions, and social interactions). During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 12/26/2022, the MDS indicated Resident 1 had severely impaired cognitive skills (thought process) for daily decision-making and required extensive to total assistance with activities of daily living (ADLs). During a review of Resident 1's physician's orders (PO), the orders indicated the following prescribed medications: 1. Zyprexa (Olanzapine) 5 milligrams ([mg] unit of measurement) give one tablet by mouth two times a day for schizophrenia manifested by hallucinations [(m/b) a sensory experience of something that does not actually exist, delusions (false belief) and/or verbal aggression] ordered on 10/26/2022. Monitor side effects associated with Zyprexa including common-sedation, drowsiness, dry mouth, constipation, and blurred vision. 3. Fleet enema [an over-the-counter saline laxative that is administered rectally (the last several inches of the large intestine closest to the anus) softens and lubricates stools, making them easier to pass) 7-19 gram (gm)/118 milliliters (ml) (sodium phosphate) insert one enema application rectally as needed for constipation, if no results from suppository, dated 6/28/2022. 4. Dulcolax Suppository ([Bisacodyl] medication which stimulates a bowel movement and softens stools inserted into the rectum]) 10 mg, insert rectally as needed for constipation, if no results from Milk of Magnesia daily, dated 6/28/2022. 5. Milk of Magnesia (medication which increases water in the intestines to stimulate bowel movements) suspension 400mg/5ml, to give 30 ml by mouth as needed for constipation daily, if no bowel movement in four days, dated 6/28/2022. A review of the website DailyMed the common side effects of Zyprexa included lack of energy, dry mouth, increased appetite, sleepiness, tremor (shaking), having hard or infrequent stools, dizziness, changes in behavior, and/or restlessness https://dailymed.nlm.nih.gov/dailymed/ During a review of Resident 1's care plan (CP) dated 3/15/2019, titled Use of psychotropic medications related to (r/t) diagnosis of schizophrenia m/b hallucinations/delusions/verbal, the goal for Resident 1 was to remain free of psychotropic (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) drug related complications including constipation, and fecal impaction. According to this CP, the nursing staff had to observed Resident 1 Zyprexa side effects every shift. During a review of Resident 1's CP revised on 5/22/2022 tiled Risk for constipation related to decreased mobility, use/side effects of medication, and psychoactive medication, the CP indicated a goal for Resident 1 was to have a normal bowel movement. The CP also indicated the nursing staff interventions included monitoring Resident 1 for constipation as medication side effects, keeping the physician informed of any problems, and observe Resident 1 for sign and symptoms of complications related to constipation including small loose stools and fecal smearing. During a review of Resident 1's Intervention/Task flowsheet for December 2022, the flowsheet indicated Resident 1's bowel elimination from 12/10/2022 to 12/26/2022, documented as follows: 1. On 12/10/2022, the resident had one bowel movement which was medium in amount and constipated/hard in consistency. 2. From 12/11/2022 to12/16/2022, a total of six days, the resident had no bowel movements. 3. On 12/17/2022, the resident had two bowel movements, one which was small and putty-like in consistency and the second one was medium in amount and formed/normal in consistency. 4. On 12/18/2022, the resident had one bowel movement which was large and loose/diarrhea (a condition in which feces are discharged from the bowels frequently and in a liquid form) in consistency. 5. On 12/19/2022, the resident had no bowel movement. 6. On 12/20/2022, the resident had one bowel movement which was medium in amount and formed/normal in consistency. 7. From 12/21/2022 to 12/23/2022, a total of three days, the resident had no bowel movement. 8. On 12/24/2022, the resident had one bowel movement which was medium in amount and putty like in consistency. 9. On 12/25/2022, the resident had two bowel movements, one was large and loose/diarrhea in consistency and the second one was medium in size and putty like in consistency. During a review of Resident 1's Change of Condition (COC) progress note dated 12/26/2022, the COC indicated Resident 1 was transferred to the GACH for shortness of breath. During a review of Resident 1's GACH history and physical (H/P), dated 12/26/2022, the H/P indicated Resident 1 was diagnosed with a fecal impaction with and possible bowel obstruction requiring an admission to the GACH for further evaluation and treatment. During a review of Resident 1's GACH Radiology [(X-ray) a photographic or digital image of the internal composition of body part or internal organ] report, dated 12/30/2022, the X-ray report indicated Resident 1 had a large fecal material impacted in the dilated rectum (abnormally enlarged intestine) causing partial colonic [(colon) the longest part of the large intestine (a tube-like organ connected to the small intestine at one end and the anus (the opening at the far end of the digestive tract through which stool leaves the body) at the other end] obstruction. During a review of Resident 1's GACH's progress notes, dated 12/30/2022 and timed at 9:35 p.m., the progress notes indicated digital (finger) dis-impaction was performed and multiple hard stool pieces were removed. During a review of Resident 1's GACH Medication Administration Record (MAR) for the month of 12/2022, the MAR indicated Resident 1 received a fleet mineral oil enema on 12/26/2022, 12/31/2022, and 1/3/2023. During a review of Resident 1's physician orders, dated 1/3/2023, the physician orders indicated Resident 1 was readmitted to the facility. During an interview on 2/9/2023 at 11:55 a.m. with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated putty-like bowel movement was not a normal consistency stool and must be reported to the charge nurse. During an interview on 2/9/2023 at 12:22 p.m. with the Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated putty-like consistency for bowel movements could mean the resident was constipated. During a review of Resident 1's MAR for the month of 12/2022, the MAR's documentation indicated from 12/10/2022 to 12/26/2022, a total of 17 days, Resident 1 did not exhibit any side effects of Zyprexa such as constipation [sic]. During a concurrent interview and record review on 2/9/2023 at 12:27 p.m. of Resident 1's MAR for the month of 12/2022 with the Director of Nurses (DON), the DON confirmed the MAR indicated from 12/10/2022 to 12/26/2022, a total of 17 days, the resident did not receive any doses of Dulcolax suppository, fleet enemas, and/or Milk of Magnesia. The DON stated putty-like bowel movement consistency was not normal. The DON stated Resident 1's bowel pattern should have been evaluated to determine what was normal for the resident. After the DON reviewed Resident 1's Intervention/Task flowsheet specific to the resident's bowel elimination for the month of 12/2022, the DON stated Resident 1's bowel pattern was not normal, and the licensed staff failed to monitor and identify signs and symptoms of constipation and provide interventions to prevent constipation and inform the physician. The DON could not provide any documentation the licensed staff had informed the physician regarding Resident 1's abnormal bowel movements pattern. The DON confirmed the facility's failure to monitor and provide interventions for Resident 1's constipation resulted in the resident's fecal impaction. The DON could not provide a policy regarding the facility's bowel management program. On the same day at 2:50 p.m., in a subsequent interview, the DON confirmed Resident 1 was receiving Zyprexa which have the side effect of constipation. During an interview on 2/10/2023 at 11:03 a.m. with the Registered Pharmacist (RPH), the RPH confirmed constipation was a side effect of Zyprexa and should be monitored. The RPH stated if a resident was already experiencing constipation, continued use of Zyprexa could worsen the constipation. During a review of the facility's policy and procedure (P/P) dated 9/2022 and titled, Provision of Quality of Care, the P/P indicated based on comprehensive assessments, the facility will ensure residents receive treatment and care by a qualified persons based on professional standards of practice and the comprehensive person-centered care plans. According to the P/P each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being.

