Every finding on record at Sunnyside Nursing Center

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) who had a history of Parkinson's Disease (a slow, progressive brain disorder that affects movement and the nervous system), Parkinson's medications including Amantadine oral capsule 100 milligrams (mg a unit of measure of weight), Entacapone oral tablet 200 mg and Carbidopa- Levodopa 25-100 mg , was re-ordered after Resident 1 was readmitted to the facility on [DATE].This deficient practice resulted in Resident 1 not receiving the three Parkinson's medications from 7/10/2026 until 8/1/2026 when Resident 1 was transferred and admitted to the General Acute Care Hospital (GACH) with the diagnosis of pneumonia (an infection/inflammation in the lungs). From 7/10/2026 through 8/1/2026, Resident 1 no longer talked, experienced stiff joints and was unable to eat small teaspoons of food and liquid.Findings:During a review of Resident 1's admission Record (Face Sheet), the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, Diabetes Mellitus (system has problems digesting sugar, could lead to poor wound healing) and Major Depressive Disorder (deep sadness or loss of interest that can last more than two weeks).During a review of Resident 1's Minimum Data Set ([MDS] resident assessment tool) dated 5/22/2026, the MDS indicated Resident 1's cognition (ability to make decisions of daily living) was intact and Resident 1 was dependent (helper does all of the effort) on facility staff to complete activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 1's GACH Discharge summary dated [DATE], the Discharge Summary indicated home medications to be continued which included the following: amantadine 100 mg capsule by mouth twice a day, carbidopa-levodopa 25 mg-100mg tablet three times a day, and entacapone 200 mg tablet three times a day.During a review of Resident 1's facility medication transfer/admission order form dated 7/10/2026, the medication transfer/admission order form indicated home medications which included: amantadine 100 mg capsule by mouth twice a day, carbidopa-levodopa 25 mg-100mg tablet three times a day, and entacapone 200 mg tablet three times a day.During a review of Resident 1's care plan titled, Resident 1 has Parkinson's disease and will experience an acceptable quality of life within the limitations imposed by Parkinson's through the review date, dated 2/16/2026, the care plan's interventions included giving medications for Parkinson's disease as ordered by the physician, observing and documenting side effects and effectiveness. During a review of Resident 1's medication administration record (MAR) for 7/2026, the MAR indicated the following:Amantadine oral capsule 100mg; give one capsule by mouth two times a day for Parkinson's Dementia (serious thinking and memory problems that interfere with daily life) ; start date 2/17/2026 8 a.m. hold date from 7/3/2026 11:23 a.m. to 7/10/2026 11:22 a.m. discontinued (d/c) date on7/10/2026 4:58 p.m.(date Resident 1 was transferred to the GACH)Entacapone oral tablet 200 mg; give one tablet by mouth three times a day for Parkinson's take with Sinemet-before meals; start date 2/17/2026 6:45 a.m. hold date from 7/3/2026 11:23 a.m. to 7/10/2026 11:22 a.m. and d/c on 7/10/2026 4:58 p.m.Carbidopa- Levodopa 25-100 mg; give one tablet by mouth three times a day for Parkinson's take with entacapone on an empty stomach; start date 2/17/2026 6:45 a.m. hold date from 7/3/2026 11:23 a.m. to 7/10/2026 11:22 a.m. d/c on 7/10/2026 4:58 p.m.The MAR indicated no doses of Amantadine, Entacapone, and Carbidopa- Levodopa were administered to Resident 1 after 7/3/2026.During a review of Resident 1's Internal medicine inpatient progress note dated 8/11/2026, the Internal medicine inpatient progress note indicated Parkinson's medication was not restarted (not reordered and administered) when Resident 1 was discharged back to the facility from the GACH according to medication reconciliation received from the facility. During an interview on 8/24/2026 at 9:33 a.m. and a subsequent interview on 8/27/2026 at 4:38 p.m., Resident 1's family (FM) stated when Resident 1 was readmitted to the facility on [DATE], the facility did not start his Parkinson's medications despite the medications being included in the discharge summary. FM 1 stated FM 2 noticed when Resident 1 was readmitted to the GACH on 7/3 Resident 1 did not close his mouth anymore, GACH staff looked at Resident 1's medication list from the facility and found out Resident 1 was only taking one Parkinson's medication, Ropinirole (medication used to treat the symptoms of Parkinson's disease). FM 1 stated the doctor at the GACH further investigated and found Resident 1 was not taking his Parkinson's medication while at the facility since his readmission on [DATE]. FM 1 stated Resident 1 did not take his Parkinson's medication for almost one month. FM 1 stated she received a call from the facility to report Resident 1 was having trouble swallowing. FM 1 stated on 8/1/2026, Resident 1's oxygen was desaturating (a sudden or sustained drop in the amount of oxygen circulating in the blood below normal levels) and Resident 1 was transferred via 911 to the GACH. During an interview on 8/25/2026 at 2:29 p.m., with Licensed Vocational Nurse (LVN 1), LVN 1 stated when a resident is readmitted to the facility she (LVN 1) reviews hospital documents including the discharge summary, history and physical, and the medication transfer list. LVN 1 stated when Resident 1 was readmitted to the facility, she reviewed each medication one by one with the physician (MD) and she ordered what the MD told her to reorder. LVN 1 stated she does not remember what the MD said when she reviewed the three Parkinson's medications and she did not document why the medications were not reordered. LVN 1 stated she only documented current orders. LVN 1 stated that after a resident stays in the GACH for three days, there is a new chart started with new orders, and she does not refer to the previous orders. During an interview on 8/25/2026 at 3:19 p.m., Resident 1's MD stated he did not remember discontinuing Resident 1's three Parkinson's medications and the medications do not cause any side effects that would cause him to discontinue the medications. The MD stated depending on the severity of the Resident 1's Parkinson's symptoms, the lack of the three medications could result in more tremors and rigidity. During an interview on 8/25/2026 at 4:25 p.m., with Registered Nurse (RN 1), RN 1 stated when Resident 1 was readmitted on [DATE], Resident 1 did not have the following Parkinson's medications ordered: Amantadine, Entacapone and Carbidopa- Levodopa. RN 1 stated when a resident is readmitted , the facility will review the medications with the attending physician. RN 1 stated if Parkinson's medications are not taken, Resident 1's symptoms could worsen. During an interview on 8/26/2026 at 11:41 am, with RN 2, RN 2 stated when a resident is readmitted to the facility, medications are reconciled with the MD. RN 2 stated Resident 1 would be expected to have Parkinson's medications due to his history. RN 2 stated if a resident missed their Parkinson's medication, their symptoms could get worse and there could be an increase in shaking and tremors. During an interview on 8/26/2026 at 12:22 p.m., with the Unit Director of Nursing (UDON), the UDON stated if a resident with Parkinson's disease, does not have Parkinson's medication ordered, it should be brought to the physician's attention. The UDON stated if a resident with Parkinson's disease does not receive their medication, depending on the severity of their symptoms, it could result in neurological issues, tremors, and falls.During an interview on 8/27/2026 at 10:18 a.m., the Pharmacy consultant (Pharm) stated Resident 1 did not have three Parkinson's medication after Resident 1 was readmitted to the facility on [DATE]. The Pharm stated stopping the three Parkinson's medications is not recommended and the medications should not have been discontinued.During a review of the facility's policy and procedure (P/P) titled, admission of the Resident dated 10/2024, the P/P indicated the facility admits residents in an organized manner and gather appropriate assessment data. The facility should review all available transfer information, review information on inquiry form, and interview residents and individuals accompanying residents if able. The P/P indicated upon admission medication, treatment, ADL record, and restorative nursing forms will be completed as needed.During a review of the facility's P/P titled, Quality of Care dated 11/6/2026, the P/P indicated the facility will provide all necessary treatment and care to residents based on thorough assessments, professional practice standards, personalized care plans, and the residents' individual choices and preferences.

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) who had a history of Parkinson's Disease (a slow, progressive brain disorder that affects movement and the nervous system) and contractures (a permanent or severe tightening of muscles, tendons, skin, or other soft tissues that causes joints to shorten and become stiff), received a rehabilitation screen (a quick, basic check by a therapist to see if a resident needs a full therapy evaluation to improve or restore muscle function and movement) when Resident 1 was readmitted to the facility on [DATE].This deficient practice resulted in Resident 1 not receiving a rehabilitation screen which prevented the therapy department from assessing Resident 1's range of motion needs and recommending interventions.FindingsDuring a review of Resident 1's admission Record (Face Sheet), the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnoses including Parkinson's Disease, Diabetes Mellitus (system has problems digesting sugar, could lead to poor wound healing) and Major Depressive Disorder (deep sadness or loss of interest that can last more than two weeks).During a review of Resident 1's Minimum Data Set ([MDS] resident assessment tool) dated 5/22/2026, the MDS indicated Resident 1's cognition (ability to make decisions of daily living) was intact and Resident 1 was dependent (helper does all of the effort) on facility staff to complete his activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 1's care plan titled, Resident was at risk for limited physical mobility due to Parkinson's disease, dated 2/16/2026, the care plan interventions included restorative nursing program ([RNA] a planned, nursing-led care system designed to help patients maintain or improve their physical, mental, and psychosocial independence after formal therapy ends).During a review of Resident 1's physician orders, the physician orders indicated the following:RNA for orthotic (a specialized medical support device worn to support, align, or improve the function of the extremity) management with left upper extremity (LUE) elbow extension orthotic daily for four-six hours as tolerated daily for contracture management dated 7/3/2026.RNA for orthotic management with left upper extremity (LUE) wrist hand finger orthosis (WHFO) daily for four-six hours as tolerated daily for contracture management dated 7/3/2026.RNA for orthotic management with right upper extremity (RUE) elbow extension orthotic daily for four-six hours as tolerated daily for contracture management dated 7/3/2026.RNA for orthotic management with RUE WHFO daily for four-six hours as tolerated daily for contracture management dated 7/3/2026.RNA for orthotic management to apply elbow extension brace bilateral daily for four hours as tolerated daily for contracture management dated 7/3/2026.RNA for orthotic management to apply knee extension brace bilateral daily for four hours as tolerated daily for contracture management dated 7/3/2026.RNA will perform lower leg extremity (LLE) passive range of motion (PROM) daily or as tolerated every day shift for LLE PROM dated 7/3/2026.RNA will perform LUE passive range of motion (PROM) daily or as tolerated every day shift for LUE PROM dated 7/3/2026.RNA will perform RLE PROM daily or as tolerated every day shift for RLE PROM dated 7/3/2026.RNA will perform RUE PROM daily or as tolerated every day shift for RUE PROM dated 7/3/2026.During an interview on 8/28/2026 at 12:21 p.m., with the Director of Rehabilitation (DOR), the DOR stated upon readmission there should be a physician order for a rehab screen. The DOR stated either her or her assistant checked every morning for rehab screen orders and Resident 1 did not have a rehab screen order after his readmission on [DATE]. The DOR stated Resident 1 was previously receiving RNA services. The DOR stated since Resident 1 did not get rehab screen, rehab staff were unable to determine what type of rehab services Resident 1 required and Resident 1 was at risk for his joints to become tighter and stiffer and facility staff would have more difficulty in completing his ADLs.During an interview on 8/28/2026 at 2:17 p.m., with the Licensed Vocational Nurse (LVN 1), LVN 1 stated upon readmission, therapy orders including RNA order are not ordered or continued automatically from previous admissions. LVN 1 stated the unit Director of Nursing (DON) and the therapy department need to discuss and determine if the resident requires a rehab screen. LVN 1 did not order a rehab screen for Resident 1.During a review of the facility's policy and procedure (P/P) titled Resident/Patient admission to Rehab program dated 2025, the P/P indicated the therapist will screen all new admits, readmitted resident/patients, referrals and resident/patients annually.

Based on interview, and record review, the facility failed to ensure a Private Caregiver (PC) hired by the family to provide companionship and assist in the care for one of three sampled residents (Resident 1), did not act as Resident 1's primary caregiver, by bathing, transferring, providing incontinent care (hygiene support given to people who cannot control their bladder or bowel movements), skin assessment, and turning and repositioning Resident 1. The PC was with Resident 1 approximately 10 hours daily and provided the majority of Resident 1's care. This deficient practice resulted in Resident 1, who was admitted to the facility without pressure ulcers ([PU] localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence), developing a Stage 2 (partial-thickness loss of skin, presenting as a shallow open sore or wound) sacrococcygeal PU (a localized injury to the skin and underlying tissue that develops over the sacrum [the large triangular bone at the base of the spine] and the coccyx [the tailbone] due to prolong pressure, friction, or shearing forces) 10 days after admission to the facility. The PU had increase in size with worsening wound characteristics and was unstageable (full thickness skin and tissue loss where the full depth of the injury could not be determined because the wound was covered by dead or damage tissue). This deficient practice had the potential for Resident 1 to develop additional wounds due to inappropriate care that was provided. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnoses including diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing) with diabetic chronic kidney disease (long-term damage to kidneys), dysphagia (difficulty swallowing), muscle wasting/atrophy (wasting away or decrease in size and strength of a body part or tissue), and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 6/29/2026, the MDS indicated Resident 1's cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired. The MDS indicated Resident 1 was dependent (helper does all of the effort) on staff for toileting, bathing, and rolling from left to right. The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort) from staff to eat, and for personal hygiene. The MDS indicated Resident 1 was always incontinent (unable to control the release of urine and stool) of bowel and bladder functions. The MDS indicated Resident 1 was at risk of developing PUs but had no unhealed PUs, venous ulcers (an open skin sore, usually on the lower leg near the ankle, that takes a long time to heal) or arterial ulcers (an open skin wound caused by a lack of blood flow and oxygen to the lower legs or feet). During a review of Resident 1's History and Physical (H&P) dated 6/20/2026, the H&P indicated Resident 1 did not have the capacity to make decisions. During a review of Resident 1's Braden Scale for Predicting Pressure Ulcer Risk Assessment, dated 6/20/2026, the Braden Scale for Predicting Pressure Ulcer Risk Assessment indicated Resident 1 had a score of 12, (a score of 12 or less represent high risk for PUs). During a review of Resident 1's Baseline Care Plan, dated 6/20/2026, the Care Plan indicated Resident 1 was at risk for the development of PUs and poor/delayed wound healing. The Care Plan indicated there was no documented goals and/or interventions created to prevent PUs from occurring. During a review of Resident 1's Progress Notes (Skin Issues) dated 6/20/2026 and timed at 5:59 p.m., the Progress Notes (Skin Issues) indicated no skin issues were identified for Resident 1, additional care included incontinence management, moisture control and moisture barrier. The Skin Issues Note indicated the plan of care was ongoing and skin issue education indicated to turn Resident 1 every two hours. During a review of Resident 1's Change in Condition (CIC) Evaluation, dated 6/30/2026 and timed at 2:27 p.m., the CIC Evaluation indicated Resident 1 had a Stage 2 PU on her sacrococcygeal area extending to her left and right buttocks, measuring 6.0 centimeters ([cm] a unit of measurement used to measure length or distance) x 10.5 cm. During a review of Resident 1's Progress Notes (Skin Issues), dated 7/1/2026 and timed at 2:12 p.m., the Progress Notes indicated Resident 1 acquired an in-house Stage 2 PU to her sacrococcygeal area measuring 6.0 cm in width x 10.5 cm in depth, extending to her left and right buttocks. During a review of Resident 1's Progress Notes (Skin Issues) dated 7/15/2026 and timed at 4:46 p.m., the Progress Notes indicated Resident 1's sacrococcygeal PU was deteriorating and had increased in size with worsening wound characteristics and was unstageable. During a review of Resident 1's Care Plan titled, The Resident Has an Actual Pressure Injury to Sacrococcygeal Extending to Left & Right Buttock - Stage 2 dated 7/1/2026, after Resident 1's PU developed, the Care Plan's goal indicated Resident 1's PU would show evidence of responding to treatment. The Care Plan's interventions indicated staff were to turn and reposition Resident 1 at least every two hours and more often as needed or requested; administer treatments as ordered and observe for effectiveness; assess, record, and observe wound healing weekly, including measuring the length, width, and depth when possible and assessing and documenting the status of the wound perimeter, wound bed, and healing progress; report a decline in healing to the physician; and observe, document, and report changes in skin status, including appearance, color, odor, wound healing, signs and symptoms of infection, wound size, and stage. The Care Plan was revised on 7/15/2026 to indicate deterioration of the wound and reclassification to unstageable. During a review of Resident 1's Care Plan titled, The Resident Has the Potential for Pressure Injury Development dated 7/7/2026, the Care Plan's goal indicated staff were to implement interventions to help reduce Resident 1's risk of developing a PU. The Care Plan's interventions indicated staff were to inspect Resident 1's skin during activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily) and report abnormal findings, float the resident's heels off the bed, keep the bed as flat as possible to reduce shear, monitor the resident's nutritional status, and turn and reposition Resident 1 every two hours during the shift. During a review of Resident 1's Nursing Progress Note, created (late entry) on 7/16/2026 and timed at 4:52 p.m., documenting an effective date of 7/16/2026 and timed at 11:46 a.m., the Nursing Progress Note indicated Resident 1's PC was observed with a disposable chux (a single use absorbent bed pad used in healthcare facilities to protect mattresses, chair, and other surfaces from bodily fluids), a brief, towels, and warm water in a basin. The Nursing Progress Note indicated, when the PC was asked who provided care to Resident 1,the PC stated Oh no, I do all this myself. I've been her caregiver; I do this every day when I'm here. The PC reported the Certified Nursing Assistant (CNAs) ask her if they can change Resident 1, but she tells them no, give me the supplies and I will do it myself. During a review of Resident 1's CIC Evaluation, dated 7/15/2026, the CIC Evaluation indicated Resident 1's sacral PU increased in size from 6 cm x 12 cm x UTD). There was an increase in slough (dead tissue that is usually yellow, tan, gray, or green in color, usually moist and stringy in texture, when found in wounds it can interfere with wound healing) from 0% to 90%. During a review of Resident 1's Skin/Wound Progress Note dated 7/17/2026 and timed at 1:51 p.m., the Skin/Wound Progress Note indicated a sharp debridement (removal of dead tissue and foreign matter from a wound to improve or facilitate the healing process) of Resident 1's sacrococcygeal PU was performed by the Wound Consultant. During a telephone interview on 8/6/2026 at 4:35 p.m., the Designated Power of Attorney ([DPOA] a legal document that gives one person the authority to make decisions and act on behalf of another) stated Resident 1 was admitted to the facility on [DATE], staff completed a skin assessment and took photographs of Resident 1's skin upon admission, and Resident 1 did not have a PU. She (DPOA) noticed during one of her visits (date unknown) that Resident 1 developed a small, dime-sized, non-blanchable (skin that does not turn lighter when pressure is applied) area to her sacral (the lower back just above the tailbone) area and she voiced her concerns to the Unit Director of Nursing (UDON) and the Chief Clinical Officer (CCO) regarding Resident 1's PU. The DPOA stated when she visited Resident 1, she would assist with changing the resident's diaper and cleaning her; however, the wound would be covered, and she did not realize how severely the wound had deteriorated until she began to smell an odor. She observed feces in the wound, which she believed was the source of the odor. Resident 1's PU subsequently became unstageable, required a wound vac (a device that uses suction to remove fluid from a wound and help it heal), and eventually extended over Resident 1's buttocks. The POA stated Resident 1's PC contacted her on 7/16/2026 and reported Resident 1 had a saturated brief that had not been changed since the night shift. The POA stated she reported the concern to the CCO. The DPOA stated she visited Resident 1 for approximately five hours on one occasion (date unknown) and she did not observe Resident 1 being turned or offloaded (reducing or removing pressure and weight from an injured or vulnerable area of the body) during that visit. During a telephone interview on 8/10/2026 at 4:39 p.m., the Primary Care Physician (PCP) stated at the end of 6/2026, the wound care nurse (TXN 1) notified him that Resident 1 had developed a PU that was not present upon admission. When he examined Resident's wound it was a large Stage 2 PU. The PCP stated the facility relied on Resident 1's PC to perform most of the resident's care during the day and stated if facility staff had been providing care to Resident 1, the PU might have been identified earlier. The PCP stated once the wound care nurse identified the PU, the treatment team increased its efforts; however, if Resident 1 was not changed and remained wet overnight, was sitting in feces, or the dressing covering the wound became soiled, the wound could worsen and become unstageable. The facility's nursing staff should have provided care to Resident 1 to offload and change her diaper when it was wet. It was an oversight by the facility to rely on the PC to perform Resident 1's care and not monitor the resident's care themselves. The facility notified him when Resident 1's PU developed necrotic tissue (dead or non-viable body tissue that results from uncontrolled death of cells due to disease, injury or lack of blood flow) and opened. When he saw the wound, it was quite large which caused him to believe the wound might have developed earlier than when it was actually identified. During an interview on 8/12/2026 at 4:44 p.m., CNA 1 stated Resident 1's PC worked during part of the 3 p.m. to 11 p.m. shift (until approximately 7 p.m. - 10 p.m. Monday through Friday) and performed Resident 1's ADL care during the hours when she (PC) was at the facility, including feeding her, changing her diapers, cleaning, and turning/repositioning the resident During an interview on 8/13/2026 at 4:49 p.m., CNA 3 stated Resident 1 had a PC who was present for extended periods (10 a.m., to 10 p.m., Monday through Friday), and who was more than a sitter because the PC was hands-on and provided much of Resident 1's care. CNA 3 stated she observed the PC changing Resident 1's diaper and night gown, providing her bed baths, feeding her, and assisting with turning and repositioning her. The PC would tell her, I got it, when she (CNA 3) offered assistance. CNA 3 stated she would check with the PC to determine whether assistance was needed but she (CNA 3) did not provide all of Resident 1's care when the PC was present because she did not want to step on the PC's toes or create conflict, as she believed the PC might take offense. Even on the days when she (CNA 3) was not assigned as Resident 1's nurse, she observed the PC obtaining towels and providing care to Resident 1. During a telephone interview on 8/14/2026 at 11:52 a.m., the DPOA stated Resident 1's PC was a non-medical companion and did not hold a nursing or other healthcare license. The DPOA stated she made the PC's role clear to the PCP and CCO from the beginning and instructed them not to rely on the PC to provide care to Resident 1. The DPOA stated the PC was present primarily for companionship and should have only assisted with Resident 1's feeding, bathing, and applying lotion, and the PC was instructed to contact her regarding decisions or concerns involving Resident 1's care. The PC was not responsible for skin assessments or turning and repositioning Resident 1. The POA stated the facility was responsible for assessing Resident 1, providing incontinent care, turning and repositioning her, monitoring her skin, intervening when necessary, and reporting changes of (COC). The facility was aware of the PC's role, but facility staff relied on the PC to provide care that she (POA) expected facility staff to provide. During a telephone interview on 8/14/2026 at 1:11 p.m., the PC stated she was hired to assist the nursing staff with feeding, bathing, and incontinent care, including changing Resident 1's diapers and clothing when the facility staff were not available. She performed much of Resident 1's ADL care because if she did not provide the care, it would either not be provided or it would be provided late. The CNAs provided her (PC) with supplies, including briefs and linens, and at times she obtained needed supplies herself to provide care to Resident 1. The PC stated she changed Resident 1's diaper, cleaned her, provided bed baths, fed her, changed her bed, transferred her into her wheelchair, and turned and repositioned her every one to two hours. Most CNAs allowed her to provide care to Resident 1 as though she worked at the facility. The PC stated she was generally present at the facility Monday through Friday from approximately 10 a.m. to 10:30 a.m. until 7 p.m. The PC stated when she arrived at the facility at approximately 10 a.m., she would check Resident 1's brief and, on multiple occasions, the brief was saturated with urine and on occasion the brief would have feces in it. She observed a small pink/open area near Resident 1's tailbone (date unknown), which she described as smaller than a dime, and reported the area to the physician and family (end of 6/2026 or early 7/2026 exact date unknown). During an interview on 8/14/2026 at 3:18 p.m., the UDON stated, Resident 1's PC was hired by Resident 1's POA to assist the nursing staff and watch Resident 1. Facility CNAs were responsible for providing Resident 1's care, including repositioning every two hours, feeding, bathing, hygiene, and incontinence care. The PC could assist with Resident 1's care but should not have independently provided care to Resident 1. The PC was very hands-on and would tell the CNAs when she turned, changed, or bathed Resident 1 and preferred to perform Resident 1's care and that was why staff allowed her to provide care to Resident 1. The CNAs should not have allowed the PC to independently provide Resident 1's ADL care or provide her with supplies to perform the care. During an interview on 8/17/2026 at 11:17 a.m., the Wound Care Coordinator (WCC) stated leaving Resident 1 in a soiled brief and allowing the wound dressing to become soiled could contribute to skin breakdown and deterioration of the wound. The PC was performing the majority of Resident 1's ADL care while she was in the facility, which interfered with the facility's plan of care for Resident 1. The WCC stated the PC was not trained to identify wounds and should have received an orientation and informed of the facility's policies and procedures regarding her role while in the facility. Resident 1's wound was identified by the PC rather than facility staff earlier identification of the wound by facility staff would have allowed for appropriate interventions to be implemented, the care plan adjusted, the physician and family to be notified and it would have prevented the outcome. The WCC stated the facility was responsible for Resident 1's care, the PC overstepped her role, and facility staff allowed it to occur. During a telephone interview on 8/17/2026 at 12:13 p.m., TXN 1 stated she began treating Resident 1's sacrococcygeal PU toward the end of 6/2026 or early 7/2026. The PC initially notified staff (unknown who) of the wound, which at that time it was a superficial Stage 2 PU. The PC performed most of Resident 1's brief changes and would contact her (TXN 1) when Resident 1's wound treatment was needed. TXN 1 stated she first noticed significant deterioration of Resident 1's PU when she returned after being off for two days (not sure of the exact date), when she returned to work Resident 1's PU had significantly worsened and contained slough. The TXN 1 stated she initially believed the PC was Resident 1's family member and later learned she was the resident's private caregiver. TXN 1 stated CNAs would indicate that the PC could perform Resident 1's care and would provide the PC with supplies to perform the care. TXN 1 stated facility staff should have intervened rather than allowing the PC to assume responsibility for Resident 1's care. During an interview on 8/17/2026 at 12:50 p.m. the Administrator (ADM) stated Resident 1's DPOA had not directed the PC to provide direct care to Resident 1. The facility staff were responsible for Resident 1's care, and the CNAs should not have allowed the PC to provide care to Resident 1 and the PC should not have provided care to Resident 1. During a review of the facility's Policy and Procedure (P&P) titled, Private Duty Sitters revised 4/2006, the P&P indicated residents/family members desiring the use of private duty sitters were required to first obtain written approval from the Attending Physician and the Director of Nursing Services. The Director of Nursing Services was required to consult with the Administrator when private duty sitters were requested. Private duty nursing personnel were required to follow the facility's established nursing care policies and procedures and instructions issued by the Nurse Supervisor/Charge Nurse. Private duty sitters were required to report to the Nurse Supervisor/Charge Nurse when coming on and going off duty and immediately report changes in a resident's condition to the Nurse Supervisor/Charge Nurse. During a review of the facility's P&P titled, Skin Breakdown Assessment Prevention and Management revised 4/1/2024, the P&P indicated the nursing staff, in collaboration with the interdisciplinary team (IDT), were to identify, assess, plan, prevent, intervene, and monitor the care of residents at risk for or experiencing pressure or non-pressure skin breakdown. The Chief Clinical Officer (CCO) or designee was responsible for implementing and enforcing the policy. Each resident was to receive a comprehensive skin and risk assessment upon admission, with the resident's skin condition documented at admission and every shift for the first 72 hours. The assigned licensed nurse was to initiate preventive measures for residents identified as at risk for pressure ulcers and update the measures as needed based on Braden Scale assessments. When a pressure ulcer was identified, the licensed nurse was to notify the attending licensed practitioner, and following any significant skin change, the licensed nurse was to complete a change of condition nursing assessment every shift for 72 hours. Care plans for residents with open skin wounds were to follow treatment orders from the licensed practitioner and include interventions that could address repositioning, nutritional support, wound treatment, and support surfaces and pressure redistribution. During a review of the facility's P&P titled, Wound Care Suggestions and Documentation revised 2/15/2025, the P&P indicated wounds were to be measured and evaluated weekly for improvement or decline, and wounds and/or dressings were to be inspected daily and documented. If there was a material change in a wound; a new assessment sheet was to be initiated with the new assessment. The physician was to be notified of changes in a wound, including improvement or decline, that necessitated changes or updates to treatment, and physician and family notification of wound care was to be documented in the resident's chart. Each wound was to be documented upon discovery and at least weekly thereafter until healed. Identified incontinence and immobility as risk factors for pressure injuries and indicated an appropriate intervention was to be implemented for each identified risk factor. Residents were to be checked for incontinence at minimum every two hours, the skin was to be inspected with each incontinence change for changes in integrity, moisture barrier ointment was to be applied as indicated, and residents unable to independently turn were to be offloaded at minimum every two hours.