Based on interview and record review, the facility failed to ensure the resident, who was receiving the psychotropic drugs (any drug that affects brain activities associated with mental processes and behavior) Zyprexa (medication used to treat certain mental/mood conditions including schizophrenia [a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions]) was monitored for medication side effects for one of two sampled residents (Resident 1). The facility failed to: 1. Ensure the licensed nurses monitored Resident 1 for constipation (less than three bowel movements a week) related to intake of Zyprexa as indicated in the plan of care titled Use of psychotropic medications related to (r/t) diagnosis of schizophrenia m/b hallucinations/delusions/verbal and a care plan titled Resident at risk for constipation related to use/side effects of medication, and psychoactive medication (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior). 2. Ensure the licensed nurses administered to Resident 1 Dulcolax suppository (used to produce bowel movements in a short time), Fleet enemas (used to relieve constipation and cleanse the colon) and Milk of Magnesia (treatment for constipation) as prescribed by the physician whenever necessary (PRN) for constipation. 3. Ensure the licensed nurses notified Resident 1's physician that the resident was not having consistent bowel movements as per the resident's plan of care titled Resident at risk for constipation related to decreased mobility, use/side effects of medication, and psychoactive medication, and the facility's policy and procedure titled Use of Psychotropic Medication. These deficient practices resulted in Resident 1 experiencing constipation, requiring a transfer to a general acute care hospital (GACH) and diagnosed with a fecal impaction (a mass of dry, hard stool that cannot pass out of the colon (large intestine [long tube like organ connected to the small intestine at one end and the anus {the opening where stool comes out at the other}) and bowel obstruction (a partial or complete block of the small or large intestine that keeps food, liquid, gas, and stool from moving through the intestines in a normal way). Resident 1 underwent a digital disimpaction (the use of fingers to manually remove stool from the rectum) and multiple enemas (medication injections of fluid used to cleanse or stimulate the emptying of the intestines). Findings: During a review of Resident 1's Admission Record (AR), the AR indicated the resident was originally admitted to the facility on [DATE] with the diagnosis including schizophrenia (a mental disorder characterized by disruptions in thought process, perceptions, and social interactions). During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 12/26/2022, the MDS indicated Resident 1 had severely impaired cognitive skills (thought process) for daily decision-making and required extensive to total assistance with activities of daily living (ADLs). During a review of Resident 1's physician's orders (PO), the orders indicated the following prescribed medications: 1. Zyprexa (Olanzapine) 5 milligrams ([mg] unit of measurement) give one tablet by mouth two times a day for schizophrenia manifested by hallucinations [(m/b) a sensory experience of something that does not actually exist, delusions (false belief) and/or verbal aggression] ordered on 10/26/2022. Monitor side effects associated with Zyprexa including common-sedation, drowsiness, dry mouth, constipation, and blurred vision. 3. Fleet enema [an over-the-counter saline laxative that is administered rectally (the last several inches of the large intestine closest to the anus) softens and lubricates stools, making them easier to pass) 7-19 gram (gm)/118 milliliters (ml) of Sodium Phosphate solution (a saline laxative that is thought to work by increasing fluid in the small intestine), insert one enema application rectally as needed for constipation, if no results from suppository, dated 6/28/2022. 4. Dulcolax Suppository ([Bisacodyl] medication which stimulates a bowel movement and softens stools inserted into the rectum]) 10 mg, insert rectally as needed for constipation, if no results from Milk of Magnesia daily, dated 6/28/2022. 5. Milk of Magnesia (medication which increases water in the intestines to stimulate bowel movements) suspension 400mg/5ml, to give 30 ml by mouth as needed for constipation daily, if no bowel movement in four days, dated 6/28/2022. According to website DailyMed the common side effects of Zyprexa included lack of energy, dry mouth, increased appetite, sleepiness, tremor (shaking), having hard or infrequent stools, dizziness, changes in behavior, and/or restlessness https://dailymed.nlm.nih.gov/dailymed/ During a review of Resident 1's care plan (CP) dated 3/15/2019, titled Use of psychotropic medications related to (r/t) diagnosis of schizophrenia m/b hallucinations/delusions/verbal, the goal for Resident 1 was to remain free of psychotropic (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) drug related complications including constipation, and fecal impaction. According to this CP, the nursing staff have to observed Resident 1 Zyprexa side effects every shift. During a review of Resident 1's CP revised on 5/22/2022 titled Resident at risk for constipation related to decreased mobility, use/side effects of medication, and psychoactive medication, the CP indicated a goal for Resident 1 was for the resident to have a normal bowel movement at least once every three days through the review date. The CP also indicated staff interventions included monitoring the resident for medication side effects of constipation and keeping the physician informed of any problems and observe sign and symptoms of complications related to constipation which include small loose stools and fecal smearing. During a review of Resident 1's Intervention/Task flowsheet for December 2022, the flowsheet indicated Resident 1's bowel elimination from 12/10/2022 to 12/26/2022, documented as follows: 1. On 12/10/2022, the resident had one bowel movement which was medium in amount and constipated/hard in consistency. 2. From 12/11/2022 to12/16/2022, a total of six days, the resident had no bowel movements. 3. On 12/17/2022, the resident had two bowel movements, one which was small and putty-like in consistency and the second one was medium in amount and formed/normal in consistency. 4. On 12/18/2022, the resident had one bowel movement which was large and loose/diarrhea (a condition in which feces are discharged from the bowels frequently and in a liquid form) in consistency. 5. On 12/19/2022, the resident had no bowel movement. 6. On 12/20/2022, the resident had one bowel movement which was medium in amount and formed/normal in consistency. 7. From 12/21/2022 to 12/23/2022, a total of three days, the resident had no bowel movement. 8. On 12/24/2022, the resident had one bowel movement which was medium in amount and putty like in consistency. 9. On 12/25/2022, the resident had two bowel movements, one was large and loose/diarrhea in consistency and the second one was medium in size and putty like in consistency. During a review of Resident 1's change of condition (COC) progress note dated 12/26/2022, the progress note indicated Resident 1 was transferred to the GACH for shortness of breath. During a review of Resident 1's GACH history and physical (H/P), dated 12/26/2022, the H/P indicated Resident 1 was found to have fecal impaction with possible bowel obstruction requiring an admission to the GACH for further evaluation and treatment. During a review of Resident 1's GACH Radiology report, dated 12/30/2022, the report indicated Resident 1 had a large fecal material impacted in the dilated rectum (abnormally enlarged intestine) causing partial colonic obstruction. During a review of Resident 1's GACH progress note, dated 12/30/2022 and timed at 9:35 p.m., the note indicated digital dis-impaction was performed and multiple hard stool pieces were removed. During a review of Resident 1's GACH Medication Administration Record (MAR), the MAR indicated Resident 1 received a fleet mineral oil enema (a medication which lubricates and softens the stool to produce a bowel movement) on 12/26/2022, 12/31/2022, and 1/3/2023. During a review of Resident 1's physician orders, dated 1/3/2023, the physician orders indicated Resident 1 was readmitted to the facility. During an interview on 2/9/2023 at 11:55 a.m. with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated putty like bowel movement was not a normal consistency and must be reported to the charge nurse. During an interview on 2/9/2023 at 12:22 p.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated putty like consistency for bowel movements could mean the resident was constipated. During a review of Resident 1's MAR for the month of 12/2022, the MAR's documentation indicated from 12/10/2022-12/26/2022 (17 days) Resident 1 did not exhibit any side effects of Zyprexa such as constipation. During a concurrent interview and record review on 2/9/2022 at 12:27 p.m. of Resident 1's MAR for the month of 12/2022 with the DON, the DON confirmed the MAR indicated from 12/10/2022-12/26/2022 (17 days), the resident did not receive any doses of Dulcolax suppository (medication which stimulates a bowel movement and softens stools), fleet enemas, and/or milk of magnesia (medication which increases water in the intestines in order to induce bowel movements). During an interview on 2/9/2023 at 12:27 p.m. with the Director of Nursing (DON), the DON stated putty-like consistency bowel movements was not normal, but it could depend on the resident's bowel pattern. After the DON reviewed Resident 1's intervention/task flowsheet specific to bowel elimination, dated 12/2022, the DON stated Resident 1's bowel [NAME] was not normal and the licensed staff failed to monitor Resident 1 and identify signs and symptoms of constipation, provide interventions to prevent constipation, and inform the physician. The DON could not provide any documentation the licensed staff had informed the physician regarding Resident 1's abnormal bowel movements or pattern. The DON confirmed the facility's failure to monitor and provide interventions for constipation lead to the resident experiencing fecal impaction. During an interview on 2/9/2023 at 2:50 p.m. with the DON, the DON confirmed Resident 1's MAR from 12/10/2022-12/26/2022 (17 days) indicated the licensed staff documented Resident 1 did not exhibit the side effects of Zyprexa such as constipation. In a subsequent interview at 2:50 p.m., the DON confirmed Resident 1 was receiving Zyprexa which has the side effect of constipation and agreed Zyprexa could be the reason why Resident 1 was experiencing constipation. During an interview on 2/10/2023 at 11:03 a.m. with the Registered Pharmacist (RPH), the RPH confirmed constipation was a side effect of Zyprexa and should be monitored closely. The RPH stated if a resident was already experiencing constipation, the continued use of Zyprexa can worsen the constipation. During a review of the facility's policy and procedure (P/P), dated 9/2/2022 and titled, Use of Psychotropic Medication, the policy indicated the effects of the psychotropic medication on a resident's physical, mental and psychosocial well-being will be evaluated on an ongoing basis including nursing assessments and medication monitoring parameters.

Based on interview and record review, the facility failed to ensure a resident was free of verbal and physical abuse for one of four sampled residents (Resident 1). Resident 1, who was dependent on staff for most of his care, was verbally abused and treated roughly by a licensed vocational nurse (LVN 1) during care. This deficient practice resulted in Resident 1 feeling embarrassed, humiliated (to make someone feel ashamed or lose respect for himself or herself) and experienced pain during a rough care procedure, resulting in rectal bleeding due to LVN 1's aggressive rough handling during a dis-impaction (a manual removal of feces [stool], due to fecal impaction [a large, hard mass of stool that gets stuck so badly in your colon or rectum that you cannot be push out]) procedure on Resident 1. Findings: During a review of Resident 1's Admission Record (face sheet), the Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 8/24/19, the MDS indicated Resident 1 had the ability to understand and be understood by others. The MDS indicated Resident 1 required limited to extensive assistance with activities of daily living ([ADLs] every day care needs, such as grooming, toileting, bathing etc.), the MDS indicated Resident 1 used a wheelchair for mobility. During a review of Resident 1's care plan titled, Bowel Incontinence dated 4/5/19, the care plan indicated Resident 1 was at risk for constipation (infrequent bowel movements or difficult passage of stools) related to decreased mobility and the use of, including side effects of narcotic pain medication (oxycodone, a drug used to treat moderate to severe pain). During a review of Resident 1's Social Services (SS) note titled, Witness Interview Form dated 9/1/19, the SS note indicated the Social Services Director (SSD) and the Director of Nurses (DON) received a call from the Registered Nurse Supervisor (RN 1) regarding a potential allegation of abuse of Resident 1. During a review of Resident 1's SS note titled, Witness Interview Form dated 9/1/19 indicated the SSD interviewed Resident 1 and reported he (Resident 1) overheard LVN 1 say, Oh he wants me to go there and play with his[OBSCENITY] . Resident 1 stated LVN 1 directly told him, I don't want to work with you anymore. During a review of Resident 1's SS note titled, Witness Interview Form, dated 9/1/19, the SS note indicated the SSD met with witness Certified Nursing Assistant (CNA 1) and confirmed LVN 1's comments made towards Resident 1. The SS note indicated LVN 1 was suspended and the incident reported to the SSD and the DON. During a review of Resident 1's Social Services note titled, Witness Interview Form dated 9/1/19 indicated LVN 1 was suspended and the incident reported to the Administrator. During a review of Resident 1's Nursing Progress Note (NPN), titled Interdisciplinary Team (a group of staff who work together to share expertise, knowledge, and skills to impact resident's care) Notes, dated 9/3/19 and timed at 9:29 a.m., the Assistant Director of Nursing (ADON) indicated on the NPN that LVN 1 was asked to dis-impact Resident 1 and LVN 1 responded, I am not going to disimpact you (Resident 1) or play or touch your a--. During an interview on 9/4/19 at 3:50 p.m., Resident 1 stated LVN 1 could be loudly heard in the hallway saying, He just wants me to play with his[OBSCENITY] , Resident 1 stated LVN 1 continued to be angry and cursing at him in his room. Resident 1 stated CNA 1 was a witness to the verbal abuse and aggressive behavior towards him. Resident 1 stated, The LVN (LVN 1) was rough and hurt me during the procedure (fecal dis-impaction). Resident 1 stated it made him feel terrible, embarrassed and had pain. During an interview on 9/4/19 at 4:45 p.m., Resident 2 stated, LVN 1 has an uncontrolled personality, as he gets loud and jokes inappropriately. During a telephone interview on 9/11/19 at 2 p.m., LVN 1 stated, I did not curse at him referring to Resident 1, LVN 1 stated, He (Resident 1) doesn't listen, that is why things got heated. LVN 1 stated, I did the disimpaction to keep him calm and didn't see any blood, but the CNA (CNA 1) said there was blood. LVN 1 was asked if there had been any other incidents with Resident 1 or other residents. LVN 1 stated there was an incident when he was putting gauze on a resident's contracted hands but the resident kept yelling in my ear; it was a difficult situation. During a review of LVN 1's employee file document titled, Suspension Pending Investigation Form, dated 7/17/18, indicated a CNA reported that LVN 1 pointed his finger in the face of a resident and yelled at her to not take the gauze off that he just put on. During an interview on 9/11/19 at 3 p.m., CNA 1 stated he witnessed LVN 1 being aggressive and verbally abusive to Resident 1. CNA 1 stated he reported the incident to the charge nurse on 9/1/19 and will write a declaration in his own words of the events that took place. During an interview on 9/12/19 at 10:35 a.m., the SSD stated Resident 1 was reluctant to report the incident for fear of retaliation (the act of harming someone who had done or said something harmful to you). The SSD stated he encouraged Resident 1 to report and provided him assurance and support. The SSD stated he was the one who interviewed the parties involved. During an interview on 9/12/19 at 11 a.m., The Director of Staff Development (DSD) stated LVN 1 was removed from duty and suspended on 9/1/19. The DSD stated on 9/3/19, LVN 1 was permanently discharged from employment at the facility. The DSD stated re-education in-services was provided to staff on 9/5/19, for managing behaviors and reducing threat of abuse/neglect. During an interview on 9/12/19 at 11:15 a.m., Registered Nurse (RN 1) stated CNA 1 reported an incident involving Resident 1 and LVN 1. RN 1 stated she spoke with both Resident 1 and LVN 1, telling LVN 1 you have to behave and control yourself. RN 1 stated LVN 1 gets mad easily and needs to be reminded to control his temper. RN 1 stated when LVN 1 gets mad or frustrated, I would tell him to calm down and take a deep breath. RN 1 stated on 9/1/19 after interviewing CNA 1, Resident 1, and LVN 1, the DON and the SSD were notified and came to the facility at approximately 8:30 p.m. on 9/1/19 to investigate. During an interview on 9/12/19 at 12:45 p.m., the Administrator stated LVN 1's employee file had a previous suspension for a resident abuse allegation, dated 7/2018. The Administrator stated after the investigation of the incident with Resident 1, LVN 1 was let go from employment on 9/3/19. The Administrator stated a report would be submitted to the Licensing Board of Vocational Nurses. During an interview and review of a declaration on 9/12/19 at 1:15 p.m., written by CNA 1, indicated on 9/1/19, while assisting LVN 1 during the dis-impaction procedure for Resident 1, he asked LVN 1 Is that blood and LVN 1 replied, Yes, that's disgusting. LVN 1 stopped the procedure and walked out of the resident's room. CNA 1 stated Resident 1 was moaning in pain and asked LVN 1 to stop the dis-impaction procedure prior. During a review of the facility's policy and procedure (P/P) titled, Protection of Residents: Reducing the Threat of Abuse & Neglect, last revised on 1/21/19 indicated, each resident has the right to be free from abuse and residents must not be subjected to abuse by anyone. It is the P/P and practice of the facility that all residents will be protected from all types of abuse. During a review of the facility's P/P titled, Our Code of Conduct last revised 1/14/16 indicated all associates will perform their jobs based on ethical (relating to moral principles and pertaining to right and wrong conduct) standards, laws and regulations of Life Care policies and directives.