Based on observation, interview and record review, the facility failed to protect one (1) out of three (3) sampled residents' (Resident 1) personal property from theft and loss in accordance with the facility's Policy and Procedure (P&P) titled Theft and Loss when the facility lost Resident 1's wallet containing his California Identification Card (CAID).The facility failed to:1.Follow up and replace Residents 1's missing CAID This deficient practice resulted in Resident 1 not having his CAID replaced for over two (2) years after the loss was reported and had the potential to cause Resident 1 to feel helpless and forgotten. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that include muscle weakness and chronic pulmonary embolism (when a blood clot blocks and stops blood flow to an artery in the lung).During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 3/18/2026, the MDS indicated Resident 1 had intact cognitive (ability to think and process information) ability. The MDS indicated Resident 1 required set up assistance for eating. The MDS indicated Resident 1 required partial assistance (helper does less than half the effort) for oral hygiene. The MDS indicated Resident 1 required substantial assistance (helper does more than half the effort) for upper body dressing and personal hygiene. The MDS indicated Resident 1 was dependent on toileting hygiene, showering, lower body dressing and putting on/taking off footwear.During an interview on 6/5/2026 at 7:14 PM with Family Member 1 (FM) 1, FM 1 stated Resident 1 had informed the facility that he lost his wallet about two and a half years ago, but they did not follow up on it. FM 1 stated the facility has not replaced Resident 1's CAID that was in his lost wallet.During an interview on 6/6/2026 at 8:45 AM with Resident 1, Resident 1 stated the facility lost his wallet which had his CAID in it over two years ago. Resident 1 stated the Social Worker (SW) had told him they would try to get him a new CAID, but they did not follow up on it. Resident 1 stated the facility got him a replacement wallet and they were keeping it in a safe.During a concurrent interview and record review on 6/6/2026 at 1:35 PM with the facility's SW, Resident 1's Inventory List dated 3/30/2021 was reviewed. SW stated the Inventory List indicated Resident 1 had a black wallet with a CAID in it. SW stated the Inventory List indicated on 5/3/2021 the wallet was kept locked in the facility's business office.During a concurrent observation and interview on 6/6/2026 at 1:40 PM with the facility's SW, the contents of Resident 1's red replacement wallet were observed. SW stated the replacement wallet did not have a CAID in it. SW stated they could not find the Loss and Theft Report for when Resident 1 reported his wallet lost but it should have been done. SW stated Resident 1 may feel helpless if he does not get help to replace his lost items. SW stated if a Theft and Loss Report was not done, the facility cannot ensure the resident will receive his property back. During a concurrent interview and record review on 6/6/2026 at 2:26 PM with the facility's Regulatory Nurse (RN), a printed email from an online shopping website dated 5/21/2025 was reviewed. The email indicated that a wallet was ordered for Resident 1 and was scheduled to arrive on 5/22/2025. The RN stated the email showed Resident 1 received a replacement wallet after he reported the original one lost.During a concurrent interview and record review on 6/6/2026 at 2:47 PM with the RN, Resident 1's Social Worker Notes dated 4/2/2021 to 6/6/2026 and Resident 1's Inventory List dated 3/30/2021 were reviewed. The RN stated the last documented attempt by the Social Worker to replace Resident 1's CAID was on 9/11/2025. She stated there was no documented follow up after that date and confirmed that if it was not documented, it was not done. The RN stated Resident 1 had a CAID in his lost wallet, as documented in his 2021 inventory.During a concurrent interview and record review on 6/6/2026 at 2:52 PM with the RN, the facility's P&P tilted Theft and Loss revised on 11/2024 was reviewed. The Theft and Loss P&P indicated It is the policy of this facility to safeguard the personal property of residents and protect residents' property from loss and theft. The Social Service Designee and or Social Service Assistant shall assist the Administrator in locating and/or investigating claims of loss property.The RN stated the policy indicated that the facility would protect residents' property from loss or theft, and the SW will assist in the investigation of lost property. The RN stated the SW should have followed up on Resident 1's missing CAID.

Based on interviews and a review of records, the facility failed to ensure one of three sampled residents (Resident 1) had her right to receive visitors of her choice and to have her visitation preferences considered prior to imposing restrictions.This deficient practice resulted in Resident 1 being unable to receive visits from her son in her room as she preferred, and had the potential to negatively impact her emotional well being, quality of life, and resident rights.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with a diagnoses including hemiplegia (paralysis of one side of the body), cerebral infarction (loss of blood flow to a part of the brain), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 1/28/2025, the MDS indicated Resident 1 was dependent (helper does all the effort) with toileting, showering, lower body dressing and putting on and taking off shoes.During a review of Resident 1's History and Physical (H&P) dated 3/27/2026, the H&P indicated, Resident 1 did not have the capacity to understand and make decisions.During an interview on 6/3/2026 at 8:15 a.m., with Resident 1, Resident 1 stated her son was not abusing her and denied that he had any intention of harming her. Resident 1 became tearful and said she wanted her son to continue visiting her. She also stated the facility forced her to have visits with her son only in the family room or other common areas instead of in her room as she preferred.During an interview on 6/3/2026 at 9:06 a.m., with Family Member (FM) 1, FM 1 stated he visited his mother five days per week from 9 a.m. to 5 p.m. He stated, he had been playing with his mother and trying to make her laugh when he pinched her left thigh. He stated LVN 1 told him he was abusing his mother and reported the incident to the Chief Clinical Officer (CCO) and the Administrator. He stated no other witnesses were present at the time of the incident. He stated approximately two weeks ago, following the incident, the Administrator told him he could not visit his mother in her room and notified FM 2 his visits were limited to the family room or the front area of the facility. He stated he was not provided with any documentation regarding the visitation restriction. He further stated that his mother cried and expressed a desire to see him in her room.During an interview on 6/3/2026 at 11:07 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she witnessed FM 1 pinch Resident 1 on her left thigh. She stated she entered Resident 1's room and observed the resident lying in bed asleep. She stated FM 1 asked his mother if she wanted him to pinch her and then pinched Resident 1 on her left thigh. She stated Resident 1 awoke after the incident and began swinging her arms. She stated she exited the room and notified the Registered Nurse Supervisor (RNS), who instructed her to inform the Chief Clinical Officer (CCO) and the Administrator. She stated she subsequently informed both the CCO and the Administrator of the incident. She stated the CCO and Administrator instructed her to return to the resident's room and reenact what she had observed. She stated the CCO and Administrator interviewed Resident 1 following the incident, and Resident 1 reported that she was not afraid of her son and did not want him to stop visiting. She stated the RNS and the CCO completed a skin assessment following the alleged incident and found no bruising, redness, swelling, or other visible signs of injury.During an interview on 6/3/2026 at 4:00 p.m., with the CCO, the CCO stated LVN 1 informed her of the alleged incident in which FM 1 pinched Resident 1's left thigh. The CCO stated when she interviewed Resident 1, the resident reported she was not afraid of her son and believed he had been joking. The CCO stated Resident 1 expressed a desire for her son to continue visiting. She stated the facility implemented a visitation restriction that limited visits to designated common areas and the family room while the allegation was under investigation. She stated FM 1 was notified of the restriction by telephone. She stated the facility did not explain grievance or appeal rights related to the visitation restriction to either Resident 1 or FM 1. She stated the facility did not fully consider Resident 1's visitation preferences before implementing the restriction. She stated the facility's investigation into the allegation involving Resident 1's son was determined to be inconclusive. The CCO stated no bruising, redness, swelling, or other injury was identified during the post incident skin assessment. She stated restricting a resident's visitation without considering the resident's preferences may negatively affect the resident's emotional well being and quality of life, and residents may experience sadness, loneliness, and feelings of isolation when they cannot receive visits from family members according to their wishes.During a review of the facility's policy and procedure titled, Visitation, dated 2016, the P&P indicated, Residents have the right to receive visitors of their choosing subject to reasonable clinical and safety restrictions, in a manner that does not impose on rights of other residents.

Based on observation, interview, and record review the facility failed to provide necessary activities of daily living ([ADLs] daily self-care activities) care and services for two of three sampled residents (Resident 1 and 2), who were dependent (helper does all the work) on staff for incontinence care (the help someone gets when they have accidental urine or stool leaks). This was evidenced by the following: 1.Resident 1 was observed with a soiled incontinence brief (diaper) containing urine and stool.2.Resident 2 was observed with urine-soiled towel positioned between her legs, which was not consistent with facility practice for managing incontinence.These deficient practices placed Resident 1 and 2 at risk for skin breakdown, worsening skin integrity, infection, discomfort, compromised dignity and decreased quality of life. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with a diagnoses including hemiplegia (paralysis of one side of the body), cerebral infarction (loss of blood flow to a part of the brain), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 1/28/2025, the MDS indicated Resident 1 was dependent (helper does all the effort) with toileting, showering, lower body dressing and putting on and taking off shoes.During a review of Resident 1's Care Plan titled Resident has bowel incontinence dated 3/20/2026, revised 04/02/2026, the care plan indicated interventions including to check resident and assist with toileting as needed, provide peri care (cleaning of the genitals and anal areas) after incontinent episodes.During a review of Resident 1's History and Physical (H&P) dated 3/27/2026, the H&P indicated, Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's Care Plan titled Resident has actual impairment to skin integrity related to moisture associated incontinence dermatitis ( skin inflammation caused by prolonged exposure to urine or feces) of the right inner thigh dated 3/27/2026, revised on 3/29/2026, the care plan interventions indicated to keep skin clean and dry, and minimize excessive moisture.During a review of Resident 1's Nursing-Skin Check dated 4/22/2026, the Nursing-Skin Check indicated, perianal (the area located immediately around the anus) moisture acquired skin damage ([MASD] inflammation and erosion of the skin caused by prolonged exposure to moisture).During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE], with a diagnoses including hemiplegia, and cerebral infarction.During a review of Resident 2's Care Plan titled Resident has an ADL self-care performance deficit related to activity intolerance dated 3/11/2021, the care plan interventions indicated to assist with transfers, turning and/or repositioning at least every two hours, maintain good personal hygiene every shift and as necessary (prn).During a review of Resident 2's H&P, dated 5/9/2026, 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 dependent (helper does all the effort) with toileting, showering, lower body dressing and putting on and taking off shoes.During a concurrent observation and interview on 6/3/2026 at 8:15 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 1 was observed with a soiled incontinence brief containing stool and urine. A dressing was present on the sacrococcyx (tail bone) area. LVN 2 stated Resident 1 was dependent on staff for all ADL care, including incontinence care and hygiene. LVN 2 state prolonged exposure to urine and stool increased the risk of skin breakdown, pressure injuries, and infection. LVN 2 stated that a resident in that condition could experience discomfort, decreased dignity, embarrassment, and distress, and that such conditions could negatively affect overall well being and skin integrity.During a concurrent observation and interview on 6/3/2026 at 8:30 a.m. with Certified Nurse Assistant (CNA) 1, Resident 2 was observed lying in bed with a urine soiled towel positioned between her legs. CNA 1 stated Resident 2 was incontinent of urine and stool. She stated that her shift began at 7:00 a.m. and that her routine included initial rounds at the start of the shift, with incontinence care provided approximately every two hours and as needed. CNA 1 stated she was unable to confirm the last time Resident 2 was checked or changed prior to the observation. She stated she had not yet provided care to Resident 2 at the time of the observation because she had been assisting with meal trays and helping another CNA. She stated she did not know why a towel was positioned between Resident 2's legs and confirmed this was not part of the resident's care plan. She stated Resident 2 did not refuse incontinence care. CNA 1 stated allowing a resident to remain in a wet or soiled condition could cause discomfort, embarrassment, and affect the resident's dignity.During a telephone interview on 6/3/2026 at 9:06 a.m. with Family Member (FM) 1, FM 1 stated he visited his mother five days per week from 9 a.m. to 5 p.m. He stated he had observed his mother remaining soiled for the past three months. He stated during his visits, he observed his mother not being changed for up to four hours.During an interview on 6/3/2026 at 1:41 p.m. with the Unit Director of Nursing (UDON), the UDON stated Resident 1 should be checked and changed every two hours and as needed. She stated Resident 1 was at increased risk for skin breakdown due to incontinence, immobility, diabetes, and dependence on staff for care. She stated Resident 1's FM 1 had reported concerns Resident 1 was not being changed in a timely manner. She stated she had identified staff noncompliance related to incontinence care and acknowledged that Resident 1 was found soiled with urine on three occasions during her rounds. She stated that she notified the assigned CNA each time these observations were made. The UDON stated towels were not an approved incontinence management intervention and were not intended to replace incontinence briefs, scheduled toileting, or routine incontinence care. She stated using a towel between a resident's legs may not adequately protect the resident's skin from exposure to urine or stool and may contribute to moisture related skin issues if not promptly identified and addressed.During a telephone interview on 6/3/2026 at 3:48 p.m. with Certified Nurse Assistant (CNA) 3, CNA 3 stated she began her shift at 11:00 p.m. and conducted initial rounds at the start of the shift. She stated she worked the night shift from 11:00 p.m. to 7:00 a.m. and was assigned to Resident 1 on the morning of the observation. She stated, she rounded on her assigned residents at the beginning of her shift and continued to round every two hours and as needed. CNA 3 stated Resident 1 was dependent on staff for all activities of daily living, including toileting, hygiene, and incontinence care. She stated the last time she provided incontinence care to Resident 1 was approximately 4:00 a.m., and that Resident 1 was cleaned and changed at that time. She stated staff should not use towels in place of incontinence pads. She stated prolonged exposure to urine and feces could cause discomfort, skin irritation, and negatively affect a resident's quality of life. CNA 3 stated she cleaned Resident 1 at approximately 5:00 p.m. during her prior shift and that the resident was changed again at 4:00 a.m. She stated staff should not leave towels between residents' legs and the only resident for whom towels were being used in this manner was Resident 2, due to an ulcer on her anus. She also stated that the facility had routinely used a towel for that purpose.During an interview on 6/3/2026 at 4:00 p.m. with the Chief Clinical Officer (CCO), the CCO stated she was aware of concerns raised by Resident 1's FM 1 regarding incontinence care, skin integrity, the condition of Resident 1's gastrostomy tube ([GT] a soft tube surgically inserted directly into the stomach to administer medication, fluids and nutrition) , and concerns about LVN 1's interactions. The CCO stated Resident 1 was dependent on staff for activities of daily living, including toileting, hygiene, repositioning, and incontinence care. She stated dependent residents should be checked and changed routinely, including every two hours and as needed, in accordance with the resident's care plan and identified needs. The CCO that prolonged exposure to urine and feces could place a resident at risk for skin breakdown, pain, infection, and worsening of existing wounds. She stated the use of towels between a resident's legs was not an approved incontinence management intervention and was not intended to replace incontinence briefs or routine incontinence care.During a review of the facility's policy and procedure (P&P) titled, Incontinence Care, dated 10/2024, the P&P indicated, It is the policy of this facility to promote skin hygiene, minimize risk of infection, and facilitate skin integrity by providing incontinent care as needed to residents.