Based on observation, interview and record review, the facility failed to notify a physician when there was a change of condition (COC) on the night shift for over 24 hours for one of three sampled residents (Residents 1). Resident 1, who had a COC and was experiencing respiratory distress (shortness of breath (SOB)), decreased oxygen saturation (oxygen (O2) level in the bloodstream (normal reference range (NRR) is ,[DATE] percent (%) on room air)) and an elevated body temperature of 103.6 Fahrenheit ((F) NRR is ,[DATE] F) without the physician being notified (crossed referenced to F725). This deficient practice of not notifying the physician in a timely manner resulted in a delay in diagnosis, care, and treatment for [REDACTED]. Resident 1's COC continued to worsen and required a 911 emergency service being called. Resident 1 was transferred to general acute care hospital (GACH) and was pronounced deceased at the hospital. Findings: During a concurrent observation and interview on [DATE] at 6:39 a.m., while in the facility's yellow zone (suspected COVID-19 (highly contagious [MEDICAL CONDITION] infection that affects breathing)) unit there was no staff seen until a registered nurse (RN 1) appeared from a room. RN 1 stated she had to leave her medication cart to run to help a resident who was yelling for assistance. RN 1 stated she worked alone on the yellow zone all night (11 p.m.-7 a.m.) with 22 residents, including two residents who were endorsed from the evening shift (3 p.m.-11 p.m.) with a COC experiencing respiratory distress. RN 1 stated she was unable to conduct assessments or provide any other care to the residents due to not having any staff help. During a concurrent interview and observation on [DATE] at 6:45 a.m., a certified nursing assistant (CNA 1) was observed on the yellow zone entering a room where a call light was activated. CNA 1 stated she could not provide care to the residents on the yellow zone because she provided care to all the residents on Stations 1A, B and C, and her assignment for both the green (non-COVID unit) and yellow zone was just too much for one person. CNA 1 stated the facility had been short staff for a few weeks, especially of CNAs on the night shift. CNA 1 stated, It was not fair to the residents they did not get the care that they needed. During a review of Resident 1's Admission Record, indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. According to the Resident 1's Admission Record, Resident 1 had a full code status (to implement all life saving measures). During a review of Resident 1's Admission and Discharge record, the record indicated Resident 1 was transferred to the GACH emergency room for evaluation and treatment related to pneumonia (an [MEDICAL CONDITION] condition of the lungs usually caused by infection with viruses or bacteria), coffee ground emesis (indicative of vomiting blood), and a fever (elevated body temperature) on [DATE] and returned to the facility [DATE]. During a review of Resident 1's Minimum Data Set (MDS), an assessment and care screening tool, dated [DATE], the MDS indicated Resident 1 had unclear speech, rarely had the ability to understand or make herself understood, and was severely impaired in cognitive (thought process) skills for daily decision-making. The MDS indicated Resident 1 was incontinent (inability to control) of bowel and bladder and was totally dependent in all activities of daily living ((ADLs)) such as grooming, toileting, bathing etc.). The MDS indicated Resident 1 had impairment of both upper and lower extremities. During a review of Resident 1's Nurse's Progress Note (NPN), dated [DATE] and timed at 8:58 p.m., the NPN indicated Resident 1 was readmitted to the facility and placed on the yellow zone. The NPN indicated Resident 1 was awake and alert, able to follow instructions and required total care. The NPN indicated Resident 1 had no SOB, cough, or fever upon admission. During a review of Resident 1's Order Summary Report, dated [DATE], the Summary Report indicated Resident 1 had an order to be readmitted to the yellow zone due to possible COVID-19 exposure and the physician's orders [REDACTED]. 1. Enteral feeding (nutrition taken through a tube that goes directly to the stomach) two times a day for 12 hours with formula and 200 cubic centimeters ((cc) a unit of measurement) water every shift. 2. [MEDICATION NAME] (an antibiotic) tablet 250 mg milligram ((mg) unit of measurement) one tablet every day by mouth for pneumonia. 3. [MEDICATION NAME] (Tylenol/pain reliever (reduces fever)) 325 mg, two (2) tablets by mouth every four hours as needed for temperature above 101 degrees Fahrenheit ((F) a temperature scale) (NRR= 97XXX,[DATE].0 F), or for mild pain. During a review of Resident 1's care plan, dated [DATE] and titled, Resident at Risk for COVID-19 pandemic, roommate tested positive for COVID-19, resident at risk for respiratory distress related to pneumonia [DATE]. The care plan indicated the following staff approaches: 1. Assess for sign and symptoms (S/S) of COVID-19 and report to MD (physician) immediately; SOB, irregular respirations, coughing, fever, weakness, nausea vomiting (throwing up), sore throat, runny nose, and diarrhea (frequent loose stool). 2. Isolate resident immediately, provide COVID testing/screening as needed, provide medications and breathing treatment as ordered; Oxygen at 4 liter/minute continuously via NC, document every shift; Oxygen saturation rates every 4 hours for SOB/congestion; [MEDICATION NAME]-DM liquid every 6 hours for cough and [MEDICATION NAME] tablet at bedtime for right upper lobe pneumonia. During a review of Resident 1's NPN, dated [DATE] and timed at 12 a.m. (midnight), the NPN indicated Resident 1 received two tablets of Tylenol 325 mg for a temperature of 101.4 F. During a review of Resident 1's NPN, dated [DATE] and timed at 3:49 a.m., the NPN indicated at 12:30 a.m. Resident 1's temperature was 98.7 F and the O2 saturation was 97%. During a review of Resident 1's NPN, dated [DATE] and timed at 6:50 p.m., the NPN indicated Resident 1 was administered two tablets of Tylenol 325 mg for mild discomfort manifested by restlessness (inability to rest or relax). The NPN did not indicate Resident 1's O2 saturation was being monitored or the physician was notified of Resident 1's change of condition (COC) of restlessness. During a review of Resident 1's NPN, there was no documented evidence of Resident 1's O2 saturation being monitored or Resident 1's physician being notified of Resident 1's change of condition (COC) including restlessness. During a review of an online undated article, by MedlinePlus and titled, Breathing Problems, the article indicated when a patient is ill, the process of breathing can become difficult at times. This is often referred to as shortness of breath/ SOB or air hunger. Breathing difficulty can create a decrease in the oxygen level in the body and signs of SOB may include restless or anxious feeling. During a review of Resident 1's physician orders, dated [DATE], the physician's orders [REDACTED]. During a review of Resident 1's NPN, dated [DATE] and timed at 8:15 a.m., the NPN