Based on interview and record review, the facility failed to maintain an infection control and prevention designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of infection for one of three sampled residents (Resident 1) by failing to:1.Ensure ongoing assessment and monitoring of Resident 1's gastrostomy tube ([GT] a soft tube surgically inserted directly into the stomach to administer medication, fluids and nutrition) for signs of deterioration or contamination.2.Ensure appropriate infection prevention measures were implemented for Resident 1 being treated for suspected scabies (a contagious skin infestation caused by tiny, [mites]- closely related to spiders and ticks).These deficient practices had the potential to result in the transmission of infectious conditions, delayed identification of infection-related concerns, impaired delivery of medications and nutrition, and increased risk of infection and other adverse health outcomes.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with a diagnoses including hemiplegia (paralysis of one side of the body), cerebral infarction (loss of blood flow to a part of the brain), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 1/28/2025, the MDS indicated Resident 1 was dependent (helper does all the effort) with toileting, showering, lower body dressing and putting on and taking off shoes.During a review of Resident 1's History and Physical (H&P) dated 3/27/2026, the H&P indicated, Resident 1 did not have the capacity to understand and make decisions.1.During an interview on 6/3/2026 at 11:07 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1's GT appeared dark or black in color and looked mold like. She stated she reported this to the Unit Director of Nursing (UDON) on 4/21/2026, and Resident 1 was sent to a General Acute Care Hospital (GACH) for replacement, returning to the facility on 4/22/2026. LVN 1 was unable to state when the resident's GT tubing was last assessed. She stated the GT should be assessed routinely, including at least every shift and during medication administration, to ensure proper placement, patency, and condition prior to use. She stated an abnormal or contaminated gastrostomy tube could place a resident at risk for infection, including localized site infection.2.During a concurrent interview and record review on 6/3/2026 at 1:41 p.m. with the Unit Director of Nursing (UDON), Resident 1's Medication Administration Record (MAR) dated May 2026 was reviewed. The MAR indicated Ivermectin, (an anti parasitic medication used to treat infections and prescribed off label for scabies) three milligram ( mg-unit of measurement), give nine milligrams via GT one time a day, every seven days for four weeks, starting on 05/10/2026 at 9:00 a.m. The UDON stated Ivermectin was ordered and administered as prophylactic treatment due to a suspicion of scabies. She stated suspected cases of scabies should be reported and residents suspected of having scabies should be placed on contact precautions ( precautions intended to prevent transmission of infectious agents) until scabies was confirmed or ruled out. The UDON stated Resident 1 was not placed on contact precautions. She stated significant changes in a resident's condition, such as suspicion of scabies, should be incorporated into the resident's care plan to ensure staff were aware of the resident's needs and required interventions.During an interview on 6/3/2026 at 3:39 p.m. with the Infection Preventionist (IP), the IPN stated Resident 1 was treated for suspected scabies and was prescribed Ivermectin as part of her treatment plan. She stated that no skin scraping (a minimally invasive diagnostic procedure in which superficial layers of the skin are gently scraped for examination), was performed when Resident 1 developed a rash in 5/2026. She stated a skin scraping was not performed because Resident 1 had undergone one in 2/2026. The IP stated the Physician Assistant made the determination to treat Resident 1 for suspected scabies. She stated that a repeat skin scraping could have been considered to help determine the cause of the rash. The IP stated contact precautions should have been implemented to reduce the risk of transmission and appropriate isolation was intended to protect other residents, staff, and visitors from potential exposure while the resident was being evaluated and treated. The IP state contact precautions were not initiated for Resident 1.During an interview on 6/3/2026 at 4:00 p.m. with the Chief Clinical Officer (CCO), the CCO stated she became aware of concerns regarding the condition of Resident 1's GT on 4/21/2026 after LVN 1 reported discoloration and dark residue within the tube. The CCO stated GT should be assessed routinely every shift, during medication administration, and as needed to identify abnormalities, deterioration, blockage, leakage, or signs of infection. She stated failure to identify abnormalities in a timely manner may place a resident at risk for infection and other medical complications requiring additional intervention. The CCO stated Resident 1 was treated with Ivermectin for suspected scabies. She stated when a resident presents with signs or symptoms consistent with possible scabies, the resident's skin should be assessed, the physician should be notified, and further evaluation-including dermatology consultation and skin scraping should be considered as clinically indicated. The CCO stated infection prevention measures, such as placing the resident in contact isolation, should be implemented.During a review of the facility's policy and procedures (P&P) titled, Scabies, dated 4/2006, the P&P indicated Implement Contact Isolation. During a review of the facility's P&P titled, Gastrostomy and Jejunostomy Care, dated 5/2026, the P&P indicated, The purposes of this procedure are to promote cleanliness and to protect the gastrostomy or jejunostomy site from irritation, breakdown and infection.

Based on interview and record review, the facility failed to ensure comprehensive person-centered Care Plans were reviewed and revised by the Interdisciplinary Team ([IDT] a group of medical professionals from different disciplines who work together to help a resident achieve their goals) when a resident (Resident 5) refused care for one of four sampled residents (Resident 5). This deficient practice had the potential for Resident 5's care needs and preferences to be unidentified and Resident 5 to continue refusing care which could negatively affect her quality of life and well-being.Findings:During a review of Resident 5's admission Record (Face Sheet), the Face Sheet indicated Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 5 had diagnoses including cerebral infarction ([stroke] loss of blood flow to a part of the brain) with hemiplegia (total paralysis of the arm, leg, trunk on the same side of the body), hemiparesis (a slight paralysis or weakness on one side of the body), and lack of coordination.During a review of Resident 5's Minimum Data Set (MDS) dated [DATE], the MDS indicated Resident 5 was able to make decisions that were reasonable and consistent and required two-person assist to complete her activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily) such as bathing, toileting hygiene, personal hygiene and transferring from chair/bed-to-chair. The MDS indicated Resident 5 was incontinent (loss of control) of bladder and bowel function.During a review of Resident 5's untitled Care Plan dated 7/21/2025, the Care Plan indicated Resident 5 had a self-care performance deficit. The Care Plan's goal indicated Resident 5 was to attain her highest functional mobility and ADLs. The Care Plan's interventions included providing Resident 5 with assistance with bathing, showering, dressing, oral care, personal hygiene, toileting hygiene and cleaning and/or trimming of fingernails during bath days and as necessary.During a review of Resident 5's untitled Care Plan dated 8/13/2025 and revised 1/23/2026, the Care Plan indicated Resident 5 refused incontinence care (brief changes) and trimming of fingernails. The Care Plan's goal indicated Resident 5 was to comply with changing of soiled briefs. The Care Plan's interventions included Resident 5 would comply with a brief change provided by the Certified Nursing Assistant (CNA).During a review of Resident 5's IDT Records, the IDT Records did not indicate Resident 5's refusal of incontinence care and fingernail trimming were discussed, and options of care preferences and/or accommodations were identified and explored by the facility team with Resident 5 or her Responsible Party (RP). The IDT Records did not indicate Resident 5 plan of care was re-evaluated and there was no recommendation and/or plan to revise and/or update the Care Plan's interventions.During an interview on 5/1/2026 at 2:22 p.m., CNA 1 stated Resident 5 refused to be changed at the start of the shift (7 a.m.), and he did not return to check on Resident 5 because he knew Resident 5 refuses care. CNA 1 stated there were no further instructions on what he needed to do when Resident 5 refused care.During an interview on 5/4/2026 at 11:35 a.m., Licensed Vocational Nurse (LVN) 3 stated there were times Resident 5 refused her fingernails to be cleaned and trimmed but she just needed to go back later during the shift to provide the care to Resident 5. During a subsequent review of Resident 5's plan of care, LVN 3 stated and confirmed Resident 5 had been identified to refuse incontinence care and fingernail trimming since 8/13/2025 but the Care Plan interventions were not revised or updated. LVN 1 stated the intervention should have been revised by identifying Resident 5's care preferences and accommodating them to gain her cooperation and offering the care not just once, but multiple times during the shift.During an interview on 5/4/2026 at 12:58 p.m., the Senior Nurse Executive (SNE) stated the facility IDT should have identified Resident 5's care preferences with Resident 5 and her Responsible Party and revised and updated the Care Plan interventions accordingly. The SNE stated the residents' plan of care shall be revised and updated as needed to ensure the interventions are unique and resident-centered.During a review of the facility's policy and procedure (P&P) titled, Care Planning-Interdisciplinary Team, revised 10/2024, the P&P indicated the IDT is responsible for the development of an individualized comprehensive care plan for each resident. The P&P indicated the residents' comprehensive care plan will be developed by the facility's interdisciplinary team.During a review of the facility's P&P titled, Care Plans-Comprehensive Person Centered, revised 10/2/2024, the P&P indicated the facility shall implement a comprehensive, person-centered care plan for each resident that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. The P&P indicated the assessments of the residents are ongoing and the care plan are revised as information about the residents and the residents' condition change.

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 5), who required two-person assistance from staff to perform her activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily), that those ADLs were performed in a timely manner. This deficient practice had resulted in Resident 5 feeling neglected and had the potential to negatively impact her dignity and quality of life.Findings: During a review of Resident 5's admission Record (Face Sheet), the Face Sheet indicated Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 5 had diagnoses including cerebral infarction ([stroke] loss of blood flow to a part of the brain) with hemiplegia (total paralysis of the arm, leg, trunk on the same side of the body), hemiparesis (a slight paralysis or weakness on one side of the body), and lack of coordination. During a review of Resident 5's Minimum Data Set ([MDS] a resident assessment tool) dated 4/11/2026, the MDS indicated Resident 5 was able to make decisions that were reasonable and consistent and required two-person assistance from staff to complete her ADLs such as bathing, toileting hygiene, personal hygiene and transferring from chair/bed-to-chair. The MDS indicated Resident 5 and was incontinent (loss of control) of bladder and bowel function. During a review of Resident 5's untitled Care Plan dated 7/4/2025, the Care Plan indicated Resident 5 had limited physical mobility. The Care Plan's goal indicated Resident 5 was to maintain the current level of mobility. The Care Plan's interventions included assisting Resident 5 with bed mobility, turning and repositioning and transferring Resident 5 from bed to chair and chair to bed. During a review of Resident 5's untitled Care Plan dated 7/21/2025, the Care Plan indicated Resident 5 had a self-care performance deficit. The Care Plan's goal indicated Resident 5 was to attain her highest functional mobility and ADLs. The Care Plan's interventions included providing Resident 5 with assistance with bathing, showering, dressing, oral care, personal hygiene, toileting hygiene and cleaning and/or trimming of fingernails during bath days and as necessary. During a review of Resident 5's untitled Care Plan dated 7/21/2025, the Care Plan indicated Resident 5 had bowel and bladder incontinence. The Care Plan's goal indicated Resident 5 will be checked for incontinence and be changed. The Care Plan's interventions include providing Resident 5 with incontinent care and peri care after each incontinence episode, observing and documenting any signs or symptoms of infection, monitoring Resident 5's skin for redness or breakdown and report changes immediately, and performing all care in a manner that maintains Resident 5's dignity and respect. During a review of Resident 5's Interdisciplinary Team Conference Record ([IDT] a group of medical professionals from different disciplines who work together to help a resident achieve their goals) dated 4/16/2026, the IDT indicated Resident 5 was identified to have self-care and mobility deficits. The IDT indicated the goal of the plan of care was to prevent functional decline through ongoing care planning, with emphasis on maintaining quality of life, sustaining functional capabilities, and preserving Resident 5's dignity and privacy. During a concurrent observation and interview on 5/1/2026 at 2:12 p.m., in Resident 5's room, Resident 5 was lying in her bed wearing a gown. Resident 5's incontinence brief was soiled, her hair was unkempt, and her fingernails were long with ragged edges and a black-colored substance underneath them. Resident 5 stated she likes to keep her fingernails long but wants them to be clean. Resident 5 cried and stated she felt uncomfortable sitting in a soiled brief for an extended period. Resident 5 stated she wanted to get out of bed today, but she has not seen her nurse since this morning. During an observation and interview on 5/1/2026 at 2:22 p.m., Certified Nursing Assistant (CNA) 1 stated Resident 5 refused to be changed at the start of the shift (7 a.m.) today and he did not return to check on Resident 5 because he knew Resident 5 refused care anyway. CNA 1 confirmed Resident 1 was still in bed in her gown, was unkempt, and had long unclean fingernails. CNA 1 stated he should have checked on Resident 5 and help with her ADLs to provide comfort, prevent skin breakdown and infection. During a concurrent observation and interview on 5/1/2026 at 2:34 p.m., Licensed Vocational Nurse (LVN) 1 stated she had not been informed by CNA 1 that Resident 5 initially refused assistance with her care. LVN 1 stated CNA 1 should have notified her so she could offer assistance and ensure Resident 5's care needs were met. LVN 1 confirmed Resident 1 was crying, remained in bed wearing a gown, and had unkept hair, long unclean fingernails, and a soiled brief. LVN 1 stated it is important for nursing staff to offer and provide assistance with residents' ADLs in a timely manner to prevent neglect and promote dignity. During an interview on 5/4/2026 at 12:58 p.m., the Senior Nurse Executive (SNE) stated CNA 1 should have rechecked Resident 5 and re-offered assistance with her ADLs and should have involved LVN 1 to ensure timely provision of Resident 5's care needs. SNE stated the nursing staff are expected to provide the residents with assistance during their ADLs and must collaborate to find ways to provide the residents' care without delay promoting dignity and quality of life. During a review of the facility's policy and procedure (P&P) titled, Dignity, revised 10/2024, the P&P indicated the facility, and its staff shall care for each resident of the facility in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. During a review of the facility's P&P titled, Quality of Life-Dignity, revised 11/8/2024, the P&P indicated the facility shall provide each resident care in a manner that promotes and enhances quality of life, dignity, respect and individuality by providing support in their personal grooming, independence and meaningful engagement. During a of the facility's P&P titled, Routine Resident Care, revised 10/2024, the P&P indicated the facility shall ensure the residents of the facility receive necessary assistance, but not limited to maintaining good grooming and personal/oral hygiene and assisting with tasks of daily living such as personal hygiene, toileting, bed mobility, transfer and locomotion on and off the unit.

Based on interview and record review, the facility failed to ensure Registered Nurse Supervisor (RNS) 1 completed and accurately documented the Discharge Summary for one of two sampled residents (Resident 6) when Resident 6 was discharged home on 4/13/2026.This deficient practice resulted in Resident 6's skin condition not depicted accurately upon Resident 6's discharge and had the potential for his continuity of care to be interrupted and/or delayed.Findings:During a review of Resident 6's admission Record (Face Sheet), the Face Sheet indicated Resident 6 was admitted to the facility on [DATE]. Resident 6 had diagnoses including multiple pressure ulcers ([pressure injury] localized damage to the skin and/or underlying tissue usually over a bony prominence) and type 2 diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 6's Minimum Data Set ([MDS] a resident assessment tool) dated 4/14/2026, the MDS indicated Resident 6 was able to make decisions that were reasonable and consistent and required one-person assist to complete his activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily) such as bathing and walking up and down the stairs. The MDS indicated Resident 6 was continent (full control) of bladder and bowel functions.During a review of Resident 6's Attending Physician's Skilled Nursing Facility Discharge Instructions (Discharge Instructions) dated 4/13/2026 and timed at 12:18 p.m., the Discharge Instructions indicated Resident 6 was to be discharged home and had the following pressure injuries: left upper back, left gluteus (buttock), right gluteus, and posterior (back) neck. The Discharge Instructions indicated the treatment for all identified pressure injuries was to cleanse each wounds/skin injury with normal saline (a sterile mixture of water and salt used to flush wounds), pat dry, apply Manuka Medi-Honey (a sterile, medical grade natural ointment made from manuka honey used to treat infected, slow healing or chronic wounds, burns and abrasions) and cover with a silicone-bordered foam dressing (used to protect and heal acute and chronic wounds such skin pressure injuries and other ulcers or surgical incision).During a review of Resident 6's Facility Discharge summary dated [DATE] and timed at 1 p.m., the Facility Discharge Summary indicated Resident 6 was discharged home with intact skin. There was no documentation indicating any existing skin conditions or indicating that any wound care or skin treatment was required after discharge During a telephone interview on 5/5/2026 at 10:33 a.m., Registered Nurse Supervisor (RNS) 1 stated she did not complete a skin assessment of Resident 6's prior to discharge and did not document Resident 6's condition and did not document Resident 6's skin condition or any pressure injury treatment in the Facility Discharge Summary. RNS 1 stated the Treatment Nurse (TN) was responsible for performing the skin assessment and documenting the findings in Resident 6's medical record. During an interview on 5/5/26 and timed at 11:35 a.m., the Senior Nurse Executive (SNE) stated RNS 1 should have performed a skin assessment of Resident 6 prior to discharge and should have documented in the Facility Discharge Summary of Resident 6's skin condition with specific treatment to each wound identified, to reflect Resident 6's accurate skin condition on discharge and to ensure continuity of his care. The SNE stated it was the responsibility of RNS 1 to ensure Resident 6's Facility Discharge Summary was complete and all information on Resident 6's general condition is depicted on the document.During a review of the facility's undated Registered Nurse Job Description, the Job Description indicated the Registered Nurse shall implement and maintain established nursing objectives and standards by providing direct care to the residents, verifying the residents' treatment, assisting in the planning of the residents' discharge, and completing the transfer and/or discharge forms in accordance with the facility's procedures.During a review of the facility's policy and procedure (P&P) titled, Discharging the Resident, revised 12/2016, the P&P indicated the residents' skin condition shall be assessed and documented at the time of discharge.During a review of the facility's P&P titled, Transfer or Discharge Documentation, revised 12/2016, the P&P indicated the residents' details of transfer and/or discharge and all other necessary information, including a copy of the residents' discharge summary shall be completed to ensure a safe and effective transition of care.