indicated Tylenol was administered to Resident 1 for unspecified mild pain. There was no documented evidence on the NPN of Resident 1's O2 saturation or vital signs (measurements which includes body temperature, blood pressure, pulse (heart rate), and respiratory rate) being assessed and the physician notified. During a review of Resident 1's NPN, dated [DATE] and timed at 11:24 p.m., the NPN indicated Resident 1 was monitored throughout the shift to maintain a O2 saturation due to the report received by the day shift of a low O2 saturation. The NPN indicated Resident 1 had SOB after he had removed oxygen. The NPN indicated Resident 1 was receiving O2 and received [MEDICATION NAME] every 6 hours when necessary for SOB and wheezing was noted. The NPN indicated Resident 1's O2 saturation was at 92% when rechecked. Resident 1 was placed in high fowlers (semi-sitting position ,[DATE] degrees) to help mild breathlessness. The NPN indicated Resident 1's COC was endorsed to the NOC (night) shift staff to continue to monitor Resident 1's O2 saturation. There was no documentation on the NPNs of Resident 1's O2 saturation or vital signs being monitor and the physician notified. During a review of Resident 1's NPN, dated [DATE] and timed at 2:43 a.m., the NPN indicated at approximately 1:30 a.m., Resident 1's breathing became more labored and the resident was thrashing (move in a violent or convulsive (frantic/spasmodic)) around in bed. According to NPN, a breathing treatment was given to Resident 1 without improvement with the inability to obtain oxygen saturation level or blood pressure on Resident 1. Tylenol was given to Resident 1 for an elevated temperature of 103.6. The NPN indicated Resident 1's color was pale with slight bluish color around the resident's lips. The physician was called and ordered to transfer Resident 1 to the GACH via 911. During a review of a Prehospital Care Report (paramedics sheet), dated [DATE] and timed at 2:15 a.m., the report indicated the paramedics were called for possible [MEDICAL CONDITION]. The resident had difficulty in breathing, was non-alert, pale, starting to turn blue, shallow rapid respirations with rhonchi (rattling, continuous and low- pitched breath sounds). The report indicated the nurse stated the resident had been like that for 45 minutes. The resident's initial blood pressure (B/P) was low, a 12- lead electrocardiogram ((EKG) monitors electrical activity of the heart) was done and the resident's breathing was slowed. The resident was moved to the gurney and he stopped breathing. CPR (cardiopulmonary resuscitation (procedure involving repeated chest compression in attempt to restore blood circulation and breathing))was started with medications given; three (3) [MEDICATION NAME] of [MEDICATION NAME] (an [MEDICATION NAME] hormone which helps regulates visceral functions (internal organs e.g., respirations, chest and stomach) and chest compressions started. The paramedic's report indicated Resident 1 was witnessed in full arrest (sudden, unexpected loss of heart function, breathing and consciousness) and was transferred to the GACH. During a review of the GACH emergency room (ER) records, dated [DATE], the ER records indicated Resident 1 arrived via ambulance at 2:58 a.m. on [DATE] in full arrest (no heart activity). The ER chief complaint indicated Resident 1 presented in cardiopulmonary arrest (sudden, unexpected loss of heart function, breathing, and consciousness) Resident 1, who had Dow[DIAGNOSES REDACTED] was a resident from a nursing home. Resident 1 apparently had a recent exposure to COVID 19 and the current test was pending. Paramedics found the resident (Resident 1) with agonal respiration (gasping breaths; when one is struggling to breathe because [MEDICAL CONDITION] or other serious medical emergency) with thready pulses (rapid pulse) and blood pressure of 60 systolic (top number) of blood pressure; millimeters of mercury (mmHg) normal reference range (NRR) is ,[DATE] mmHg). The ER note indicated once the paramedics put the resident in the ambulance the resident became pulseless. Resident 1 received three doses of [MEDICATION NAME], but the resident continued to be in PEA (pulseless electrical activity (unresponsiveness and impalpable pulse)). Resident 1 was intubated (an insertion of a tube into the trachea (windpipe) to provide air into the lungs) for ventilation) in the ER and two rounds each of [MEDICATION NAME], sodium [MEDICATION NAME] (a salt used to treat metabolic acidosis (too much acid accumulated in the body)) and calcium chloride (a mineral used to treat abnormally low levels of calcium causing muscle spasms) unsuccessfully resuscitation. Resident 1 was pronounced deceased at 3:12 a.m. on [DATE]. During an interview with RN 1 on [DATE] at 10:20 p.m., RN 1 stated on [DATE] she did not see Resident 1 from 1 a.m., to approximately 3:30 a.m., due to another resident (Resident 2) also having respiratory problems at the same time. RN 1 stated she was the only staff on the yellow zone, when Resident 1's condition changed. There was no available staff to assist her with providing care or monitoring Resident 1. RN 1 stated the facility did not have a Director of Nursing and/or an Administrator. During a review of Resident 1's death certificate, the certificate indicated the resident expired on [DATE] at 3:12 a.m. and the cause of death was listed as [MEDICAL CONDITION] (oxygen deficiency where oxygen fails to reach body tissues) and [MEDICAL CONDITIONS] (buildup of a waxy plaque on the inside of blood vessels). During a subsequent interview with RN 1 on [DATE] at 6:59 a.m., RN 1 stated on [DATE] and [DATE], she was the only staff on the yellow zone caring for 22 residents. RN 1 stated there were at least 60 residents on the green zone with one charge nurse and one CNA. RN 1 stated once Resident 1 went into severe respiratory distress there was no one to call for assistance, there was no other staff there to call. RN 1 stated when Resident 1 had an elevated temperature of 101.4 degrees F, she administered Tylenol as ordered. Resident 1 was breathing on his own. RN 1 stated Resident 1 was receiving oxygen via nasal cannula ((N/C) though the nostrils) but was not able to verbalize due to his decreased cognition. RN 1 stated she did not notify the primary care physician (PCP) of Resident 1's elevated temperature because there was an order to treat the temperature. RN 1 stated when she went to check Resident 1, he had labored breathing (an abnormal respiration characterized by increased effort to breathe, while using other muscles or nasal flaring) and was thrashing about with his eyes wide open. RN 1 stated she was unable to check the blood pressure due to Resident 1 thrashing too much in bed and that point she knew it was something she could not handle, and she called 911. Resident 1 was transferred to the GACH. During a review of the facility's undated policy and procedure (P/P) titled, Changes in Status, the P/P indicated notification of the resident's physician and representative would be done for any change of condition, which included elevated temperature, shortness of breath and other medical changes.

Based on interview and record review, the facility failed to follow its policy, a resident plan of care, and physician orders [REDACTED]. Resident 1, who was diabetic (high blood sugar), was not provided with blood sugar level monitoring before meals and at bedtime and was not provided with Insulin (medication used to control high blood sugar levels) administration as ordered. These deficient practices resulted in Resident 1 having a hyperglycemic (high levels of blood sugar in the blood) episode, in which the resident became confused and disoriented requiring a transfer to a general acute care hospital (GACH) for further evaluation and treatment. Findings: A review of Resident 1's Nursing Progress Note, dated 9/27/18 and timed at 12 p.m., indicated Resident 1's family member (FM 1) called the facility and spoke to Licensed Vocational Nurse 1 (LVN 1) asking for Resident1's blood sugar check result. The note indicated LVN 1 discovered that there was no record testing/sliding scale in Resident 1's Medication Administration Record (MAR). FM 1 acknowledged that Resident 1 should have checks and on Insulin Sliding Scale. LVN 1 noted that there was a physician's orders [REDACTED]. LVN 1 administered 14 units of insulin per sliding scale at 12 noon. Blood Sugar was rechecked again 45 minutes later which read again HIGH. Resident 1 was transferred to the general acute care hospital for being confused and disoriented via 911 emergency transport. A review of Resident 1's Admission Sheet indicated the resident was admitted to the facility on [DATE] from a general acute care hospital (GACH). Resident 1's [DIAGNOSES REDACTED].), and [MEDICAL CONDITION] (condition that affect a person's memory). A review of Resident 1's Minimum Data Set (MDS), an assessment and care-screening tool, dated 9/27/18, indicated Resident 1 required an extensive assistance with bed mobility, transferring, dressing, toilet use, and personal hygiene. According to the MDS, Resident 1 received Insulin injections. A review of a physician's orders [REDACTED]. following blood sugar (BS) levels: 70 - 149 mg/dL = no insulin coverage 150 -199 mg/dL = three units of insulin 200 -249 mg/dL = four units of insulin 250 -299 mg/dL = seven units of insulin 300 -349 mg/dL = ten units of insulin 350 -399 mg/dL = twelve units of insulin BS over 400 mg/dL = fourteen units of insulin and call the physician A review of Nursing Progress Note titled, Summary of Findings, dated 9/25/18 and timed at 7:57 a.m., indicated Resident 1 was alert and verbally responsive with periods of confusion. A review of a Nursing Progress Note, dated 9/26/18 and timed at 3:29 p.m., indicated Resident 1 was alert and verbally responsive with confusion and disorientation. A review of a physician's orders [REDACTED]. The order indicated to hold the Insulin if Resident 1's blood sugar was less than 150 mg/dl. The order indicated to administer 70/30 Insulin 10 units subcutaneously BID (twice a day) for elevated blood sugar levels. A review of a physician's orders [REDACTED]. A review of Resident 1's Medication Administration Record (MAR), for the month of (MONTH) (YEAR), indicated there was an order, dated 9/24/18, that Resident 1 was to receive blood sugar monitoring with Insulin Sliding Scale at 6:30 a.m., 11:30 a.m., 4:30 p.m., and 9 p.m. The MAR indicated Resident 1 received 14 units of Insulin and eight (8) units of 70/30 Insulin subcutaneously for a high blood sugar reading on 9/27/18 at 2:10 p.m. The MAR indicated Resident 1's blood sugar was not checked on the following dates and times: 1. On 9/24/18 at 4:30 p.m. and 9 p.m. 2. On 9/25/18 at 6:30 a.m., 11:30 a.m., 4:30 p.m., and 9 p.m. 3. On 9/26/18 at 6:30 a.m., 11:30 a.m., 4:30 p.m., and 9 p.m. 4. On 9/27/18 at 6:30 a.m. A review of Resident 1's care plan, dated 9/27/18, titled, Blood Sugar Sliding Scale Not Done 9/24, 9/25, 9/26, 9/27/18 (a.m.) as Ordered on Admission, indicated the concern/problem was discovered on 9/27/18 at approximately 12:30 p.m. and Resident 1's admission orders [REDACTED]. A review of a Nursing Progress Note titled, Change of Condition, dated 9/27/18 and timed at 3:48 p.m., indicated at approximately 1 p.m. on 9/27/18, Licensed Vocational Nurse 1 (LVN 1) checked Resident 1's blood sugar. The note indicated the blood sugar level registered as HIGH and [MEDICATION NAME] Regular (R) insulin 14 units was given per sliding scale. The note indicated Resident 1 was alert by name but had increased confusion and restlessness, and showed episodes of spinning her head. At 1:30 p.m., on the same day, Resident 1's blood sugar was rechecked and still registered HIGH. According to the note, Resident 1 continued to remain anxious (feeling of unease, excessive worry). A review of a Nursing Progress Note titled, Summary of Findings, dated 9/27/18 and timed at 4:05 p.m., indicated Resident 1 appeared sleepy, oriented to person and place with confusion at the start of the shift. The note indicated Resident 1's family member (FM 1) asked for the resident's blood sugar level and LVN 1 reported it as HIGH, with a maximum dosage of [MEDICATION NAME] R 14 units administered at 12 noon per sliding scale. The note indicated LVN 1 rechecked Resident 1's blood sugar and the results read HIGH and the physician was notified. According to the note, LVN 1 gave 10 units of 70/30 [MEDICATION NAME] Insulin per physician's orders [REDACTED]. Resident 1 was transferred to the GACH via 911 related to change in level of consciousness. A review of an untimed paramedic run sheet, dated 9/27/18, and titled, Narrative, indicated Resident 1 was not acting within normal limits per facility staff. The paramedic run sheet indicated Resident 1 was alert and oriented to person and place. According to the paramedic run sheet, a Fire Medic checked Resident 1's blood glucose (sugar) level and displayed a reading of above 600 mg/dL. A review of Resident 1's Prehospital Care Report Summary, from the Los Angeles County Fire Department, dated 9/27/18 and untimed, indicated Resident1's blood glucose was high and facility staff were unable to bring Resident 1's blood sugar levels to normal levels with Insulin. A review of the GACH's Emergency Department (ED) note, dated 9/27/18 and timed at 14:56 (2:56 p.m.), indicated Resident 1 presented with altered mental status and [MEDICAL CONDITION]. The ED note indicated emergency medical services (EMS) were called to the skilled nursing facility by FM 1 because Resident 1 appeared comatose (state of unconsciousness). The ED note indicated, per EMS, Resident 1 was not administered Insulin for three (3) days and the resident's blood sugar measured approximately 600 mg/dL. The ED note indicated Resident 1 received intravenous ((IV) though a vein) [MEDICATION NAME]-Tazobactam ((antibiotic) medication used to treat bacterial infections), IV fluids, and placed on an Insulin drip (continuous infusion of IV Insulin used to treat high glucose levels). The ED note indicated Resident 1 was admitted to the GACH with a blood sugar level of 682 mg/dL, which decreased to 147 mg/dL at 22:51 (10:51 p.m.). A review of the GACH's History and Physical, dated 9/27/18 and timed at 19:01 (7:01 p.m.), indicated Resident 1 was diagnosed and admitted to the GACH for diabetic ketoacidosis ((DKA) a life-threatening condition in which there is a buildup of acids in your blood that happens when your blood sugar is too high for too long, causing coma or death), and acute [MEDICAL CONDITION] (a sudden loss of kidney function). The note indicated Resident 1 was lethargic with tachypnea (elevated respiratory rate) upon examination. A review of the GACH's Discharge Summary, dated 9/30/18, indicated Resident 1 was to be discharged home with Hospice (end of life care that focuses on a person's last six months of life or less). On 10/3/18, at 10:45 a.m., during an interview, Registered Nurse 1 (RN 1) stated she was responsible for printing out Resident 1's MAR and was getting familiarized with the admission process of residents. RN 1 stated that during Resident 1's admission process of entering the physician's orders [REDACTED]. RN 1 verified Resident 1's Sliding Scale order was not followed since 9/24/18 because it was not recorded on the MAR. RN 1 stated the licensed staff were not aware of the discrepancy until FM 1 called for Resident 1's blood sugar results on 9/27/18 at approximately 12 p.m. RN 1 stated she was responsible for printing out the MAR, however the licensed nurses had to exercise the six rights of medication administration (right patient, right medication, right route, right frequency, right time, and right diagnosis) before giving medications. RN 1 stated licensed nurses administered medications to Resident 1 without comparing the MAR with the physician order. RN 1 added, before giving medications to Resident 1, the licensed nurses needed to check the physician orders. On 10/3/18 at 11a.m., during an interview, LVN 1 stated before giving medications she was to exercise the six rights. LVN 1 stated she only checked the residents' blood sugar levels when FM 1 called to tell her that Resident 1 needed to have her blood sugar checks before meals and at bedtime. LVN 1 stated she failed to compare the physician's orders [REDACTED]. LVN 1 stated that Resident 1 looked very tired at the start of her shift on 9/27/18. LVN 1 added the other shifts who were taking care of Resident 1 also did not check the resident's blood sugar levels as well. On 10/3/18 at 11:47 a.m., during an interview, LVN 2 stated before giving medication to the residents, she checked the MAR, allergies [REDACTED]. LVN 2 stated she gave Resident 1 oral (by mouth) medications without [MEDICATION NAME] the six rights of medication administration. LVN 2 stated she failed to compare the MAR with the physician's orders [REDACTED]. On 10/3/18 at 12:05 p.m., during an interview, Registered Nurse 2 (RN 2) stated before giving medications, the licensed nurses were to check the MAR with the physician's orders [REDACTED]. [REDACTED]. On 10/3/18 at 12:15 p.m., during an interview, the Director of Staff Development (DSD) stated any change of condition such as confusion, pain any complaints needed to be reported to the charge nurse or RN supervisor. The DSD stated licensed nurses were to input admission orders [REDACTED]. The DSD stated the reason Resident 1 did not get her blood sugar levels checked was because the licensed nurses failed to compare the MAR with the physician's orders [REDACTED]. On 10/3/18 at 1:05 p.m., during an interview, RN 3 stated the reason LVN 1 and other licensed nurse failed to check Resident 1's blood sugar levels was because RN 1 did not print out the physician's orders [REDACTED]. On 10/3/18 at 3:30 p.m., during an interview, the Executive Director stated that the licensed nurses failed to follow the facility policy and protocol in regards to medication administration for Resident 1. A review of the facility's policy titled, Diabetic Management Protocol, dated 11/16/17, indicated upon admission, the nurse obtains orders for the frequency of finger stick blood glucose (FSBG) checks along with other pertinent labs, as indicated for residents with [DIAGNOSES REDACTED]. A review of the facility's policy titled, General Dose Preparation and Medication Administration, dated 1/1/13, indicated the facility staff were to confirm that the Medication Administration Record reflects the most recent medication order.