Based on interviews and record review, the facility failed to ensure facility's water boiler was maintained and in proper working condition to provide residents with consistent access to hot water for bathing and personal hygiene.These failures resulted in residents being unable to access hot water consistently for bathing, which is necessary to maintain comfort, hygiene, and a safe living environment.Findings:During an interview on 4/8/2026 at 10:48 a.m. with Resident 220, Resident 220 stated the facility runs out of hot water in the mornings because the kitchen uses all the hot water. Resident 220 stated for the past couple of weeks had to shower early in the morning to avoid receiving a cold shower. During an interview on 4/8/2026 at 12:08 p.m. with Resident 171, she stated that on 4/5/2026 (Sunday) and 4/6/2026 (Monday) she refused to shower because the water was cold. Resident 171 stated cold water was uncomfortable and did not kill germs, and she did not feel as clean after using it. She also stated she has bowls in her closet that the CNAs fill with water for her bed baths, and they heat the water in the microwave before using it.During an interview on 4/8/2026 at 1:33 p.m. with Resident 273, Resident 273 stated she had not showered in three weeks because the water was cold. Resident 273 stated that on one occasion she screamed because the shower water was so cold. She stated she does not feel as clean when the water was cold during a shower or bath, and that cold showers are uncomfortable and unpleasant.During an interview on 4/8/2026 at 1:45 p.m. with Certified Nursing Assistant (CNA) 10, CNA 10 stated the water in the showers was sometimes cold because the kitchen uses a large amount of hot water. CNA 10 stated the water in the showers becomes cold after 12 p.m.During an interview on 4/8/2026 at 1:47 p.m. with CNA 8, CNA 8 stated she was working at the facility on 4/6/2026 and the hot water was not functioning in the evening. During an interview on 4/8/2026 at 1:55 p.m. with Maintenance Supervisor (MS), the MS stated he had received complaints from CNAs about the shower water not getting hot. The MS stated the boiler was not working on 4/7/2026 and it was repaired on 4/7/2026 at 8 a.m.During an interview on 04/09/2026 at 11:17 a.m., with CNA 2, CNA2 could not clean the resident's hair because there was no hot water from the sink in Resident 139's room. CNA 2 stated she usually filled a small container with water from the bathroom sink in the front bathroom to warm it CNA 2 stated she had experienced the lack of hot water twice in the past a month in all the rooms. CNA 2 stated the problem was reported to charge nurse. CNA 2 stated it was inappropriate to use cold water to provide resident care and had to microwave the water to provide comfortable water temperature.During an interview on 04/09/2026 at 1:11 p.m., with Maintenance Supervisor (MS 1), MS 1 stated two days earlier the laundry called him that the water boiler was not producing hot water. MS 1 stated staff members had previously complained about difficulty obtaining hot water. MS 1 stated laundry personnel informed MS1, on the morning of 4/7/26 that the water boiler was not working properly. MS 1 stated he also received complaints from CNAs almost daily that the water boiler was not producing hot water. MS1 tested the water temperature himself and stated it took 45 seconds to one minute to become hot. MS 1 stated 4/7/2026 was the first time he heard that staff were microwaving water. MS 1 stated he was the appropriate person to notify when the boiler was not functioning. MS1 stated he installed a circulation pump (pump that distribute hot water round the building) about three months ago because some nursing stations did not have regular hot water.During a review on 4/10/2026 at 3:19 p.m. with the Director of Nursing (DON), the DON stated it was not appropriate or acceptable for residents to bathe in cold water. The DON stated nursing staff should not heat water in the microwave to bathe residents, as they cannot accurately determine the water temperature and residents could be at risk for scalding.During a review of the facility's invoice dated 4/7/2026, the invoice indicated the MS contacted a heating repair company due to lack of hot water. The invoice indicated a failed igniter and ignition module were identified and replaced. The invoice indicated after both parts were replaced the unit was functioning properly.During a review of the facility's policy and procedure (P&P), titled Safety of Water Temperatures, dated 12/2007, the P&P indicated, If at any time water temperatures feel excessive to the touch., staff will report this finding to the immediate supervisor. During a review of facility's receipt titled Cash Sales Order dated 1/30/26, indicated facility ordered for circulatory pump and many other items to repair the water boiler three months ago.During a review of the facility's policy and procedure (P&P) titled Water Temperatures, Safety dated 12/2007, the P&P indicated.1.Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 120 * F (48.89* C), or the maximum allowable temperature per state regulation.2.Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log.3.Maintenance staff shall conduct periodic tap water temperature checks and record the water temperatures in a safety log. During a review of the facility's policy and procedure (P&P) titled Maintenance Service dated 12/2009, the P&P indicated; Maintenance service shall be provided to all areas of the building, grounds, and equipment. Crossed Reference F-584

Based on observations, interview and record review the facility failed to have a safe, and homelike environment for six of five sampled residents ( Resident 56, 171,220,273,139 and Resident 31. The facility failed to:1.Ensure the room clocks for Resident 139, 31, and 56 room displayed the correct time.This failure had the potential to cause confusion and disorientation for Resident 139, Resident 31 and Resident 56 and staff.2. Ensure hot water was consistently available at the bathroom sink in Resident 56's room and ensure hot water was available for showers for Resident 171, 220, and 273.This resulted in delays in providing Resident 56 with bed baths and other activities of daily living (ADL-daily self-care activities) and Resident 171, 220 and 273 unable to shower in comfortable water temperature due to the lack of consistently available hot water.Findings: 1.During a review of Resident 139's admission Record, the admission Record indicated Resident 139 was initially admitted to facility on 12/28/23 and readmitted on [DATE]. The admission Record indicated Resident 139 with a diagnosis that included type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) with hyperglycemia (elevated blood sugar), long time use of insulin (medication that lowers blood sugar) and hyperlipidemia (high level of oil/fat in the body). During a review of Resident 139's Minimum Data Set (MDS - a resident's assessment tool) dated 1/2/2026, the MDS indicated Resident 139 had mild cognitive (ability to understand and be understood by others) impairment for daily decision making. The MDS indicated Resident 139 was dependent (helper does all the effort. The resident makes no effort to complete the activity) with bed mobility, oral hygiene, toileting hygiene, personal hygiene, shower and upper/lower body dressing. During a review of Resident 139's History and Physical (H&P), dated 7/24/2024, the H&P indicated, Resident 139 has fluctuating capacity due to cognitive impairment. During a review of Resident 31's admission Record, the admission Record indicated Resident 31 was initially admitted to facility on 4/2/25 and readmitted on [DATE]. The admission Record indicated Resident 31 with a diagnosis of dementia (group of symptoms that affects the memory, thinking, and social abilities), major depressive disorder (persistent mood disorder that negatively affects how a person feels, thinks, and handles daily activities), and anxiety disorder (a feeling of persistent, overwhelming and interferes with the ability to lead a normal life). During a review of Resident 31's MDS dated [DATE], the MDS indicated Resident 31 had cognitive impairment for daily decision making. The MDS indicated Resident 31 was dependent with bed mobility, oral hygiene, toileting hygiene, personal hygiene, shower and upper/lower body dressing. During a review of Resident 56's admission Record, the admission Record indicated Resident 56 was initially admitted to facility on 3/20/20. The admission Record indicated Resident 56 with a diagnosis of hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) type 2 diabetes , and hyperlipidemia. During a review of Resident 56's MDS dated [DATE], the MDS indicated Resident 56 had intact cognitive skills for daily decision making. The MDS indicated Resident 56 was independent with eating and oral care and requires assistant with bed mobility, toileting hygiene, personal hygiene, shower and upper/lower body dressing. During a concurrent observation and interview on 04/07/2026 at 10:58 a.m. in Residents' 56 rooms with Certified Nursing Assistant (CNA 4) and Resident 56, Resident 56 stated the bathroom sink did not produce hot water. CNA 4 stated this had been an ongoing problem in the facility. CNA 4 stated most of the time there was no hot water from the sink, and CNA 4 had to microwave cold water before providing resident care. CNS 4 stated the water temperature fluctuated and it was very difficult to provide care when hot water was not available in the sink. During an observation and interview on 4/8/26 at 9:35 a.m., with CNA 3, and Resident 31 in Resident 31's room, observed the room clock displayed 5 p.m., despite the actual time being 9:35 a.m. Resident 31 did not know the clock was incorrect and wanted to know if it was the same in other resident's room. Resident 31 stated the clock was supposed to be correct to help residents know time of the day correctly without confusion. CNA 3 stated the clocks in the rooms were not working and needed repair. CNA 3 stated it was confusing when the clock has incorrect time. During an interview on 04/09/2026 at 11:17 a.m., with CNA 2, CNA2 could not clean the resident's hair because there was no hot water from the sink in Resident 139's room. CNA 2 stated she usually filled a small container with water from the bathroom sink in the front bathroom to warm it CNA 2 stated she had experienced the lack of hot water twice in the past a month in all the rooms. CNA 2 stated the problem was reported to charge nurse. CNA 2 stated it was inappropriate to use cold water to provide resident care and had to microwave the water to provide comfortable water temperature. During an interview on 04/09/2026 at 1:11 p.m., with Maintenance Supervisor (MS 1), MS 1 stated two days earlier the laundry called him that the water boiler was not producing hot water. MS 1 stated staff members had previously complained about difficulty obtaining hot water. MS 1 stated laundry personnel informed MS 1, on the morning of 4/7/26 that the water boiler was not working properly. MS 1 stated he also received complaints from CNAs almost daily that the water boiler was not producing hot water. MS1 tested the water temperature himself and stated it took 45 seconds to one minute to become hot. MS 1 stated 4/7/2026 was the first time he heard that staff were microwaving water. MS 1 stated he was the appropriate person to notify when the boiler was not functioning. MS1 stated he installed a circulation pump (pump that distribute hot water round the building) about three months ago because some nursing stations did not have regular hot water. During an interview on 04/09/26 at 1:30 p.m., with MS 1, MS 1 stated all staff share responsibility for ensuring the clocks in resident rooms function correctly. MS 1 stated staff who enter the rooms and notice a malfunctioning clock can report it to maintenance. MS 1 stated the maintenance department also conducts room rounds to check the functionality of room supplies and equipment. MS1 stated anyone who frequently enters the rooms, including nurses, can notify maintenance if anything was not working properly. During a review of facility's receipt titled Cash Sales Order dated 1/30/26, indicated facility ordered for circulatory pump and many other items to repair the water boiler three months ago. During a review of the facility's policy and procedure (P&P) titled Water Temperatures, Safety dated 12/2007, the P&P indicated. Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 120 * F (48.89* C), or the maximum allowable temperature per state regulation. Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log. Maintenance staff shall conduct periodic tap water temperature checks and record the water temperatures in a safety log. During a review of the facility's policy and procedure (P&P) titled Maintenance Service dated 12/2009, the P&P indicated; Maintenance service shall be provided to all areas of the building, grounds, and equipment. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. The maintenance Director is responsible for developing and maintaining a schedule of maintenance service to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner. Functions of maintenance personnel, include, but are not limited to: Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. Maintaining the building in good repair and free of hazards. Establishing priorities in providing repair service. Providing routinely scheduled maintenance service to all areas. 2.During a review of Resident 171's admission Record, the admission Record indicated Resident 171 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 171 with diagnoses of but not limited to urinary tract infection (UTI- an infection in the bladder/urinary tract), polyneuropathy (disease or dysfunction of multiple nerves, typically causing numbness or weakness in the hands and feet), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and chronic pain (pain that lasts longer than three months). During a review of Resident 171's Physician History and Physical (H&P), dated 11/13/2025, the H&P indicated Resident 171 had the capacity to understand and make decisions. During a review of Resident 171's Minimum Data Set (MDS-a resident assessment tool), dated 11/20/2026, the MDS indicated Resident 171 was dependent (helper does all the effort) on nursing staff with showering, toileting, and transferring. During a review of Resident 220's admission Record, the admission Record indicated Resident 220 was admitted to the facility on [DATE] with diagnoses of but not limited to gout (a common and highly painful form of inflammatory arthritis), polyneuropathy, chronic viral hepatitis C (a viral infection of the liver that leads to illness and can be spread by contact with the contaminated blood), and pain in the left and right ankles and joints. During a review of Resident 220's H&P, dated 12/12/2025, the H&P indicated Resident 220 had the capacity to understand and make decisions. During a review of Resident 220's MDS, dated [DATE], the MDS indicated Resident 220 needed nursing staff supervision or touching assistance (helper provides verbal cues and or touching, steadying, and or contact guard assistance as resident completes activity) with showering, toileting oral hygiene, and transferring. During a review of Resident 273's admission Record, the admission Record indicated Resident 273 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of but not limited to quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), dermatitis, peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs) and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 273's H&P, dated 11/7/2025, the H&P indicated Resident 273 had the capacity to understand and make decisions. During a review of Resident 273's MDS, dated [DATE], the MDS indicated Resident 273 was dependent (helper does all the effort) on nursing staff with showering, oral hygiene, personal hygiene and transferring. During a review of Resident 273's Order Summary Report, dated 3/23/2026, the Order Summary Report indicated Resident 273 had an order to cleanse the left and right breast fold with soap and water every day for skin maintenance. During an interview on 4/8/2026 at 10:48 a.m. with Resident 220, Resident 220 stated the facility runs out of hot water in the mornings because the kitchen uses all the hot water. Resident 220 stated for the past couple of weeks had to shower early in the morning to avoid receiving a cold shower. During an interview on 4/8/2026 at 12:08 p.m. with Resident 171, she stated that on 4/5/2026 (Sunday) and 4/6/2026 (Monday) she refused to shower because the water was cold. Resident 171 stated cold water was uncomfortable and did not kill germs, and she did not feel as clean after using it. She also stated she has bowls in her closet that the CNAs fill with water for her bed baths, and they heat the water in the microwave before using it. During an interview on 4/8/2026 at 1:33 p.m. with Resident 273, Resident 273 stated she had not showered in three weeks because the water was cold. Resident 273 stated that on one occasion she screamed because the shower water was so cold. She stated she does not feel as clean when the water was cold during a shower or bath, and that cold showers are uncomfortable and unpleasant. During an interview on 4/8/2026 at 1:45 p.m. with Certified Nursing Assistant (CNA) 10, CNA 10 stated the water in the showers was sometimes cold because the kitchen uses a large amount of hot water. CNA 10 stated the water in the showers becomes cold after 12 p.m. During an interview on 4/8/2026 at 1:47 p.m. with CNA 8, CNA 8 stated she was working at the facility on 4/6/2026 and the hot water was not functioning in the evening. During an interview on 4/8/2026 at 1:55 p.m. with Maintenance Supervisor (MS), the MS stated he had received complaints from CNAs about the shower water not getting hot. The MS stated the boiler was not working on 4/7/2026 and it was repaired on 4/7/2026 at 8 a.m. During a review on 4/10/2026 at 3:19 p.m. with the Director of Nursing (DON), the DON stated it was not appropriate or acceptable for residents to bathe in cold water. The DON stated nursing staff should not heat water in the microwave to bathe residents, as they cannot accurately determine the water temperature and residents could be at risk for scalding. During a review of the facility's invoice dated 4/7/2026, the invoice indicated the MS contacted a heating repair company due to lack of hot water. The invoice indicated a failed igniter and ignition module were identified and replaced. The invoice indicated after both parts were replaced the unit was functioning properly. During a review of the facility's policy and procedure (P&P), titled Safety of Water Temperatures, dated 12/2007, the P&P indicated, If at any time water temperatures feel excessive to the touch., staff will report this finding to the immediate supervisor. Cross Reference F921

Based on observation, interview, and record review, the facility failed to ensure staff followed infection control practices for two of three sampled residents (Residents 242 and 180). The facility failed to:1.Sanitize the blood pressure (BP) cuff and stethoscope(instrument used to hear heart beat) before using them during Resident 242's 9:00 a.m. medication administration.2.Perform hand hygiene on two separate occasions while takingResident 242's blood pressure during Resident 242's 9:00 a.m. medication administration.3.Perform hand hygiene before distributing the lunchtime meal trays.4.Perform hand hygiene while providing care to Resident 180.These failures had the potential for cross contamination (the transfer of bacteria, viruses, microorganisms, or other harmful substances from one surface to another through improper or unsanitary equipment, procedures, or products) and the transmission of infectious agents.Findings: During a review of Resident 242's admission Record, the admission Record indicated, Resident 242 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnosis including anemia (low blood count), hypertension (HTN-high blood pressure), and dementia (a progressive state of decline in mental abilities). During a review of Resident 242's History and Physical (H&P), dated 3/1/2026, the H&P indicated Resident 242 was alert and oriented. During a review of Resident 242's Minimum Data Set (MDS – a resident assessment tool) dated 1/1/2026, the MDS indicated Resident 242 cognition (ability to think, understand, learn, and remember) was intact. The MDS indicated Resident 242 was dependent (helper does the work) with activities of daily living ([ADLs] daily self-care activities like toileting, bathing and dressing). During a review of Resident 242's Order Summary Report dated 4/9/2026, the Order Summary Report indicated Resident 242 had orders for carvedilol ( BP medication) 25 milligrams (mg- unit of measure) give two times (BID) a day for hypertension (HTN) hold if systolic blood pressure (SBP- top number) less than (<) 110, hold for heart rate (HR) 60. During an observation on 4/8/2026 at 9:28 a.m. in Resident 242's room, observed Licensed Vocational Nurse (LVN) 4 remove an automated (electronic device that automatically inflates and deflates) blood pressure cuff from the medication cart, enter the room, and take Resident 242's blood pressure. The machine displayed an error message, and LVN 4 stated he needed to retake the blood pressure. LVN 4 did not perform hand hygiene or sanitize the blood pressure cuff before or after using it on Resident 242. 2.During an observation on 4/8/2026 at 9:40 a.m. in Resident 242's room, observed LVN 4 remove a manual blood pressure cuff and stethoscope from the medication cart, enter the room, and retake Resident 242's blood pressure. LVN 4 did not perform hand hygiene or sanitize the blood pressure cuff or stethoscope before or after taking the resident's blood pressure. After completing the task, LVN 4 placed the cuff and stethoscope on top of the medication cart and again did not perform hand hygiene. LVN 4 stated he would clean the blood pressure cuff and stethoscope later. During an interview on 4/8/2026 at 1:41 p.m., LVN 4 stated he forgot to clean the blood pressure cuffs and stethoscope and did not perform hand hygiene because he was nervous. LVN 4 stated he should have performed hand hygiene and sanitized the blood pressure cuff and stethoscope before taking Resident 242's blood pressure to prevent the spread of germs and bacteria. 3. During an observation on 4/7/2026 at 12:10 p.m. in the main dining room, observed the Activities Assistant (AA) serving the lunchtime meal trays. The AA took a pen out of his pocket and wrote something down, then opened a resident's milk without performing hand hygiene. The AA returned to the meal cart, picked up another meal tray, and served a resident. The AA again removed the pen from his pocket, wrote something down, and opened another resident's milk without performing hand hygiene. The AA then proceeded back to the meal cart, retrieved another tray, and served another resident. The AA opened additional milk and removed the plastic lid from a cranberry juice container, and no hand hygiene was observed at any time during the process. During an interview on 4/7/2026 at 12:59 p.m., with the AA, the AA stated he put his hand in his pocket to retrieve his pen and wrote on the residents' meal tickets without performing hand hygiene before continuing to distribute the lunch trays. The AA stated staff were expected to perform hand hygiene before serving residents their meal trays to avoid spreading germs to the residents. During an interview on 4/10/2026 at 9:15 a.m., with the Infection Preventionist (IP), the IP stated staff were expected to perform hand hygiene before and after every task and whenever they come into contact with a resident or the resident's belongings. The IP stated that multi use equipment, such as blood pressure cuffs and stethoscopes, must be sanitized before and after each use. The IP stated that when staff do not sanitize multi use equipment and do not perform hand hygiene, both residents and staff were at risk for infection from the spread of germs and bacteria and may become susceptible to disease. During an interview on 4/10/2026 at 2:12 p.m., with the Director of Nursing (DON), the DON stated staff must perform hand hygiene between residents, after touching any item, and before passing out residents' meal trays. The DON stated blood pressure cuffs and stethoscopes must be sanitized every time they come into contact with residents. The DON stated when staff do not follow infection control practices, there was a potential for cross contamination. 4. During a review of Resident 180 's admission Record, the admission Record indicated Resident 180 was admitted to the facility on [DATE] with diagnoses including muscle weakness (loss of muscle strength).) polyneuropathy (a condition that cause weakness, numbness, and burning pain, typically starting in the hands and feet ), and type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) with hyperglycemia (high blood sugar) During a review of Resident 180's Minimum Data Set ( MDS-a resident assessment tool) dated 03/25/2026, the MDS indicated Resident 180 was cognitively intact. The MDS indicated Resident 180 needs partial/moderate assistance (helper does less than half the effort ) with ADLs. During an observation on 04/09/2026 at 4:14 p.m., observed Certified Nursing Assistant (CNA) 7 walking with a clear plastic bag containing a gown and a towel. CNA 7 entered Resident 180 room and placed the bag on a table without performing hand hygiene. CNA 7 then exited the room, retrieved a blood pressure machine from the hallway, and entered Resident 180's to perform vital signs on Resident 180 without performing hand hygiene. After taking Resident 180's blood pressure, CNA 7 walked toward the next bed to take another blood pressure reading. During an interview on 04/10/2026 at 12:39 p.m. with Certified Nursing Assistant (CNA) 7, CNA 7 stated it was important to sanitize her hands before entering any resident rooms and to sanitize and clean the blood pressure machine after each use to prevent the spread of infection. CNA 7 stated she needs to be more careful and aware that residents are on enhanced barrier precautions. CNA 7 stated residents can become sick and spread germs if staff do not wash or sanitize their hands. During an interview on 04/10/2026 at 12:28 p.m. with Registered Nurse Supervisor 1 (RNS 1), RNS 1 stated staff should always disinfect equipment before and after use and wash their hands to avoid the spread of infection. RNS 1 stated staff receive continual education on the importance of infection control and stated she does not know why some staff still enter rooms without performing hand hygiene, but she will continue to provide in service training. During a review of the facility's policy and procedure (P&P) titled Hand Hygiene dated 2/2025, the P&P indicated to reduce the risk of infection transmission and protect residents, staff, and visitors by ensuring proper hand hygiene practices are consistently followed in all areas of the nursing home. Hand hygiene is the single most effective method to prevent the spread of infections in healthcare settings. All staff must perform hand hygiene at appropriate times using approved techniques and products. During a review of the facility's policy and procedure (P&P) titled Cleaning and Disinfecting Non- critical Resident – Care Items dated 6/2011, the P&P indicated, reusable items are cleaned and disinfected or sterilized between residents ( e.g., stethoscopes, durable medical equipment).