Based on observation, interview, and record review, the facility failed to follow the recommendations by the Los Angeles County Department of Public Health Acute Communicable Disease Control (LAC DPH [DIAGNOSES REDACTED]) and Environmental Health (EH), after two confirmed cases of Legionnaire ' s disease (caused by a type of bacteria called Legionella), to help prevent the development and transmission of Legionella. These deficient practices placed all 107 residents in the facility at risk for harm from exposure to Legionella. The facility failed to provide: 1. Point of use filters on water faucets to prevent exposure to Legionella when there was one of 107residents (Resident 1), who was alert, oriented and was fully aware that he was not supposed to use the water from the faucet without point of use filter for washing his face and brushing his teeth but chose to use it anyway (non-compliant). 2. Follow manufacturer's recommendations on the proper care and disinfection of the shower filters. 3. Ensure that adequate bottled water for drinking was provided to the residents according to the registered dietitian's recommendation when consumption of potable water from the faucet was restricted. The facility also failed to attempt to investigate, identify, and eliminate potential sources of Legionella by having collection of water on the floor coming from draining pipes in the residents' patio, water leaks in residents ' shower rooms, broken toilet with potential for exposure to aerosolized particles emitted from the toilet when flushed. On [DATE] at 6:50 p.m., the facility administrator and director of nursing were verbally informed of an Immediate Jeopardy (IJ) regarding failure to establish and implement an effective infection control program to prevent the development and transmission of Legionnaire's disease and placing all of the residents in the facility at risk. On [DATE] at 5:25 p.m., the facility administrator was notified that the IJ was corrected after verified compliance with infection control. The facility installed filters to all water faucets in the residents' rooms and the kitchen, followed manufacturer's guidelines on the proper care and disinfection of the shower filters and provided in-services to the staff, purchased adequate bottled water for the residents to drink before and during installation of the filters, the facility installed toilet lids to all the toilets, and hired a plumber to inspect the facility's external and internal environment to identify and repair water leakage. Findings: According to <http://www.cdc.gov/legionella/about/causes-transmission.html> last update [DATE], indicated Legionella bacteria are found naturally in the environment, usually in water. The bacteria grow best in warm water, like the kind found in hot tubs, cooling towers, hot water tanks, large plumbing systems, and decorative fountains. People get Legionnaire's disease when they breathe in a mist or vapor (small droplets of water in the air) containing the bacteria. One example might be from breathing in droplets sprayed from a hot tub that has not been properly cleaned and disinfected. The key to preventing [DIAGNOSES REDACTED] is maintenance of the water systems in which Legionella grow including drinking water systems. Most people with Legionnaire's disease will have pneumonia (lung infection) since the Legionella bacteria grow and thrive in the lungs. An e-mail from the Acute Communicable Disease Control, dated [DATE] at 2:31 p.m., indicated the confirmation of two cases of Legionella. Case #1 was a [AGE] year old male admitted to the skilled nursing facility (SNF) on [DATE] and admitted to the hospital on [DATE] with onset of symptoms on [DATE]. Urine [MEDICATION NAME] was positive on admission to the hospital and chest x-ray on [DATE] showed infiltrates (substance other than air that fills the lungs). The resident expired [DATE]. Case #2 was a [AGE] year old female admitted to the SNF from [DATE] to [DATE] and [DATE] to current date with onset of symptoms [DATE] per chest x-ray performed in SNF. The resident was admitted to the hospital on [DATE] and returned to SNF on [DATE]. 1. A review of Resident 1's admission records indicated he was originally admitted to the facility on [DATE] and readmitted from the acute hospital on [DATE] with [DIAGNOSES REDACTED]. During a tour of the facility on [DATE] at 12:20 p. m., in the presence of the administrator, running water from the faucet of the hand-washing sink in the bathroom in room [ROOM NUMBER]-C was heard. Resident 1 was in the bathroom and using the water from the hand-washing sink in the bathroom to wash his face. During a subsequent interview, at the time of observation, Resident 1 stated he was aware he was not supposed to use the water from the sink to wash his face and that he had been provided with bottled water from which he drinks. Resident 1was asked which water did he use when brushing his teeth and he stated he used either the water from the sink or the bottled water. The resident stated he was fully aware that he was not supposed to drink the water from the faucet even though he sometimes used the water for washing his face. There was an e-mail sent by the LAC DPH [DIAGNOSES REDACTED] on [DATE] at 10:36 am, notifying the Department that [DIAGNOSES REDACTED] received reports of two cases of [DIAGNOSES REDACTED] from a skilled nursing facility (SNF). A review of LAC DPH [DIAGNOSES REDACTED] recommendation established on [DATE], to help prevent the development and transmission of Legionella was for the facility to ensure provision of: 1. Filters at shower and water faucet fixtures to prevent exposure to Legionella 2. Filters that were installed according to the manufacturer's guidelines and, 3. Potable water and ice only from faucets/water dispenser/ice machines with appropriate filter in place. Otherwise, the consumption of bottled water was to continue. During interviews with the administrator and the maintenance staff on [DATE] at 3:40 p.m., they both stated that filters were only installed on the shower heads in the facility bathrooms and that filters were not installed at any of the plumbing fixtures in the residents' restrooms. 2. On [DATE] at 12:15 p.m., during an interview, the quality assurance/acting director of staff development stated the LAC DPH [DIAGNOSES REDACTED] recommended filters to be installed in the showers on [DATE]. She stated the facility installed the recommended filters on all five showers on Saturday, [DATE], and the residents had resumed showers. A review of the manufacturer's use and care of the disposable shower head filter indicated It is designed to be used for a maximum of one calendar month (31 days) following initial connection. Where possible, the filter should be stored after use in an upright position at a level even or above that of the shower supply pipe that exits the wall. In between uses, the filter should not be stored upside down at the end of a shower hose or placed on the floor, in a basin or in a bath. It incorporates an effective [MEDICATION NAME] compound (mixture of substances that kills bacteria) to minimize the risk of inadvertent retrograde (backward) contamination. The extent of any contamination on the filter housing will depend upon local environmental and hygiene factors. The [MEDICATION NAME] compound does not replace the requirement for periodic surface disinfection of the filter's external housing and quick connect adaptors, which may be disinfected using agents containing [MEDICATION NAME] Alcohol, Quaternary Ammonium Compounds, [MEDICATION NAME] Ammonium Chlorides, [MEDICATION NAME] and non-ionic surfactants. Periodic wiping or spraying of these agents onto the filter housing and housing outlet is appropriate as part of a regimen that conforms to local protocols and does not affect filter integrity. On [DATE] at 2:15 p.m., during an observation of Shower room [ROOM NUMBER], the maintenance director retrieved the shower head that was positioned horizontally on top of the grab bar and demonstrated how to detach and attach the filter to