Based on observation, interview, and record review, the facility failed to ensure the residents' right to privacy and dignity was maintained during care and while in common areas for one of three sampled residents (Resident 256).This failure resulted in Resident 256 being visibly exposed on multiple occasions, with legs and indwelling urinary catheter (foley catheter-a tube inserted into the bladder [tubing] drains the urine into a collection bag) tubing observable to others, which had the potential to cause embarrassment, decreased self-esteem and self-worth.Findings:During a review of Resident 256's admission Record, the admission Record indicated Resident 256 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease (a progressive disorder that affects movement), and atrial fibrillation (irregular heartbeat). During a review of Resident 256's History and Physical (H&P), the H&P indicated Resident 256 has limited decision-making capacity.During a review of Resident 256's Minimum Data Set (MDS a resident assessment tool) dated 3/24/2026, the MDS indicated Resident 256 was dependent (helper does all of the effort) of care and required assistance with eating, toileting, and showering.During a concurrent observation and interview on 4/8/2026 at 9:41 a.m., observed Licensed Vocational Nurse (LVN) 1 administer medication to Resident 256 while the resident's privacy curtain remained open from the hallway. Resident 256's legs and foley catheter tubing. LVN 1 stated staff should close the privacy curtain while performing care to maintain the resident's privacy and dignity. LVN 1 stated leaving the curtain open could make the resident feel exposed, uncomfortable, and embarrassed.During a concurrent interview and record review on 4/8/2026 at 9:48 a.m. with Licensed Vocational Nurse (LVN) 1, reviewed Resident 256's Care Plan dated 3/2026. LVN 1 stated there was no documentation indicating that the resident preferred or consented to having the privacy curtain remain open during care or medication administration.During a concurrent observation and interview on 4/9/2026 at 10:11 a.m. with the Occupational Therapist (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Assistant (OTA), observed Resident 256 sitting in a wheelchair in the hallway while accompanied by the OTA. Resident 256 legs were exposed, and the foley catheter tubing was visible. The OTA acknowledged that exposing the resident's legs and catheter tubing in the hallway did not maintain the resident's dignity and stated that staff should have intervened immediately to cover the resident and reposition the tubing. The OTA stated such exposure could cause Resident 256 to feel humiliated, experience a loss of dignity, and lose trust in staff's ability to protect their privacy.During an interview on 4/10/2026 at 3:24 p.m., with the Senior Nurse Executive (SNE), SNE stated facility policy requires staff to maintain residents' dignity at all times. The SNE stated this includes closing privacy curtains or doors during care, keeping residents properly covered, and ensuring that medical devices, such as foley catheters, were not exposed in public areas. The SNE stated staff were expected to close privacy curtains or doors before providing care, including medication administration, and to ensure the resident was not exposed. The SNE stated residents sitting in a wheelchair in the hallway should be fully dressed or covered and that any tubing or medical devices should be discreetly positioned to protect dignity and privacy. The SNE stated failing to follow these expectations can result in psychosocial harm to the resident, including embarrassment and loss of dignity, and reflects a breakdown in the facility's system to ensure staff compliance with resident rights.During a review of the facility's policy and procedure (P&P) titled, Catheter Care, Indwelling, dated 2024, the P&P indicated, Provide privacy and explain the procedure.During a review of the facility's policy and procedure (P&P) titled, Dignity, dated 2024, the P&P indicated, Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.During a review of the facility's policy and procedure (P&P) titled, Policy and procedure (P&P) titled, Resident Rights, dated 2024, the P&P indicated Employees shall treat all residents with kindness, respect, and dignity.

Based on observation, interview, and record review, the facility failed to:1.Ensure three of four sampled residents (Resident 241,193, and 120) call light device was within reach to each resident.This deficient practice had the potential to result in the residents being unable to summon health care workers for assistance with care and services as needed.2.Provide a safe and appropriate bed frame for one of one sampled resident (Resident 58).This deficient practice placed the resident at risk for skin breakdown, discomfort, and an inability to safely position himself in bed, creating a potential for accident hazards. Findings: 1, During a review of Resident 241's admission Record, the admission Record indicated Resident 241 was admitted to the facility on [DATE] with diagnoses including overactive bladder (causes a sudden, uncontrollable urge to urinate), paraplegia, unspecified, (partial or complete paralysis of the lower half of the body), and anxiety disorder, unspecified (emotion characterized by feelings of tension, worried thoughts ) During a review of Resident 241's Minimum Data Set ( MDS-a resident assessment tool) dated 03/27/2026, the MDS indicated Resident 241 was cognitively (ability to think, understand, learn, and remember) intact. The MDS indicated Resident 241 was dependent (helper does all the effort. Residents do none of the effort to complete the activity) with activities of daily living (ADL). During a review of Resident 193's admission Record, the admission Record indicated Resident 193 was admitted to the facility on [DATE] with diagnoses including cachexia, (life-threatening metabolic condition causing significant muscle and fat loss), dysphagia unspecified ( difficulty swallowing), and contracture (a permanent tightening of muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) left hand. During a review of Resident 193's MDS dated [DATE] indicated Resident 193 cognition was severely impaired The MDS indicated Resident 193's, was dependent with ADLs. During a review of Resident 120's admission Record, the admission Record indicated Resident 120 was admitted to the facility on [DATE] with diagnoses including, functional quadriplegia (the complete inability to move all four limbs due to severe physical or mental frailty), adult failure to thrive (unintentional weight loss, cognitive decline, and reduced physical activity), and dysphagia unspecified. During a review of Resident 120's MDS dated [DATE], the MDS indicated Resident 120 cognition was moderately impaired. The MDS indicated Resident 120's, was dependent with ADLs. During a concurrent observation and interview on 04/07/2026 at 3:03 p.m., with Resident 241, observed Resident 241 lying awake in bed, calling for help and asking to pull her up in bed. The call light was tied to the back of the bed rail and was not within her reach. When asked if she was able to press the call light, Resident 241 shook her head to indicate no and stated she needed help and could not find it. During a concurrent observation and interview on 04/07/2026 at 3:04 p.m., with Licensed Vocational Nurse 3 (LVN 3), LVN 3 entered the room observed Resident 241 lying in bed. The resident's call light was tied to the back of the bed rail and was not within her reach. Resident 241 was unable to press the call light. LVN 3 stated the call light was supposed to be within reach and when it was not, it caused delays in care, could be frustrating for the resident, and could lead to other issues. During an observation on 04/07/2026 at 3:14 p.m., observed the call lights for Residents 193 and 120 were not within their reach. During an interview on 04/10/2026 at 12:59 p.m., with Certified Nursing Assistant (CNA) 6, CNA 6 stated that she did not tie the call light to the back of the bed rail but forgot to check the call light during her rounds at the end of her shift. CNA 6 stated when a call light was not within reach, residents were unable to ask for help, may fall, and may experience other issues. During an interview on 04/10/2026 at 1:04 p.m. with the Director of Nursing (DON), the DON stated the call light was essential and serves as the resident's first means of communication. The DON stated all staff were expected to ensure call lights were within reach for the residents. During a review of the facility's P&P titled, Dignity, dated 10/2024, the P&P indicated, Individual needs and preferences of the resident are identified through the assessment process. 2.During a review of Resident 58's admission Record, the admission Record indicated Resident 58 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and spinal stenosis (the narrowing of the spaces within your spine, which puts pressure on the nerves and spinal cord). During a review of Resident 58's Height Summary dated 4/19/2025, the Height Summary indicated Resident 58's height was 73 inches (standard unit of length). During a review of Resident 58's Minimum Data Set (MDS- a resident assessment tool) dated 1/26/2026, the MDS indicated Resident 58's cognition (ability to think, understand, learn, and remember) was intact. The MDS indicated Resident 58 required maximal (helper does more than half the effort) assistance with toileting, showering, bathing, and personal hygiene. During a concurrent observation and interview on 4/7/2026 at 10:33 a.m., in Resident 58's room, Resident 58 stated his bed was too short and he has mentioned this to the staff, but nothing was done. Resident 58's feet were observed pressed up against the foot of the bed on the bed board. During a concurrent observation and interview on 4/7/2026 at 1:10 p.m., with Certified Nurse Assistant (CNA) 5, in Resident 58's room, CNA 5 stated Resident 58's bed appears too short for him because he is a tall man which can potentially make him uncomfortable. During an interview on 4/10/2026 at 2:45 p.m., with the Director of Nursing (DON), the DON stated Resident 58 should have a longer bed so he is comfortable because his feet should not be touching the bed board. The DON stated Resident 58 having a bed of inadequate length could cause Resident 58 to be uncomfortable. During a review of the facility's policy and procedure (P&P) titled, Quality of Life- Home Like Environment, dated 11/2024, the P&P indicated, It is the policy of this facility to provide each resident with a safe, clean, comfortable, and homelike environment. During a review of the facility's P&P titled, Dignity, dated 10/2024, the P&P indicated, Individual needs and preferences of the resident are identified through the assessment process.

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS- a resident assessment tool) accurately reflected the care and services provided to one of three sampled residents (Resident 7)This deficient practice resulted in the transmission of inaccurate data to the Centers for Medicare and Medicaid Services (CMS) regarding Resident 7's health status and individual healthcare needs.Findings:During a review of Resident 7's admission Record, the admission Record indicated Resident 7 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 7's diagnoses included diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and dementia (a progressive state of decline in mental abilities).During a review of Resident 7's MDS dated [DATE], the MDS indicated Resident 7's cognition (ability to think, understand, learn, and remember) was severely impaired. The MDS indicated Resident 7 was dependent (helper does all of the effort) on activities of daily living (ADLs- activities such as bathing, dressing, and toileting a person performs daily).During a concurrent interview and record review on 4/9/2026 at 3:31 p.m., with the Minimum Data Set Nurse (MDSN) 2, Resident 7 MDS was reviewed. MDSN 2 stated Resident 7 was not currently on any anticoagulants (medication that prevent blood clots from forming in the bloodstream). MDSN 2 stated Resident 7's MDS was inaccurate and stated it was important to ensure the MDS was coded correctly because it reflects the assessment and care plan for Resident 7.During an interview on 4/10/2026 at 2:45 p.m., with the Director of Nursing (DON), the DON stated it was important the MDS was completed accurately because it reflects the resident's condition in real time.During a review of the facility's policy and procedure (P&P) titled, Resident Assessment Instrument {RAI}Process, dated 10/2024, the P&P indicated, The purpose of the policy is to establish a standardized process for conducting and completing comprehensive assessments of residents, in accordance with the guidelines outlined in the RAI Manual that ensures accurate and timely assessments reflecting the resident's needs and support appropriate care planning. The P&P indicated, MDS provides a core set of screening, clinical, and functional status elements that forms the foundation of the comprehensive assessment for all residents of long-term care facilities

Based on observation, interview, and record review, the facility failed to ensure that one of three sampled residents (Resident 139) received a bed bath and an incontinent (loss of the ability to control urine and feces) pad change on 4/7/2026. This deficient practice resulted in Resident 139 experiencing itching and scratching from a wet incontinent pad, lowered self esteem, and appearing emotional while in the facility.Findings:During a review of Resident 139's admission Record, the admission Record indicated Resident 139 was initially admitted to facility on 12/28/23 and readmitted on [DATE]. The admission Record indicated a diagnosis that included type 2 diabetes ( a disorder characterized by difficulty in blood sugar control and poor wound healing) with hyperglycemia (elevated blood sugar), long time use of insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) and hyperlipidemia (high level of oil/fat in the body).During a review of Resident 139's Minimum Data Set (MDS - a resident's assessment tool) dated 1/2/2026, the MDS indicated Resident 139 had mild cognitive (ability to think, understand, learn, and remember)skills for daily decision making. The MDS indicated Resident 139 was dependent (helper does all the effort. The resident makes no effort to complete the activity) with bed mobility, oral hygiene, toileting hygiene, personal hygiene, shower and upper/lower body dressing.During a review of Resident 139's History and Physical (H&P), dated 7/24/2024, the H&P indicated, Resident 139 has fluctuating capacity due to cognitive impairment.During a review of Resident 139's Care plan dated 1/11/2024, the Care Plan indicated Resident 139 has a self-care deficit related to muscle weakness. The Care Plan intervention indicated facility will honor and respect Resident 139's preference for bathing which is a bed bath per schedule. Resident 139 is totally dependent on toileting and incontinent care. Encourage Resident 139 to use call light for assistance.During a concurrent observation and interview on 4/7/26 at 11:54 a.m., with Resident 139 in Resident 139's rooms, Resident 139 was laying down in bed. Resident 139 stated she was itching and had not been changed since the morning. Resident 139 stated she had pushed the call light, and Certified Nursing Assistant CNA 1 answered the call light at 11:20 a.m., and informed her that (CNA 2) would come in approximately 10 minutes to change Resident 139. Resident 139 was significantly itching and was still in a wet incontinent pad. During a concurrent observation and interview on 4/7/26 at 11:58 a.m., with Licensed Vocational Nurse 2 (LVN 2) and Resident 139, LVN 2 entered Resident 139's room and stated that CNA 2 went on break at 11:35 a.m. and was expected to return at 12:30 p.m. While LVN 2 was in the room, Resident 139 stated the last perineal care (cleaning of the genital and anal areas) occurred on 4/7/2026 at 4:30 a.m., and no additional care had been provided since then. LVN 2 stated that CNA 2 provided personal care to Resident 139's roommate earlier that morning but did not change Resident 139's incontinent pad. LVN 2 stated Resident 139 had requested to be kept comfortable and to avoid itching caused by a wet incontinent pad. Resident 139 stated this occurred almost daily and she expect to receive care no later than 10:00 a.m. to 11:00 a.m. Resident 139 appeared emotional, was scratching the skin due to itching, and verbally expressed discomfort from remaining in a wet incontinent pad.During a concurrent observation and interview on 4/7/26 at 12:08 p.m. with CNA 2, CNA 2 stated she had changed Resident 139's roommate and then went on break at 11:45 a.m. Resident 139 stated that while CNA 2 was in the room, no staff asked whether the resident needed to be changed. CNA 2 stated she was unable to change Resident 139 alone and required assistance, but she did not request help from other co workers.During an interview on 4/9/26, at 10:58 a.m., with CNA 1, CNA 1 stated her responsibilities include ensuring residents were safe, comfortable and their needs were addressed. CNA 1 stated all CNAs provide incontinent care to promote comfort, prevent pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure on the skin), maintain dignity, and prevent infection. CNA 1 stated delays in providing incontinent care can result in skin breakdown, discomfort, irritation, skin redness and loss of dignity. CNA 1 stated on 4/7/26 at 11:20 a.m. she answered Resident 139's call light. The resident requested to be changed because the incontinent pad was wet and causing itching. CNA 1 stated she informed Resident 139 she would check with the assigned CNA (CNA 2) and return in approximately 10 minutes. CNA 1 stated she did not inform anyone because she was in the middle of providing care to another resident. CNA 1 stated she did not provide the needed assistance and did not communicate Resident 139's need for incontinent care to another CNA.During a review of facility's policy and procedure (P&P) titled' Activities of Daily Living (ADLs), dated 10/2024, the P&P indicated Each resident of the facility receive and must be provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being consistent with the resident's comprehensive assessment and plan of care. This will include nursing staff conducting routine resident monitoring to ensure resident safety and well-being. Staff will ensure ADL is monitored, assisted with, and provided to residents who are unable to perform ADL.Ensure the following ADL are performed, supervised and assisted included. CNAs will perform self-care with ADLs at the level on the CNA care plan. Encourage the residents to make choice related to their daily living-clothing, time to get up, time for a bath, and type of bath.Bathing showering/ and personal hygieneEating/feedingDressingGroomingToiletingTransferring bed/chairRepositioningWalking /Ambulation

Based on observation, interview, and record review the facility failed to ensure Resident 242 received ferrous sulfate (iron - mineral) and carvedilol (blood pressure medications) as prescribed on 4/10/2026 at 9:00 a.m.This failure had the potential to prevent the medications from maintaining a therapeutic dose level (a level in the blood needed for the medication to work effectively) when medications are not administered according to the physician's orders.Findings:During an observation on 4/8/2026 at 9:28 a.m. in Resident 242's room, Licensed Vocational Nurse 4 (LVN 4) was observed preparing and administering the resident's 9:00 a.m. medications. LVN 4 did not prepare or administer Resident 242's 9:00 a.m. ferrous sulfate or carvedilol as ordered by the physician. The carvedilol was not administered because the medication was not available.During a review of Resident 242's admission Record, the admission Record indicated, Resident 242 was admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 242 with diagnosis including anemia (a condition where the body does not have enough healthy red blood cells), hypertension (HTN-high blood pressure), and dementia (a progressive state of decline in mental abilities).During a review of Resident 242's History and Physical (H&P), dated 3/1/2026, the H&P indicated Resident 242 was alert and oriented.During a review of Resident 242's Minimum Data Set (MDS - a resident assessment tool) dated 1/1/2026, the MDS indicated Resident 242 cognition (ability to think, understand, learn, and remember) was intact. The MDS indicated Resident 242 was dependent (helper does the work) with activities of daily living ([ADLs] daily self-care activities like toileting, bathing and dressing).During a review of Resident 242's Order Summary Report dated 4/9/2026, the order summary report indicated Resident 242 had an order for iron (mineral) 325 milligrams (mgs- unit of measure) give one tablet by mouth at 9:00 a.m. for anemia. Carvedilol (blood pressure medication) 25 mgs give two times a day (BID) for hypertension hold if systolic blood pressure (SBP- top number) less than (<) 110, hold for heart rate (HR) < 60.During an interview on 4/8/2026 at 1:41 p.m. with Licensed Vocational Nurse 4 (LVN 4), LVN 4, stated he missed administering Resident 242's ferrous sulfate because he did not see the order on the computer screen. LVN 4 stated Resident 242's carvedilol was not administered because the medication was unavailable. LVN 4 stated not receiving these medications placed Resident 242 at risk for a stroke (blood flow to the brain is blocked) or a heart attack (blood flow to heart is blocked).During an interview on 4/10/2026 at 2:02 p.m. with the Director of Nurses (DON), the DON stated medications should be administered as prescribed by the physician and must be available for nurses to give. The DON stated when these medications were not administered as prescribed there would be a delay in treatment and a possibility Resident 242 could experience high blood pressure.During a review of the facility's policy and procedure (P&P) titled Medication Administration dated 5/2022, the P&P indicated Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so.Cross reference F759

Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5 percent % (percent) during medication pass for one of seven sampled residents (Residents 242) by failing to:1.Administer ferrous sulfate (iron-mineral) and carvedilol (blood pressure medication) as prescribed by Resident 242's physician.These deficient practices resulted in a medication administration error rate of 6.9%, which exceeded the 5% threshold and medications not to maintain a therapeutic dose level (maintain a certain level in your blood to work well) when not administering medications according to physician's orders.Findings:During a review of Resident 242's admission Record, the admission Record indicated, Resident 242 was admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 242 with diagnosis including anemia (a condition where the body does not have enough healthy red blood cells), hypertension (HTN-high blood pressure), and dementia (a progressive state of decline in mental abilities).During a review of Resident 242's History and Physical (H&P), dated 3/1/2026, the H&P indicated Resident 242 was alert and oriented.During a review of Resident 242's Minimum Data Set (MDS - a resident assessment tool) dated 1/1/2026, the MDS indicated Resident 242 cognition (ability to think, understand, learn, and remember) was intact. The MDS indicated Resident 242 was dependent (helper does the work) with activities of daily living ([ADLs] daily self-care activities like toileting, bathing and dressing).During a review of Resident 242's Order Summary Report dated 4/9/2026, the order summary report indicated Resident 242 had an order for iron (mineral) 325 milligrams (mgs- unit of measure) give one tablet by mouth at 9:00 a.m. for anemia. Carvedilol (blood pressure medication) 25 mgs give two times a day (BID) for hypertension hold if systolic blood pressure (SBP- top number) less than (<) 110, hold for heart rate (HR) < 60.During an interview on 4/8/2026 at 1:41 p.m. with Licensed Vocational Nurse 4 (LVN 4), LVN 4, stated he missed administering Resident 242's ferrous sulfate because he did not see the order on the computer screen. LVN 4 stated Resident 242's carvedilol was not administered because the medication was unavailable. LVN 4 stated not receiving these medications placed Resident 242 at risk for a stroke (blood flow to the brain is blocked) or a heart attack (blood flow to heart is blocked).During an interview on 4/10/2026 at 2:02 p.m. with the Director of Nurses (DON), the DON stated medications should be administered as prescribed by the physician and must be available for nurses to give. The DON stated when these medications were not administered as prescribed there would be a delay in treatment and a possibility Resident 242 could experience high blood pressure.During a review of the facility's policy and procedure (P&P) titled Medication Administration dated 5/2022, the P&P indicated Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so.Cross Reference F755

Based on observations, interviews, and record review, the facility failed to ensure medications were stored safely and in accordance with manufacturer expiration dates and facility policy. The facility failed to:1.Remove expired medications, expired vaccines from medication rooms2. Replaced an outdated insulin emergency kit (Ekit- emergency medication used to treat high blood sugar) after it was last on 11/16/2025.These failure had the potential to result in ineffective treatment, delayed access to emergency medications, and compromised resident safety for residents who received these medications.Findings:During a concurrent observation and interview on 4/7/2026 at 11:00 a.m. with Registered Nurse Supervisor 3 (RNS 3), in medication room [ROOM NUMBER], observed a container of Gavilyte -G sol (laxative) with an expiration date of 6/16/2025. RNS 3 stated staff must discard expired medications because they may no longer be effective and should not be given to a resident.During a concurrent observation and interview on 4/7/2026 at 2:15 p.m. with Licensed Vocational Nurse 5 (LVN 5), in medication room [ROOM NUMBER] two expired pneumococcal (respiratory illness) vaccines (medical treatment that helps the body fight disease) with expiration date of 3/12/2026 and 3/24/2026, two expired COVID-19 (respiratory illness) vaccines with expiration date of 3/12/2026, and 3/24/2026), and an open insulin e-kit last accessed (opened) on 11/16/2025. LVN 5 stated staff must discard expired medications because they are not safe to give to residents. LVN 5 stated that the insulin e-kit opened on 11/16/2025 should have been reordered on that day. LVN 5 stated e-kits are for emergencies and medications need to be available.During an interview on 4/10/2026 at 2:02 p.m. with the Director of Nursing (DON), the DON stated staff should not store expired medications in the medication rooms and must discard them because they may lose their potency and become ineffective. The DON stated Ekit should be reordered on the day they were opened to ensure medications were available in an emergency.During a review of the facility's policy and procedure (P&P) titled, Medication Ordering and Receiving dated 2024, the P&P indicated, the nurse records the medication use from the emergency kit on the medication order form and calls the pharmacy for replacement of the kit/dose and/or flags the kit with a color coded lock to indicate need for replacement of kit/dose, as soon as possible after the medication has been administered. The kits are monitored/inventoried by the (consultant pharmacist/provider pharmacy at least every thirty (30) days) for completeness and expiration dating of the contents.During a review of the facility's P&P titled, Medication Storage in the facility dated 2024, the P&P indicated, no expired medication will be administered to a resident. All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 10), who was admitted to the facility from a General Acute Care Hospital (GACH) on [DATE], was not administered Baclofen (a medication that relaxes the muscles to relieve spasm, tightness, and cramps) due to a known side effect of confusion, when: 1. Registered Nurse (RN) 1 did not review Resident 10's entire Discharge Instructions dated [DATE] and [DATE] for accuracy, prior to transcribing the orders in Resident 10's chart. 2. RN 1 did not review and clarify conflicting instructions outlined in the GACH's Discharge Instructions dated [DATE] which indicated do not use Baclofen since caused confusion versus the Discharge instructions dated [DATE], which indicated Medications to Continue to Take with no Change which indicated Baclofen 10 milligrams ([mg] metric unit of measurement, used for medication dosage and/or amount) give 0.5 tablet three times daily, with Resident 10's physician. 3. RN 1 administered 5 doses of Baclofen 5 milligrams ([mg] metric unit of measurement, used for medication dosage and/or amount) to Resident 10 without reconciling the orders with Resident 10's physician. 4. RN 1 did not follow the facility's Policy and Procedure (P/P), titled, Medication Orders Non-Controlled Medication Order Documentation revised 8/20219, which indicated nurses are to verify the GACH's order with attending physician before medication (Baclofen) was transcribed for administration. These deficient practices resulted in Resident 10 receiving Baclofen 5 mg from [DATE] through [DATE] (a total of six doses), experiencing shortness of breath (SOB), elevated blood pressure (BP), generalized weakness and increased confusion. Resident 10 was transferred to a GACH, where he was diagnosed with acute toxic encephalopathy (a condition characterized by sudden and severe brain dysfunction caused by exposure to toxic substances) and was dialyzed (treatment to remove waste products and excess fluid from the blood when the kidneys are unable to do so). On [DATE] at 3:28 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called in the presence of the facility's Administrator (ADM), the Interim Chief Clinical Officer (CCO) and the Senior Nurse Executive (SNE) due to the facility's failure to recognize a discrepancy in the GACH's discharge instructions and follow up with Resident 10's attending physician to clarify discharge/transfer orders prior to transcribing Baclofen for administration to Resident 10. On [DATE], the facility submitted an acceptable IJ Removal Plan ([IJRP] interventions to immediately correct the deficient practices). After onsite verification of the facility's IJRP's implementation through observation, interview, and record review, the IJ was removed on [DATE] at 3:40 p.m., in the presence of the facility's DON and ADM. The facility's IJRP included the following immediate actions: 1. On [DATE], Resident 10 was discharged to a GACH and was readmitted to the facility on [DATE] the admitting nurse verified the admissions orders with the attending physician. A medication error report for Baclofen was completed on [DATE] for the [DATE] admission orders and was reported to the attending physician and Resident 10's family. Resident 10 was discharged home on [DATE]. 2. On [DATE] the Interim Chief Clinical Officer (CCO)/ Designee provided a 1:1 (a personalized, process where an experienced person works directly with a learner to teach a specific task, process, or skill) in-service training to RN 1 on reviewing discharge orders, reconciling and verifying orders with attending physicians prior to carrying out the orders, the facility's P/P titled, Medication Orders Non-Controlled Medication Order Documentation which requires the licensed nurses to verify the GACH's order with attending physician before medications (Baclofen) are transcribed for administration. 3. On [DATE], a random audit of all in-house patients was completed by Health Information Manager (HIM) and the Interim CCO/designee. A total of 12 residents who were receiving Baclofen were identified and there were no concerns. On [DATE], a random audit of all newly admitted residents in the past 24 hours was conducted by the HIM and Interim CCO/designee. A total of 10 residents identified and their physicians 'orders were reviewed, reconciled with their attending physicians, no concerns were found. 4. On [DATE] the DSD/ Clinical Trainer provided re-training beginning to licensed nurses on entering orders into Electronic Treatment Administration Record ([eMAR/eTAR]) prior/pending confirmation, reconciliation and verification of orders. Licensed Nurses who are on leave, vacation, out sick or newly hired nurses will be educated prior to the start of their shift. 5. On [DATE], the DSD and the Clinical Trainer conducted an in-service training for licensed nursing staff on the facility's P/P titled, Medication Orders Non-Controlled Medication Order Documentation which requires the licensed nurses to verify the GACH's order with attending physician before medications is transcribed for administration. The training will continue until all licensed nursing staff have attended the training by [DATE]. Licensed Nurses who are on leave, vacation, out sick or newly hired nurses will be educated prior to the start of their shift. 5. On [DATE] during the ad hoc (created or done for a particular purpose when necessary or needed) QAPI (Quality Assurance/Quality Assurance and Performance Improvement-a data driven proactive approach to improvement used to ensure services are meeting quality standards) Committee meeting, a root cause analysis (RCA) revealed multiple system-level factors that contributed to the medication reconciliation error. RN 1, who was not the facility's regular admitting nurse, did not follow the reconciliation policy and bypassed physician verification, reflecting a knowledge gap in high-risk medication reconciliation requirements. Although the facility had a policy in place (Medication Orders Non-Controlled Documentation), it was not consistently applied, and there was no structured admission process to support nurses unfamiliar with admissions. Leadership oversight was also limited, with QAPI audits not consistently addressing reconciliation compliance and no real-time monitoring system to ensure medication reconciliation was completed upon admission. The RCA identified the root cause as the absence of a medication reconciliation process that ensured physician verification, standardized documentation, and active leadership oversight. 6. Team Members: Medical Director, Executive Director, Chief Clinical Officer, Director of Staff Education, Regulatory Compliance Nurse. Each member will perform the following: i. Medical Director: will monitor the system, recommend changes, and oversee corrective action plans. This role includes identifying and implementing medical interventions to reduce medication errors. ii. Executive Director (ED): will oversee all corrective actions initiated on [DATE] and continue monthly reviews during QAPI meetings. iii. Chief Clinical Officer (CCO): will oversee the investigation, reporting, and resolution of medication reconciliation audit, ensuring patient safety and regulatory compliance. The CCO will implement corrective actions, conduct audits, monitor staff adherence to policies, and collaborate with the DSD to provide ongoing training, reinforcing best practices in medication management. iv. Regulatory Compliance Nurse: This role entails staying updated on regulatory changes, collaborating with the interdisciplinary team to update policies, and ensuring staff adherence to these policies. It includes participating in quality improvement initiatives, analyzing compliance data, assisting with corrective actions, identifying risks, and investigating incidents to prevent recurrence. This role involves planning, developing, organizing, implementing, coordinating, and directing the quality assurance and assessment program designed to enhance the quality of resident care, in accordance with current rules, regulations, and guidelines that govern the facility. v. Director of Staff Development: This role involves educating staff and plays a critical role in addressing medication reconciliation audits by providing targeted training and education to licensed nursing staff, ensuring compliance with facility policies and regulatory standards. The role includes conducting in-service sessions on proper medication administration, overseeing competency evaluations, and implementing corrective action plans to prevent future errors while promoting a culture of accountability and continuous improvement.Findings: During a review of Resident 10's admission Record (Face Sheet), the Face Sheet indicated Resident 10 was admitted to the facility on [DATE] with diagnosis including osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage, end stage renal disease ([ESRD] irreversible kidney failure and was dependent on hemodialysis. During a review of Resident 10's Minimum Data Set ([MDS] a resident assessment tool) dated [DATE], the MDS indicated Resident 10 was able to make decisions that were reasonable and consistent. The MDS indicated Resident 10 required a one person assist to complete her 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 10's GACH's Discharge summary dated [DATE] and timed at 2:09 p.m., the Discharge Summary indicated to discharge Resident 10 to the facility with the following instructions. a. Do not use Baclofen since the medication caused confusion b. Administer Baclofen 10 mg, give 0.5 tablet, three times daily. During a review of the GACH's discharge instructions, dated [DATE] and timed 8:44 a.m., the Discharge Instructions indicated administer Baclofen 10 mg, give 0.5 tablet, three times daily During a review of Resident 10's Clinical Record there was no written documentation to indicate the admitting nurse (RN 1) notified Resident 10's physician to clarify conflicting instructions to determine if Baclofen should or should not be administered to Resident 10. During a review of Resident 10's Physician's Order Summary, the Physician Order Summary dated [DATE] indicated to administer Resident 10 Baclofen 10 mg, give 0.5 tablet three times a day for muscle spasms. During a review of Resident 10's Medication Administration Record ([MAR] a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 8/2025, the MAR indicated Resident 10 was administered six doses of Baclofen 5 mg from [DATE] to [DATE]. During a review of Resident 10's Change of Condition Evaluation (COC) dated [DATE] and timed at 8:04 a.m., the COC indicated Resident 10 was observed with SOB, weakness, confusion and drowsiness, with a BP of 180/110 millimeters of mercury (mmhg-unit of measurement) and an oxygen saturation ([O2 Sat] oxygen level in the body that indicates the body has enough oxygen supply, normal range of 95 to 100%) rate of 92% to 94 % on room air. The COC indicated Resident 10's physician was notified of Resident 10's COC on [DATE] at 8:45 a.m., and an order was obtained to transfer Resident 10 to the GACH by paramedics. During a review of the Resident 10's Physician's Order Summary, dated [DATE], the Physician's Order Summary indicated to call 911 for Resident 10 because of SOB, elevated blood pressure and generalized weakness. During a review of the GACH's Emergency (ED) Note dated [DATE] and timed at 10:28 a.m., the ED Note indicated Resident 10 was brought to the emergency room by the paramedics because of dizziness, fatigue, and nausea with a BP of 182/69. During a review of the GACH's History and Physical dated [DATE] and timed at 5:08 p.m., the H&P indicated Resident 10 presented at the emergency room (ER) with new onset altered mental status ([AMS] a person not as awake, alert or able to understand or respond to their surroundings as they normally would be), dizziness, nausea and weakness after confirmed administration of Baclofen at the facility. The H&P indicated a few weeks ago, Resident 10 was hemodialyzed at another GACH (date unknown) related to Baclofen toxicity (the extent to which a substance is poisonous and harmful to living thing).The H&P indicated Resident 10 might have received a second unintentional dose of Baclofen and was placed on delirium precautions (simple actions used to help a confused person to stay calm and oriented), frequent reorientation, and admitted for acute encephalopathy, likely due to Baclofen toxicity. During a review of the GACH's Nephrology (a branch of medicine that focuses on the diagnosis, treatment, and management of kidney diseases) Consultation Notes dated [DATE] and timed at 6:49 p.m., the Nephrology Consultation Notes indicated Resident 10 will undergo hemodialysis due to Baclofen toxicity. During a review of the GACH's Discharge summary dated [DATE] and timed at 2:44 p.m., the Discharge Summary indicated a diagnosis of acute toxin encephalopathy. During a review of Resident 10's Skilled Nursing Facility History and Physical (SNF H&P) dated [DATE] and timed at 12:45 p.m., the H&P indicated the facility's nursing department restarted Resident 10's home medications including Baclofen, The H&P indicated Resident 10's medications were started (transcribed and ordered) and administered to Resident 10, without clarifying the discharge medication list with the primary care physician (PCP). During a telephone interview on [DATE] at 12:23 p.m., Resident 10's Family Member (FM) 1 stated Resident 1 was transferred to the facility from a GACH on [DATE] with instructions not to give Resident 10 Baclofen because it made Resident 10 feel weak and confused. FM 1 stated on [DATE] Resident 10 called her complaining she did not feel well, and the facility had given her Baclofen. FM 1 stated she arrived at the facility at 10 a.m., and Resident 10 had been transferred to a GACH due to dizziness, fatigue, SOB and hallucinations. FM 1 stated when she arrived at the GACH, the GACH had not been informed by the facility that Resident 10 was given Baclofen or that it caused Resident 10 confusion. FM 1 stated she notified the GACH and the GACH immediately performed dialysis on Resident 10. FM 1 stated Resident 10 could have died because Resident 10's kidneys no longer functioned. During an interview on [DATE] at 4:11 p.m., RN 1 stated when she received Resident 10's admission papers from the GACH on [DATE], she determined Resident 10 was not allergic to any medication and transcribed the discharge medications listed on the GACH's Discharge Instructions. RN 1 stated she did not call Resident 10's physician to verify and/or clarify Resident 10's discharge medications or instructions because the physicians at the GACH normally prepare the discharge instructions and the primary care physician at the facility could see the orders in Resident 10's medical record. During a interview on [DATE] at 11:57 a.m., RN 1 stated after reviewing the Discharge summary dated [DATE], she did not see the instructions indicating Baclofen should not be given to Resident 10 due to confusion. RN 1 stated had she read the Discharge Summary, compared the GACH's discharge instructions, discharge medication list, and called Resident 10's physician to clarify the instructions, Resident 10 would never have been given Baclofen that caused a COC. During a telephone interview on [DATE] at 12:32 p.m., RN 3 stated on [DATE] during the 7 a.m. to 3 p.m. shift, she received endorsement from the outgoing nurse (11 p.m. - 7 a.m.) that Resident 10 was feeling weak and dizzy. RN 3 stated she assessed Resident 10 at the start of her shift (7 a.m. - 3 p.m.), and Resident 10 complained of right buttock pain, rated at 3 out of 10 on an eleven point scale (0=no pain, 1-3=mild pain, 4-6=moderate pain, and 7-10=severe pain, and 10=worst imaginable pain) and she (RN 3) applied a lidocaine patch (a topical adhesive patch containing lidocaine, used for pain) to the affected site and gave Resident 10 5 mg of Baclofen. RN 3 stated at approximately 8:30 a.m., Resident 10 still felt weak, dizzy, had become more lethargic (a state of decreased consciousness such as fatigue, drowsiness or sleepiness) and was not talking, her B/P was high, she was SOB, and her O2 Sat was 92% on O2 (liters of O2 unknown). RN 3 stated she administered an anti-hypertensive medication to Resident 10, but her BP remained high, she (RN 3) then called Resident 10's physician and was given an order to call the paramedics. During an interview on [DATE] at 12:47 p.m., the SNE stated the admission process included checking the discharge papers from the GACH including the doctor's discharge summary, discharge instructions and the medication list. The SNE stated it was the responsibility of the admitting nurse to call Resident 10's physician to verify and/or reconcile the residents' medications to ensure the residents' prescribed medications were accurate. During a telephone interview on [DATE] at 1 p.m., the facility's Pharmacist stated Baclofen causes central nervous system depression (a condition when the brain and the spinal cord slow down, and the body cannot function properly), dizziness and confusion. The Pharmacist stated physicians should be aware of the side effects of this medication and adjust the dose and/or stop the medication based on the residents' kidney function, response and/or tolerance to the medication. The Pharmacist stated Baclofen cannot be excreted (eliminate or discharge wastes from the body) well from the body when the kidneys are impaired and could increase a resident's risk of side effects associated with the use of the medication. During a telephone interview on [DATE] at 2:51 p.m., the on-call physician, who covered for Resident 10's attending physician, stated the admitting nurse should have contacted the Resident's attending physician to discuss the residents' discharge summary and discharge medications to identify and/or resolve any inconsistencies and discrepancies. During a telephone interview on [DATE] at 4:28 p.m., the GACH's Nephrologist stated Baclofen was not nephrotoxic (poisonous to the kidneys), but it could accumulate in the blood when the kidneys were impaired and cause a resident to have an altered level of consciousness ([ALOC] a change in a patient's state of awareness [ability to relate to self and the environment] and arousal [alertness]) During a telephone interview on [DATE] at 1:20 p.m., the facility's Medical Director stated it was the facility's policy and common practice for the doctors and the licensed nurses to conduct a thorough reconciliation of the residents' discharge medications and review of discharge instructions including the discharge summary to clarify and/or decide the residents' treatment and medications. The Medical Director stated licensed nurses were not to transcribe any medication order without the approval of the primary care physician to ensure the residents were free from inappropriate medications that could affect their safety and wellbeing. During an interview on [DATE] at 11 a.m., the CCO stated Resident 10's COC and the life threatening complications could have been prevented if the admission process was followed. During an interview on [DATE] at 12:33 p.m., the Administrator (ADM) stated the failure to reconcile the medications with Resident 10's physician should not have happened because the facility has ongoing policies and procedures related to admission medication reconciliation. According to Mayo Clinic (a non-profit medical group practice that provides comprehensive and integrated healthcare services renowned for its expertise in cardiology, cancer care, neurology, orthopedics and transplant medicine), BACLOFEN (Oral Route)- Side effects and Dosage dated [DATE], Baclofen was used to help relax the muscles to relieve spasms and cramping by acting on the central nervous system to produce muscle relaxant effects. This medication must be prescribed and used with caution if anyone has an allergy or unusual reaction to it and limit use in elderly because of age-related kidney, liver or heart problems that may likely cause side effects of hallucination, confusion, mental depression, and severe drowsiness. The presence of a medical problem such as a kidney disease may increase the effects of the medication because of slower removal of medicine form the body and should be avoided because of increased risk of serious brain problems such as encephalopathy (a medical condition of the brain affected by some agent or condition such as toxins in the blood). https://www.mayoclinic.org During a review of the facility's P/P titled, Medication Orders Non Controlled Medication Order Documentation revised 8/2019, the P/P indicated the written transfer orders (sent with a resident by a hospital or other healthcare facility) shall be verified with the current order attending physician before medications are administered and the nurse who transcribes the orders must document in the admission form the date, time and by whom the orders were noted.