the hose that was connected to the water supply pipe. The water supply pipe was located approximately six feet high from the wall. He stated the shower head was practically the filter. After the demonstration, the maintenance director placed the shower head back on the parallel grab bar horizontally. On [DATE] at 4 p.m., during an interview with the maintenance director, he stated there was no cleaning required and no in-service given regarding cleaning because the shower filters were disposable. When asked if he had read the manufacturer ' s recommendation on the use and care of the disposable showerhead filter, the maintenance director did not make a comment. On [DATE] at 4:14 p.m., in the presence of the registered nurse supervisor (RN 1), Shower room [ROOM NUMBER] was inspected. When asked to state where the shower heads were located, RN 1 stated, (Shower Head 1) Right now, it is on the floor. (Shower Head 2) The shower head is on the seat and is on right now. The seat was observed attached to the wall and was folded against the wall and Shower Head 2 was tucked in between the seat and the wall with the shower head upside down at the end of the hose. Shower Head 2 was observed constantly dripping. When asked how high the water supply pipe was, RN 1 stated, About six feet. RN 1 stated showers were given to the residents by the CNAs on the day shift (7 am to 3 pm shift). On [DATE] at 4:20 p.m., during an interview, the certified nursing assistant (CNA 1), who regularly worked the 7 am to 3 pm shift, stated she was not given an in-service regarding the care of the new shower filters. On [DATE] at 4:45 p.m., during an interview, when asked the reason why the CNAs were not given in-service on the care and use of the new shower filters, the maintenance director stated, That's the way it has been set-up; housekeepers are given in-services and not the CNAs. 3. On [DATE] at 12 p.m., residents' bedsides tables in Rooms 40, 47, 49 and 51 were observed without bottled water. A review of the facility's census indicated the following: On [DATE], there were 110 residents, On [DATE], 110 residents, On [DATE], 110 residents, On [DATE], 109 residents, On [DATE], 110 residents, On [DATE], 109 residents, On [DATE], 111 residents, On [DATE], 111 residents, On [DATE], 109 residents, On [DATE], 109 residents, On [DATE], 107 residents, On [DATE], 109 residents, On [DATE], 109 residents, On [DATE], 108 residents, On [DATE], 107 residents, On [DATE], 106 residents, On [DATE], 105 residents, On [DATE], 106 residents, On [DATE], 107 residents, On [DATE], 107 residents, Adding the numbers of the residents from [DATE] to [DATE], the total number of residents were 2,169 residents. On [DATE] at 5:50 p.m., a review of the facility's invoices indicated there were four purchase invoices for water bottles. 1. On [DATE], the facility purchased 18 cases of 35 (500 milliliters) bottles of water (630 bottles). 2. On [DATE], the facility purchased 36 cases of 35 (500 milliliter) bottles of water (1260 bottles). 3. On [DATE], the facility purchased 42 cases of 24 (500 milliliters) bottles of water (1008 bottles) 4. On [DATE], the facility purchased 45 cases of 24 (500 milliliters) bottles of water (1080 bottles). The facility purchased a total of 3978 bottles of water from [DATE] to [DATE]. The provision of bottled water for drinking started on [DATE] at 1:30 p.m. According to the facility's census, the facility should have purchased 6183 bottles of water to have enough water supply at the rate of one bottled water per resident per shift, to cover for 2 shifts (evening and night) on [DATE], three shifts (day, evening, and night) and each day from [DATE] to [DATE] and one shift (day) for [DATE]. The facility was short of 2,205 bottles of water. On [DATE] at 9:30 p.m., during an interview, the facility's administrator stated when the water supply for drinking has been changed on [DATE]; she called the facility's registered dietitian for consultation. The administrator stated according to the dietitian, the facility should provide 3 bottles of water per day (one bottle per shift). The administrator stated there was nothing in writing; it was just a verbal consultation. A review of an undated note from the registered dietitian (RD) titled, Bottled Water Distribution per Day indicated, to distribute 1 bottle of 12.6 ounces/500 milliliter (ml) of water between meals three times a day. The total water distributed per person, per day was three bottled water (1500ml). 4. During an interview with Infection Control Specialists 1 and 2 on [DATE] at 12:30 pm, Infection Control Specialist 2 confirmed the Acute Communicable Disease Unit and the Environmental Health Unit of the Public Health Department investigated the Legionella outbreak at the facility on [DATE]. When asked what measures were taken to prevent the residents from exposure to Legionella, Infection Control Specialist 1 stated they followed the guidelines provided by Public Health and they were waiting for further instructions from Public Health. When asked if the facility infection control committee conducted a meeting to discuss the Legionella outbreak and made plans to investigate, control, and prevent exposure to Legionella and if she could provide documentation, Infection Control Specialist 1 stated there were no meetings or plans other than the recommendations provided by Public Health. a. On [DATE] at 1:40 pm, during a tour of the facility, water was dripping through drains onto the ground and forming collection of water in the residents' open patio and by the sliding doors of Rooms: 40; 42; 46; and 10. room [ROOM NUMBER] had 2 inches gap in the sliding door and did not close completely. The ceiling in room [ROOM NUMBER] had brown spots. The walls in room [ROOM NUMBER] Bed B and room [ROOM NUMBER] Bed C were peeling. During a concurrent interview with the maintenance director, he stated room [ROOM NUMBER] had rain damage and was repaired. He was not able to tell when the repair took place. b. On [DATE] at 2:40 pm, during a tour of Shower room [ROOM NUMBER], there was a single toilet observed in the room. When the toilet was flushed, the water splashed and observed a moderate amount of brown liquid leaked from the base of the toilet. During a concurrent interview with the maintenance director, he stated the toilet broke that day, [DATE]. c. On [DATE] at 3:30 p.m., during the observation of Shower room [ROOM NUMBER], in the presence of the maintenance director, water was observed leaking from the drain pipe that extended from the wall opposite the shower area, and hot water faucet above the leaking drain in the area where the whirlpool used to be installed. The water that was leaking from both drain pipes and hot water faucet were draining into a floor sink that had accumulation of dirt and black and brown colored debris that had clogged portion of the floor sink, but enough to let water through. On [DATE] at 4:40 pm, during an interview with Infection Control Specialist 1, she was asked if the facility took measures, while the Legionella outbreak was being investigated, to prevent residents from exposure to aerosolized particles in the water when flushing the toilet by covering the toilet with toilet lids, she stated no. According to the Control of Communicable Disease Manual, 18th edition, David L. Heyman, MD, Editor [DIAGNOSES REDACTED] Reservoir-Primarily [MEDICATION NAME] Mode of transmission: Airborne (i.e. inhalation of water spray) and other modes are possible including aspiration of water. On [DATE] at 9:10 pm, during an interview with the administrator, she stated the facility toilets did not have toilet lids. During an interview with the facility administrator on [DATE] at 9:15 pm, when asked about the leaks in the shower rooms and outside of residents' rooms, she stated she was awaiting recommendations from Environmental Health. A review of the policy and procedure, dated [DATE], titled Scope of Infection Control Program indicated the infection control program addresses detection, prevention and control of infection among the residents.