Based on interview and record review, the facility failed to prevent an avoidable, facility acquired, unstageable (when the stage is not clear, the base of the wound is covered by a layer of dead tissue that may be yellow, grey, green, brown, or black) pressure injury (damage to the skin and underlying structures caused by unrelieved pressure) for one of three sampled residents (Resident 1) by: 1. Failing to reposition Resident 1 every two hours as per physician's orders. 2. Failing to implement its Policy and Procedure (P&P) titled, Wound Care Suggestions and Documentation, dated 2/2025 which indicated Residents who were unable to turn independently would be turned and repositioned every two hours and would be checked for incontinence (loss of voluntary control of bowel and bladder movements) every two hours. As a result of these deficient practices, Resident 1 who was admitted to the facility on [DATE] with intact skin (no wounds) on the Sacrococcyx (area where sacrum [triangular bone at the base of the spine] and coccyx [tailbone] fuse together) area, developed an unstageable pressure injury to the sacrococcyx extending to bilateral (both) buttocks on 5/27/2025 (approximately 11 days after admission), that required evaluation and treatment at a general acute care hospital (GACH) on 6/8/2025. Resident 1's Sacrococcyx pressure injury was debrided (medical removal of dead, damaged, or infected tissue to improve the healing potential of the wound) and reclassified as a stage 4 pressure injury (the most severe stage of a pressure ulcer, characterized by extensive tissue damage extending to muscle, tendon, and sometimes even bone). Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including, post laminectomy syndrome (failed back surgery syndrome which causes lingering pain), disease of the spinal cord, malignant neoplasm of the kidney (kidney cancer), and malignant neoplasm of the bone (bone tumor). During a review of Resident 1's history and physical (H&P) dated 5/17/2025, the H&P indicated Resident 1 was admitted to the facility for physical therapy (PT - a rehabilitation profession that restores, maintains, and promotes optimal physical function) and occupational therapy (OT - rehabilitative profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities). The H&P indicated Resident 1 had the capacity to make medical decisions. The H&P indicated Resident 1 was experiencing weakness and a burning sensation in bilateral lower extremities (legs). The H&P indicated Resident 1 was free from pressure injuries on the Sacrococcyx area. During a review of Resident 1's Skin Check dated 5/17/2025, the Skin Check indicated Resident 1 had a wound on his mid back due to previous spinal surgery. The Skin Check did not indicate there were any other skin issues including the sacrococcyx area. During a review of Resident 1's care plan focused on Resident has a callus (thick skin) to the Left Heel dated 5/17/2025, the care plan goal indicated Resident 1 would not have any complications and interventions included Resident 1 requiring assistance to turn and reposition at least every two hours or more often as needed or requested. During a review of Resident 1's skilled nursing facility (SNF)- Documentation Survey Report for May through June 2025, the SNF Documentation Survey Report indicated: Intervention/ Task turn reposition every 2 hours every shift. The SNF Documentation Survey Report indicated Resident 1 was not turned on the following occasions (N = No, not turned and repositioned): 1. 5/19/2025 (11p.m. to 7 p.m. shift) 2. 5/19/2025 (7 a.m. to 3 p.m. shift) 3. 5/20/2025 (11 p.m. to 7 a.m. shift) 4. 5/21/2025 (11 p.m. to 7 a.m. shift) 5. 5/23/2025 (3 p.m. to 11 p.m. shift) 6. 5/25/2025 (11 p.m. to 7 p.m. shift) 7. 5/26/2025 (11 p.m. to 7 p.m. shift) 8. 5/27/2025 (11 p.m. to 7 a.m. shift) 9. 5/29/2025 (3 p.m. to 11 p.m. shift) 10. 5/30/2025 (11 p.m. to 7 a.m. shift) 11. 5/31/2025 (11 p.m. to 7 a.m. shift) 12. 6/1/2025 (11 p.m. to 7 a.m. shift) 13. 6/4/2025 (3 p.m. to 11 p.m. shift) 14. 6/7/2025 (3 p.m. to 11 p.m. shift) During a review of Resident 1's Alert Note dated 5/21/2025, the note indicated Resident 1 had a coccyx pressure injury, stage two (a shallow open wound). During a review of Resident 1's Order Summary Report, the Order Summary report indicated an order was placed on 5/21/2025 to reposition Resident 1 every two hours. The Order Summary Report also indicated for Sacrococcyx pressure injury stage two; cleanse with normal saline, pat dry and apply triad paste (paste that creates a moist wound healing environment), leave open to air, every shift for 21 days. The Order Summary report indicated the order was discontinued on 5/27/2025. During a review of Resident 1's minimum data set (MDS, a resident assessment tool) dated 5/23/2025, the MDS indicated Resident 1 was cognitively (relate to acquiring knowledge and understanding through thought, experience, and the senses) intact. The MDS indicated Resident 1 was dependent (helper does all the effort) on staff for toileting and bathing. The MDS indicated Resident 1 was partial/ moderate assist (helper does less than half the effort) for rolling left to right and chair to bed transfers were not attempted during the MDS assessment. The MDS indicated Resident 1 was at risk for developing pressure injuries. During a review of Resident 1's Change of Condition (COC) Evaluation dated 5/27/2025, the COC indicated Resident 1's stage two pressure injury had deteriorated (became progressively worse). The COC indicated the wound was noted with peeling skin, and multiple areas with skin gaps. The COC indicated Resident 1's physician (MD 1) ordered a low air loss mattress (a special mattress designed to relieve pressure). The COC indicated Resident 1 would be encouraged to turn and reposition every two hours. During a review of Resident 1's Skin/ Wound Progress Note dated 5/28/2025, the Progress Note indicated Resident 1's sacrococcyx pressure injury had deteriorated and was reclassified as an unstageable pressure injury. During a review of Resident 1's Order Summary Report dated 5/28/2025, the Order Summary Report indicated Santyl Ointment (medication used to remove damaged tissue from pressure injuries) 250 units (a unit of measurement) per gram (GM, a unit of measurement) apply to the sacrococcyx topically (outside of body) each day shift for unstageable pressure injury. During a review of Resident 1's GACH Record titled, Wound Care Consult dated 6/8/2025, the Consult Note indicated Resident 1 was admitted to the GACH on 6/8/2025 with an unstageable sacrococcyx pressure ulcer extending to the bilateral buttocks. The consultation note indicated Resident 1's bone was palpable (abnormaly, able to be touched or felt) under the slough and the wound had a strong malodorous smell (indicating presence of an infection). The Consult Note indicated Resident 1 was to be seen by a surgeon for debridement. During a review of Resident 1's GACH Record titled, Surgery Consult/ H&P dated 6/8/2025, the H&P indicated Resident 1's sacrococcyx wound was debrided at the bedside and a wound culture (sample) was taken of the purulent (pus) drainage. During a review of Resident 1's GACH Record titled, Wound Care Consult- Follow Up dated 6/9/2025, the Consult Note indicated Resident 1's sacrococcyx pressure injury had deteriorated and was reclassified as stage 4 pressure injury after the debridement on 6/8/2025. During a review of Resident 1's GACH Record titled, Hospital Course dated 6/8/2025 to 6/16/2025, the GACH record indicated Resident 1 had a debridement on 6/8/2025 and 6/10/2025. The GACH record indicated the wound culture obtained on 6/8/2025 was positive for enterococcus faecalis (E. Faecalis, an opportunistic pathogen [an organism that causes disease] capable of causing severe infection) and there was unclear evidence of osteomyelitis (bone infection). The GACH record indicated Resident 1 was started on a two-week course of Zosyn (medication used to treat infection). During an interview on 6/18/2025 at 12:25 p.m., with Resident 1's family member (FM) 1, FM 1 stated Resident 1 was still at the GACH because Resident 1 developed a bad pressure injury right where the butt crack starts at the facility that became infected. FM 1 stated Resident 1 had extensive cancer of the kidney and the GACH informed her they were unable to start chemotherapy (powerful drugs to treat cancer) because of the infection of Resident 1's pressure injury. FM 1 stated when Resident 1 was admitted to the facility he did not have any pressure injuries but when he left the facility, he had a huge wound. FM 1 stated she or another family member visited Resident 1 daily. FM 1 stated for four or more hours staff never repositioned Resident 1 or checked if he was wet. FM 1 stated even when Resident 1 was sitting up in the wheelchair in the patio staff never repositioned him. FM 1 stated sometimes, Resident 1 did not have any padding (cushion to relieve pressure off his Sacrococcyx area) on the wheelchair while sitting in it. FM 1 stated after Resident 1 had surgery on his spine he could no longer feel his legs, so he needed help, and he needed to be reminded to change positions. During an interview on 6/18/2025 at 3:48 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was assigned to and cared for Resident 1 frequently during the 11 p.m. to 7 a.m. shift. CNA 1 stated Resident 1 was usually asleep from the beginning of her shift (11 p.m.) to about 4 a.m. to 5 a.m., and she did not turn and reposition him every two hours during that time because he (Resident 1) refused to be woken up. During an interview on 6/20/2025 at 11:45 a.m., with Treatment Nurse (TXN) 1, TXN 1 stated Resident 1 did not have any skin issues on the sacrococcyx area when he was admitted to the facility on [DATE]. TXN 1 stated on 5/21/2025 she (TXN 1) first noticed a very shallow stage 2 pressure injury in Resident 1's sacrococcyx area. TXN 1 stated the wound edges deteriorated and were peeling with slough and then the wound was reclassified as an unstageable pressure injury. TXN 1 stated Resident 1 was up in the wheelchair multiple times a day to visit family. TXN 1 stated wounds could develop if residents sat up in wheelchairs for extended periods of time, and the pressure on the bony areas was not relieved. TXN 1 stated Resident 1's legs were flaccid (weakness, loss of muscle tone, and loss of reflexes) when she provided wound treatments. TXN 1 stated if a resident refused to turn or reposition, the nursing staff should have made a care plan for noncompliance and wrote it in the progress notes. TXN 1 stated turning and repositioning was the number one intervention to prevent worsening of Resident 1's pressure injury. During an interview on 6/20/2025 at 2:02 p.m., with LVN 2, LVN 2 stated he usually worked the 11 p.m. to 7 a.m. shift and he was never notified Resident 1 was refusing to be turned or repositioned. During a concurrent interview and record review on 6/20/2025 at 2:42 p.m., with the unit Director of Nursing (DON), Resident 1's medical records were reviewed. The DON stated Resident 1 was mostly a bed bound patient that had no feeling in his lower body due to spinal surgery. The DON stated Resident 1 required assistance to do his daily routines. The DON stated turning and repositioning every 2 hours was important to keep pressure off the site and turning and repositioning every 2 hours as ordered had the potential to keep pressure sores from developing or worsening. The DON reviewed Resident 1's SNF- Documentation Survey Report for May through June 2025 and stated there were multiple days marked No for turning and repositioning, and each shift that was marked No indicated staff did not turn or reposition Resident 1 for the whole 8-hour shift. The DON stated residents were to be turned every two hours. The DON stated, per the documentation, Resident 1 was not turned and repositioned every two hours as ordered and there was no documentation in the chart to explain why. During a review of the facility's P & P titled Wound Care Suggestions and Documentation dated 2/2025, the P& P indicated care plans were to be updated accordingly to reflect current interventions to prevent further breakdown as appropriate. The P& P indicated each wound a resident had, was to be documented upon admission. The P& P indicated if a resident was refusing care (e.g. refusing to turn), the education provided to the resident was to be documented in the chart. The P &P indicated unstageable pressure injuries; the true extent of the wound could not be determined until the slough was removed. The P/P indicated Residents who were unable to turn independently would be turned and repositioned every two hours and would be checked for incontinence every two hours.

Based on observation, interview, and record review, the facility failed to ensure the facility's Rehabilitation (Rehab) room equipment was not readily accessible for unauthorized use by residents and/or visitors or used as a weapon to hit for one of four sampled residents (Resident 1). The facility failed to: 1. Ensure the Rehab room and equipment located in the Rehab room was secured and supervised at all times to prevent unauthorized access by residents and/or visitors. 2. Ensure Resident 1 did not gain access to a Dowel (a pole or rod used in rehabilitation to improve shoulder mobility and strength) from the facility's Rehab room without staff knowledge. 3. Ensure Resident 1 did not use a Dowel to physically assault Resident 2 and Resident 3. 4. Ensure staff followed the facility Policy and Procedure (P&P) titled, Safety and Supervision of Residents dated 7/2017, which indicated, the facility has individualized resident centered approach to safety, addresses safety and accident hazards for individual residents. The interdisciplinary care team ([IDT] a group of health care professionals with various areas of expertise who work together toward the goals of the residents) shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment. These deficient practices resulted in Resident 1 obtaining a Dowel (used to improve range of motion ([ROM] the direction a joint can move to its full potential), strength, and coordination, particularly for upper body movements like the shoulder and the hand) from the facility's Rehab room without staff knowledge or consent and using the Dowel to hit Resident 2 on her left arm on 2/24/2025 and Resident 3 on her right arm, right shoulder, and face then pushing Resident 3 to the floor on 4/19/2025. Resident 3 sustained a fracture (a break in a bone) to the mid sacrum (a triangular bone located at the base of the spine [back]) and was transferred to a General Acute Care Hospital (GACH) on 4/22/2025. These deficient practices placed residents' and/or visitors at risk for serious harm and death. On 5/8/2025, at 5:27 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 facility's Administrator (ADM) and Director of Nursing (DON) due to the facility's failure to keep the Rehab room equipment secured at all times and not accessible to Resident 1 or any other resident without supervision. On 5/9/2025, the facility submitted an acceptable IJ Removal Plan ([IJRP] an intervention to immediately correct the deficient practices). After onsite verification of the facility's IJRP implementation through observation, interview, and record review, the IJ was removed on 5/9/2025 at 5:23 p.m., in the presence of the facility's ADM and DON. The IJRP included the following: 1. Corrective and appropriate actions to be implemented for the affected residents identified in the deficiencies. a. Immediate Action: On 4/19/2025, Resident 1 and Resident 3's incident was reported to the California Department of Public Health (CDPH) with final investigation of the report completed on 4/25/2025 and submitted. Following the resident-to-resident incident on 4/19/2025, Resident 1 and Resident 3 were immediately separated from each other on 4/19/2025. b. Immediate action: Resident 3 was transferred to another room in a different wing of the building with ongoing monitoring by staff of Resident 3's psychosocial wellbeing. Resident 3 was transferred to the hospital on 4/22/2025 for additional assessment related to an acute fracture of the mid sacrum and was returned to the facility on the same day with no new orders. Resident 3's care plan was updated by the assigned licensed nurse on 4/22/2025 to include a resident-to-resident altercation. c. Immediate action: Resident 1's care plan for behaviors was reviewed and updated on 4/19/2025 to include physical aggressive behavior. On 4/22/2025, Resident 1 was referred to a psychiatric mental health Nurse Practitioner (NP) but refused to meet with a mid-level practitioner (NP). On 4/23/2025 the Interdisciplinary Team ([IDT] a group of health care professionals with various areas of expertise who work together toward the goals of the residents) met with Resident 1 and her family member who agreed to intervene to assist Resident 1 to be seen by a psychiatrist. Resident 1 was sent out to General Acute Care Hospital (GACH) on 4/28/2025 for in-patient psychiatric evaluation related to physical aggression. Resident 1 returned on 4/29/2025 with a diagnosis of a urinary tract infection ([UTI] an infection in the bladder/urinary tract) and an order for antibiotics. Resident 1's care plan and IDT note was updated on 5/09/25 to address Resident 1's use of a dowel during the episode of aggressive behavior on 4/19/2025. d. Immediate Action: Effective 5/8/2025 a tracking system was implemented requiring Rehab staff to sign weighted dowels, free weights, and ankle weights in and out, noting their location and assigned user. If any item is found missing, staff must immediately notify the Rehab Manager and complete an incident log to initiate a prompt search and resolution process. e. Immediate Action: On 5/7/2025, the Executive Director was assigned to the Rehab Manager to ensure that weighted dowels, free weights, and ankle weights were properly locked and secured at the end of each treatment day. A log was created on 5/8/2025 to document and verify daily compliance with this security measure. f. Immediate action: On 5/8/2025, the Executive Director designated the Rehab Manager to ensure that access to the Rehab room is secured when staff were not present to supervise the gym. A log was created on 5/8/2025 to document daily compliance and serve as evidence of adherence to this protocol with rehab staff assigned with responsibility of documenting the time the room was secured and verification that no residents remain inside, to prevent unauthorized and unsupervised access. 2. Governing Body -Quality Assurance Performance Improvement (QAPI) committee a. Immediate Action: The IDT was in-serviced on 5/8/2025 by the Senior Nurse Executive (SNE) to review how to conduct an IDT meeting when reviewing resident to resident incidents. b. Immediate Action: An ad hoc (created or done for a particular purpose as necessary) QAPI Committee meeting was scheduled for 5/9/2025 to conduct a root cause analysis (RCA) to determine key issues stemming from the recent resident to resident altercation to determine process breakdowns, including communication breakdowns, inconsistent documentation, and training gaps in high-risk monitoring protocols/interventions. c. The Executive Director (ED) will oversee corrective actions initiated on 5/8/2025 and monthly thereafter during QAPI meetings which were based on the results of the RCA and plan of corrections for the findings during the survey. Any corrective actions not meeting the 100% compliance benchmark, as determined by medical record audits, such as IDT, care plan and change of condition audits as well as safety equipment monitoring of rehab equipment random audits will be reviewed and revised with the QAPI Committee for revision, further evaluation, and recommendations, with a designated IDT member assigned to each corrective action. d. Any new issues found during medical record audits on resident to resident altercation will be presented to the IDT members for immediate action. The Chief Clinical Officer (CCO) will monitor the immediate actions for implementation of monitoring/audit needs at least monthly for the next 3 months or until compliance is 100% or is achieved. 3. Specific staff involved in implementing the corrective actions. a. Team Members: Medical Director, Executive Director, Chief Clinical Officer, Director of Staff Education, and Regulatory Compliance Nurse. Each member will perform: i. Medical Director: Through the QAPI committee, the Medical Director will monitor the system, recommend changes, and oversee corrective action plans. This role includes identifying and implementing medical interventions related to injuries resulting from resident-to-resident altercation. ii. Executive Director (ED): The ED will oversee all corrective actions initiated on 5/8/2025 and continue monthly reviews during QAPI meetings. iii. Chief Clinical Officer: Leading the IDT, the Chief Clinical Officer will regularly review at-risk residents who have physical aggression behaviors and assess intervention effectiveness and adjust care plans as needed. This role also ensures that abuse prevention practices are standardized, monitors staff compliance, coordinates equipment maintenance, educates staff, oversees data analysis, and conducts reviews to recommend preventive measures. iv. Regulatory Compliance Nurse/ Designee: This role entails staying updated on regulatory changes, collaborating with the interdisciplinary team to update policies, and ensuring staff adherence to these policies. It includes participating in quality improvement initiatives, analyzing compliance data, assisting with corrective actions, identifying risks, and investigating incidents to prevent recurrence. v. Director of Staff Education: This role involves educating staff on care planning, documentation, and protocols for abuse prevention and management, covering incident reporting, preventive measures, and emergency responses. Responsibilities include training new hires on resident safety, conducting competency assessments, and ensuring accurate documentation related to resident-to-resident altercation. 4. Identification of other residents who may need to be included (who may have been affected by the deficient practice: a. All residents were identified as potentially affected by the deficient practice. b. There are 4 independent residents who can walk 10 to 50 feet. Out of these 4 residents, 3 can walk 150 ft and above. Out of these residents 1 resident with physical aggression - Resident 1. 5. Systemic Changes and Measures: a. Immediate Action: The Interdisciplinary Team (IDT) in-service on 5/8/2025 by the Senior Nurse Executive (SNE) to review how to conduct an interdisciplinary team meeting when reviewing resident to resident incidents. b. System Change: A log was created on 5/08/2025 to document and verify daily compliance with securing weighted dowels, free weights, and ankle weights and locking the rehab room when no staff were present to supervise. Beginning 5/09/2025, the Activity Director and/or designee will use a monitoring tool to document compliance of logs created by the Rehab Department. Audits will be conducted daily for three days, then weekly for two weeks, and monthly thereafter. The issues found will be referred to the ED for further review and revision of the action plan and/or to determine any further training needed for staff involved. c. System Change: Starting 5/9/2025, the Medical Records Department will use a monitoring tool to audit the documented IDT and care plan for change of conditions related to any resident-to-resident altercations. Audits will be conducted daily for three days, then weekly for two weeks, and monthly thereafter. Any issues found will be referred to the Chief Clinical Officer (CCO) immediately for further review and revision of the action plan and/or to determine any further training needed for staff involved. 6. Training and Education Started on 5/08/2025 by Senior Nurse Executive and/or Designee. a. Immediate action: Inservice training for staff license nurses was started on 5/8/2025 on updating comprehensive care plans for residents that have been identified with physical aggression. A total of 16 nurses have been trained. The facility will continue training until all staff nurses have attended by 5/10/2025. b. Immediate action: Inservice training for IDT was started on 5/8/2025 on updating comprehensive care plan and interdisciplinary team investigation and documentation for residents that have been identified with physical aggression and those with resident-to-resident altercations. A total of 4 IDT members have been trained and will continue training until all IDT members have attended by 5/10/2025. c. Immediate action: Inservice training for rehab staff was started on 4/25/2025 on how to secure weighted dowels, free weights, and ankle weights and the rehab room door when no staff are present in the gym to supervise, as well as additional in-service initiated on 5/09/2025 on how to track and sign equipment in and out, noting its location and assigned user. A total of 10 rehab staff have been trained and will continue training until all Rehab staff have attended by 5/10/2025. Findings: During a review of Resident 1's Face Sheet (the front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including anxiety disorder (a mental health condition characterized by excessive worry and fear that significantly interferes with daily life) and unspecified signs and symptoms (s/s) involving cognitive function decline (changes in thinking, memory, or attention that are not clearly categorized as a specific type of cognitive deficit) following a cerebral infarction ([stroke] loss of blood flow to a part of the brain)). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 2/23/2025, the MDS indicated Resident 1's cognition was intact (able to make independent and reasonable decisions), and she could walk 150 feet. During a review of Resident 2's Admission Record, (Face Sheet), the Face Sheet indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including mild cognitive impairment (a brain condition that causes noticeable but mild memory and thinking problems) unspecified dementia (a progressive state of decline in mental abilities without behavioral disturbance, psychotic disturbance (a state where a person's thinking, perception, and behavior are significantly altered, leading to a loss in contact with reality), mood disturbance (a serious mental illness that causes persistent and intense changes in a person's mood, energy, and behavior), and anxiety. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognition was intact. During a review Resident 3's Admission record (Face sheet), the Face Sheet indicated Resident 3 was admitted to the facility on [DATE], with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or inability to move on one side of the body) following a cerebral infarction affecting Resident 3's left non dominant side. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 's cognition was intact. The MDS indicated Resident 3 used a walker (a device used to assist with walking) for mobility. During a review of Resident 3's H&P dated 2/19/2025, the H&P indicated Resident 3 was alert and able to make decisions regarding routine medical decisions and her immediate needs. During a review of Resident 1's Progress Note, dated 2/24/2025, the Progress Note indicated Resident 2 reported that Resident 1 hit her with a cane on her left arm. During a review of Resident 1's Change in Condition (COC) Evaluation, dated 2/24/2025, the COC indicated at 10:43 p.m., Resident 2 reported that Resident 1 struck her with a stick. During a review the facility's Investigation of Resident 2's allegation dated 2/24/2025, the Investigation indicated the cane/stick was not located and there were no witnesses who saw the cane/stick. During a review of Resident 3's Nurses Progress Note, dated 4/20/2025, the Nurse Progress Note indicated Resident 3 reported that Resident 1 pushed her down and hit her with a stick multiple times on 4/19/2025. The Nurses Progress Note indicated three Certified Nursing Assistants (CNA 2, 3 and 4) reported seeing Resident 1 walking away from Resident 3's bed with a stick wrapped in a white sheet. The Nurses Progress Note indicated Resident 1 reported that Resident 3 always disrespected her and would always close the sliding door in the room and the room was always hot. The Nurses Progress Note indicated Resident 1 reported today (4/19/2025) she (Resident 3) closed the sliding door, and she (Resident 1) opened it. During a review of Resident 1's Nurses Progress Note, dated 4/21/2025 and timed at 10:06 a.m., the Nurses Progress Note indicated Resident 3 requested an X-ray (a procedure used to generate images of tissue and structures inside the body) of her right shoulder and back. A subsequent Nurses Progress Note dated 4/21/2025 timed at 12 p.m., indicated the Nurse Practitioner (NP) ordered a STAT (immediately) X-ray for Resident 3. During a review of Resident 3's X-ray results dated 4/21/2025, the X-ray results indicated an acute fracture of the mid sacrum. During a review of Resident 3's Physician's Order, dated 4/22/2025, the Physician's Order indicated to transfer Resident 3 to the GACH for an X-ray of her lumbar spine (lower portion of the back) and sacrum. During a review of Resident 3's Nurses Progress Note, dated 4/22/2025 and timed at 2:40 p.m., the Nurses Progress Note indicated Resident 3 was transported to a GACH for evaluation due to an X-ray result that indicated a fracture of the mid sacrum. During a review of the GACH's Face Sheet, the Face Sheet indicated Resident 3 was admitted to the GACH on 4/22/2025. During a review of GACH's Radiology (the science dealing with X-rays for the diagnosis and treatment of disease) Results, dated 4/22/2025, the Radiology Results indicated Resident 3 sustained a non-displaced fracture (a broken bone where he bone fragments remain in their correct alignment after the break) of the mid sacrum. During a review of the GACH's Assessment and Plan, dated 4/22/2025, the Assessment and Plan indicated Resident 3 was given Percocet (no dosage indicated) and a Lidocaine patch (no dosage indicated) for pain management. During a review of Resident 1's IDT Conference Record, dated 4/23/2025, the IDT Conference Record indicated Resident 1 had poor impulse control and was easily angered. The IDT Conference Record indicated there was no reference to the Dowel Resident 1 used to strike Resident 3 or interventions to prevent access to the Dowel During an interview on 5/5/2025, at 3:40 p.m., Resident 3 stated, approximately two Saturdays ago (unsure of the date), Resident 1 was upset because the patio door, that was located near her (Resident 3) bed, was closed and locked. Resident 3 stated Licensed Vocational Nurse (LVN) 1 explained to Resident 1 that the door had to remain closed at 7 a.m., because it was cold. Resident 3 stated Resident 1 argued with LVN 1 about the door being closed but thought she finally accepted what LVN 1 said. Resident 3 stated she was lying in bed watching television (4/19/2025) when Resident 1 called her names using expletives (a swear word). Resident 3 stated, Resident 1 had a pole in her hand and walked over to her (Resident 3) bed and hit her (Resident 3) on her right arm, right shoulder, and the pole grazed the right side of her face. Resident 3 stated she stood up because she was afraid of what Resident 1 would do next. Resident 3 stated she screamed for help and that was when Resident 1 turned and pushed her and she (Resident 3) fell backwards, hitting a wheelchair and bedside table on her way to the floor. Resident 3 stated Resident 1 tried to hide the pole in a sheet, but a CNA (unknown) saw the pole and took it away from Resident 1. Resident 3 stated she does not feel safe; she can't sleep and is afraid Resident 1 will find her and harm her. During an interview on 5/5/2025, at 3:55 p.m., Resident 1 refused to speak about the alleged incident. During an interview on 5/5/2025, at 4:10 p.m., CNA 2, stated on 4/19/2025 she heard yelling and screaming coming from a room (Resident 1 and Resident 3's shared room) and when she entered the room, she saw Resident 3 on the floor against the wall and Resident 1 was standing over Resident 3 holding a pole in her hand and calling Resident 3 expletives. Resident 3 stated the pole that Resident 1 used to hit Resident 3 with, was approximately two to three feet long, wrapped in a sheet. During an interview on 5/6/2025, at 2:32 p.m., CNA 3, stated, around 10 p.m., (4/19/2025) she heard loud yelling coming from Resident 1's room. CNA 3 stated she, CNA 2, and CNA 4, who also heard the yelling, ran to Resident 1's room. CNA 3 stated when she arrived at the room, she saw Resident 1 holding a pole that was approximately three feet long, wrapped in a sheet, Resident 1 was standing over Resident 3 who was lying on the floor between the bed and the patio door in a fetal position (lying on one's side with knees pulled up towards the chest). During an interview on 5/6/2025, at 3:37 p.m., Registered Nurse Supervisor (RNS) 1 stated, a few months ago Resident 2, Resident 1's former roommate, accused Resident 1 of hitting her (Resident 2) with a stick. RNS 1 stated she looked everywhere for the stick but couldn't find it. During an interview on 5/7/2025, at 11:15 a.m., the Director of Rehabilitation (DOR) stated, when staff from the Rehab Department were not in the Rehab room, they close the door, but they don't lock it. The DOR stated, when the Rehab staff leave the facility, between 5 p.m. and 7 p.m., they (Rehab staff) lock the door. The DOR stated there were a total of 10 weighted dowels hanging on the wall in the Rehab room, and one of them was used by Resident 1 to hit Resident 3. The DOR stated the Dowel weighed two pounds. During an observation on 5/7/2025 (18 days after Resident 1 struck Resident 3 with the Dowel that was identified coming from the Rehab room), at 2:20 p.m., with the ADM and the DON present, in the rehabilitation room, Dowels and free weights of different weight and sizes were observed hanging unsecured on a wall in the Rehab room. During a concurrent observation and interview on 5/7/2025, at 2:57 p.m., the DOR showed the Dowel to Resident 2, Resident 2 confirmed that the Dowel looked like the object that Resident 1 hit her with on 2/24/2025. During a review of the facility's Policy and Procedure (P&P), titled, Safety and Supervision of Residents dated 7/2017, the P&P indicated, our individualized resident centered approach to safety addresses safety and accident hazards for individual residents. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment. The P&P indicated Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment.

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 3) was not subjected to abuse by Resident 1, when Resident 1 without authorization obtained a Dowel (a pole or rod used in rehabilitation to improve shoulder mobility and strength) from the facility's Rehabilitation (Rehab) room and used the Dowel as a weapon and struck Resident 1 on her right arm, right shoulder and face. The facility failed to: 1. Ensure the Rehab room and equipment located in the Rehab room was secured and supervised at all times to prevent unauthorized access by residents and/or visitors. 2. Ensure Resident 1 did not gain access to the Dowel from the facility's Rehab room without staff knowledge or permission. 3. Ensure Resident 1 did not use the Dowel as a weapon to physically assault Resident 2 and Resident 3. 4. Ensure staff followed the facility Policy and Procedure (P&P) titled, Prevention, Reporting and Correction of Inappropriate Conduct, Including Abuse Neglect and Mistreatment of Residents and Investigations of Injuries of Unknown Origin dated 7/2023, which indicated, It is the policy of the facility that each resident will be free from abuse. These deficient practices resulted in Resident 1 obtaining a Dowel (used to improve range of motion ([ROM] the direction a joint can move to its full potential), strength, and coordination, particularly for upper body movements like the shoulder and the hand) from the facility's Rehab room without staff knowledge or consent and using the Dowel to hit Resident 2 on her left arm on 2/24/2025 and Resident 3 on her right arm, right shoulder, and face then pushing Resident 3 to the floor on 4/19/2025. Resident 3 sustained a fracture (a break in a bone) to the mid sacrum (a triangular bone located at the base of the spine [back]) and was transferred to a General Acute Care Hospital (GACH) on 4/22/2025. These deficient practices placed residents' and/or visitors at risk for serious harm and death. Findings: During a review of Resident 1's Face Sheet (the front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including anxiety disorder (a mental health condition characterized by excessive worry and fear that significantly interferes with daily life) and unspecified signs and symptoms (s/s) involving cognitive function decline (changes in thinking, memory, or attention that are not clearly categorized as a specific type of cognitive deficit) following a cerebral infarction ([stroke] loss of blood flow to a part of the brain)). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 2/23/2025, the MDS indicated Resident 1's cognition was intact (able to make independent and reasonable decisions), and she could walk 150 feet. During a review of Resident 2's Admission Record, (Face Sheet), the Face Sheet indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including mild cognitive impairment (a brain condition that causes noticeable but mild memory and thinking problems) unspecified dementia (a progressive state of decline in mental abilities without behavioral disturbance, psychotic disturbance (a state where a person's thinking, perception, and behavior are significantly altered, leading to a loss in contact with reality), mood disturbance (a serious mental illness that causes persistent and intense changes in a person's mood, energy, and behavior), and anxiety. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognition was intact. During a review Resident 3's Admission record (Face sheet), the Face Sheet indicated Resident 3 was admitted to the facility on [DATE], with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or inability to move on one side of the body) following a cerebral infarction affecting Resident 3's left non dominant side. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 's cognition was intact. The MDS indicated Resident 3 used a walker (a device used to assist with walking) for mobility. During a review of Resident 3's H&P dated 2/19/2025, the H&P indicated Resident 3 was alert and able to make decisions regarding routine medical decisions and her immediate needs. During a review of Resident 1's Progress Note, dated 2/24/2025, the Progress Note indicated Resident 2 reported that Resident 1 hit her with a cane on her left arm. During a review of Resident 1's Change in Condition (COC) Evaluation, dated 2/24/2025, the COC indicated at 10:43 p.m., Resident 2 reported that Resident 1 struck her with a stick. During a review the facility's Investigation of Resident 2's allegation dated 2/24/2025, the Investigation indicated the cane/stick was not located and there were no witnesses who saw the cane/stick. During a review of Resident 3's Nurses Progress Note, dated 4/20/2025, the Nurse Progress Note indicated Resident 3 reported that Resident 1 pushed her down and hit her with a stick multiple times on 4/19/2025. The Nurses Progress Note indicated three Certified Nursing Assistants (CNA 2, 3 and 4) reported seeing Resident 1 walking away from Resident 3's bed with a stick wrapped in a white sheet. The Nurses Progress Note indicated Resident 1 reported that Resident 3 always disrespected her and would always close the sliding door in the room and the room was always hot. The Nurses Progress Note indicated Resident 1 reported today (4/19/2025) she (Resident 3) closed the sliding door, and she (Resident 1) opened it. During a review of Resident 1's Nurses Progress Note, dated 4/21/2025 and timed at 10:06 a.m., the Nurses Progress Note indicated Resident 3 requested an X-ray (a procedure used to generate images of tissue and structures inside the body) of her right shoulder and back. A subsequent Nurses Progress Note dated 4/21/2025 timed at 12 p.m., indicated the Nurse Practitioner (NP) ordered a STAT (immediately) X-ray for Resident 3. During a review of Resident 3's X-ray results dated 4/21/2025, the X-ray results indicated an acute fracture of the mid sacrum. During a review of Resident 3's Physician's Order, dated 4/22/2025, the Physician's Order indicated to transfer Resident 3 to the GACH for an X-ray of her lumbar spine (lower portion of the back) and sacrum. During a review of Resident 3's Nurses Progress Note, dated 4/22/2025 and timed at 2:40 p.m., the Nurses Progress Note indicated Resident 3 was transported to a GACH for evaluation due to an X-ray result that indicated a fracture of the mid sacrum. During a review of the GACH's Face Sheet, the Face Sheet indicated Resident 3 was admitted to the GACH on 4/22/2025. During a review of GACH's Radiology (the science dealing with X-rays for the diagnosis and treatment of disease) Results, dated 4/22/2025, the Radiology Results indicated Resident 3 sustained a non-displaced fracture (a broken bone where he bone fragments remain in their correct alignment after the break) of the mid sacrum. During a review of the GACH's Assessment and Plan, dated 4/22/2025, the Assessment and Plan indicated Resident 3 was given Percocet (no dosage indicated) and a Lidocaine patch (no dosage indicated) for pain management. During a review of Resident 1's IDT Conference Record, dated 4/23/2025, the IDT Conference Record indicated Resident 1 had poor impulse control and was easily angered. The IDT Conference Record indicated there was no reference to the Dowel Resident 1 used to strike Resident 3 or interventions to prevent access to the Dowel During an interview on 5/5/2025, at 3:40 p.m., Resident 3 stated, approximately two Saturdays ago (unsure of the date), Resident 1 was upset because the patio door, that was located near her (Resident 3) bed, was closed and locked. Resident 3 stated Licensed Vocational Nurse (LVN) 1 explained to Resident 1 that the door had to remain closed at 7 a.m., because it was cold. Resident 3 stated Resident 1 argued with LVN 1 about the door being closed but thought she finally accepted what LVN 1 said. Resident 3 stated she was lying in bed watching television (4/19/2025) when Resident 1 called her names using expletives (a swear word). Resident 3 stated, Resident 1 had a pole in her hand and walked over to her (Resident 3) bed and hit her (Resident 3) on her right arm, right shoulder, and the pole grazed the right side of her face. Resident 3 stated she stood up because she was afraid of what Resident 1 would do next. Resident 3 stated she screamed for help and that was when Resident 1 turned and pushed her and she (Resident 3) fell backwards, hitting a wheelchair and bedside table on her way to the floor. Resident 3 stated Resident 1 tried to hide the pole in a sheet, but a CNA (unknown) saw the pole and took it away from Resident 1. Resident 3 stated she does not feel safe; she can't sleep and is afraid Resident 1 will find her and harm her. During an interview on 5/5/2025, at 3:55 p.m., Resident 1 refused to speak about the alleged incident. During an interview on 5/5/2025, at 4:10 p.m., CNA 2, stated on 4/19/2025 she heard yelling and screaming coming from a room (Resident 1 and Resident 3's shared room) and when she entered the room, she saw Resident 3 on the floor against the wall and Resident 1 was standing over Resident 3 holding a pole in her hand and calling Resident 3 expletives. Resident 3 stated the pole that Resident 1 used to hit Resident 3 with, was approximately two to three feet long, wrapped in a sheet. During an interview on 5/6/2025, at 2:32 p.m., CNA 3, stated, around 10 p.m., (4/19/2025) she heard loud yelling coming from Resident 1's room. CNA 3 stated she, CNA 2, and CNA 4, who also heard the yelling, ran to Resident 1's room. CNA 3 stated when she arrived at the room, she saw Resident 1 holding a pole that was approximately three feet long, wrapped in a sheet, Resident 1 was standing over Resident 3 who was lying on the floor between the bed and the patio door in a fetal position (lying on one's side with knees pulled up towards the chest). During an interview on 5/6/2025, at 3:37 p.m., Registered Nurse Supervisor (RNS) 1 stated, a few months ago Resident 2, Resident 1's former roommate, accused Resident 1 of hitting her (Resident 2) with a stick. RNS 1 stated she looked everywhere for the stick but couldn't find it. During an interview on 5/7/2025, at 11:15 a.m., the Director of Rehabilitation (DOR) stated, when staff from the Rehab Department were not in the Rehab room, they close the door, but they don't lock it. The DOR stated, when the Rehab staff leave the facility, between 5 p.m. and 7 p.m., they (Rehab staff) lock the door. The DOR stated there were a total of 10 weighted dowels hanging on the wall in the Rehab room, and one of them was used by Resident 1 to hit Resident 3. The DOR stated the Dowel weighed two pounds. During an observation on 5/7/2025 (18 days after Resident 1 struck Resident 3 with the Dowel that was identified coming from the Rehab room), at 2:20 p.m., with the ADM and the DON present, in the rehabilitation room, Dowels and free weights of different weight and sizes were observed hanging unsecured on a wall in the Rehab room. During a concurrent observation and interview on 5/7/2025, at 2:57 p.m., the DOR showed the Dowel to Resident 2, Resident 2 confirmed that the Dowel looked like the object that Resident 1 hit her with on 2/24/2025. During a review of the facility's P/P, titled Prevention, Reporting and Correction of Inappropriate Conduct, Including Abuse Neglect and Mistreatment of Residents and Investigations of Injuries of Unknown Origin dated 7/2023, the P/P indicated It is the policy of the facility that each resident will be free from abuse.

Based on observation, interview and record review, the facility failed to ensure a resident did not develop a Stage II ( partial-thickness loss of skin, presenting as a shallow open sore or wound) pressure injury ( a localized pressure related damage to the skin and or underlying tissue) to sacrococcyx (bones at the base of the spine) area which progressed to a Stage IV (wound that penetrate all layers of skin exposing muscles, tendons [tissue that unites a muscle with a bone] cartilage {tissue that lines a joint}, and bones caused by prolonged pressure on the skin) pressure injury for one of one sampled residents (Resident 36). The facility failed to: 1. Ensure Resident 36 received treatment to a Stage II sacrococcyx pressure injury for 14 days from 11/8/2024-11/21/2024 as ordered by the physician. 2. Ensure Treatment Nurse (TX) assessed Resident 36 sacrococcyx pressure injury on weekly basis from 10/13/2024 to 12/12/2024 to prevent Resident 36's pressure injury from getting worse from Stage II to Stage IV. 3. Ensure the licensed nurses conducted weekly Resident 36's sacrococcyx pressure injury assessment per Care Plan titled, Resident has the potential for pressure injury development revised 1/7/25. and report any abnormal findings to Resident 36's physician. 4. Ensure Interdisciplinary Team ([IDT] - a coordinated group of staff from different fields who work together toward a common goal) recommendation for Registered Dietician ([RD]-certified healthcare professional who specializes in nutrition) consultation was completed in a timely manner. 5. Ensure staff followed the facility policy and procedure (P&P) titled, Wound Care Suggestions and Documentation, dated 10/2021 which indicated wounds should be measured and reviewed weekly for improvement or decline. The wound will be observed for improvement or decline with dressing changes and treatment orders will be changed accordingly. These failures resulted in Resident 36's developing a sacrococcyx Stage II pressure injury which progressed to a Stage IV pressure injury. Findings: During a review of Resident 36's Admission Record, dated 2/16/25 the Admission Record indicated Resident 36 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including persistent vegetative state (a condition in which a person is awake but lacks awareness of themselves of their surroundings) chronic respiratory failure (condition where lungs cannot adequately exchange oxygen and carbon dioxide leading to low blood oxygen level), malignant neoplasm (cancer) of the trachea (windpipe), tracheostomy (an opening surgically created in the trachea) and gastrostomy tube ([G-tube] a thin, flexible tube surgically inserted into the stomach for administration of nutrition, hydration, and medication) in place. During a review of Resident 36's, History and Physical (H&P) dated 5/4/2024, the H&P indicated Resident 36 did not have the capacity to understand and make decisions. During a review of Resident 36's, Change of Condition Evaluation ([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive (ability to think, understand, learn, and remember) behavioral, or functional status which without immediate intervention, may result in complications or death) dated 8/21/2024, the COC Evaluation indicated Resident 36 developed a Stage II pressure injury on the sacrococcyx measuring 5.0 cm in length by 0.5 cm in width with surrounded moist and slightly macerated (prolonged exposure to moisture) skin. During a review of Resident 36's, Physician Order Summary Report dated 8/22/2024, the Physician Order Summary Report indicated the order to clean reopened Stage II pressure injury with Normal Saline ([NS]-cleansing solution), pat dry and apply Medihoney gel (used to treat a variety of wounds) cover with foam dressing (type of dressing) every day for 21 days. During a review of Resident 36's, Minimum Data Set ([MDS] - a resident assessment tool) dated 10/6/2024, the MDS indicated Resident 36 was in a persistent vegetative state/no discernible consciousness (shows evidence of consciousness). The MDS also indicated Resident 36 was totally dependent (helper does all the effort) on staff assistance with Activities of Daily Living ([ADLs]- activities such as hygiene, dressing and toileting a person performs daily. The MDS indicated Resident 36 was at risk for developing pressure injury, had a Stage II pressure injury, no Stage IV pressure injury, and no unstageable pressure injury (a type of pressure ulcer where the depth of the wound cannot be determined due to the presence of slough [dead tissue] or eschar [dead tissue]). The MDS indicated treatment included pressure reducing device for bed, turning/repositioning program, and application of non-surgical dressings (a type of wound dressing used on wounds that do not require surgical intervention). During a review of Resident 36's Braden Scale (assessment tool used to assess a resident risk of developing pressure injury) dated 10/8/2024, the Braden Scale indicated Resident 36 had a score of eleven (10-12 indicated a high risk of developing pressure injury). During a review of Resident 36's Skin and Wound Evaluation dated 10/13/2024 the Skin and Wound Evaluation indicated Resident 36 had a Stage II pressure injury to the coccyx acquired at the facility on 8/21/2024 in stable condition measuring 2.5 cm in length by 2.0 cm in width with 0.2 cm in depth, with a 100 percent (%) granulation tissue (pink fleshy tissue that forms in the healing process of wounds ) and light serosanguinous (clear watery fluid and blood) drainage. During a review of Resident 36's Interdisciplinary Team ([IDT] team members from different departments working together with a common purpose to set goals and make decisions that ensure residents receive the best care) Conference Record Skin dated 10/13/2024 the IDT Conference Record indicated Resident 36 had a Stage II sacrococcyx pressure injury. The IDT Conference Record indicated recommendations to turn and reposition the resident, provide wound treatment of cleanse with NS, pat dry, apply collagen powder (wound therapy agent used to accelerate the healing process) then apply Silvadene cream (used to prevent and treat wound infections), cover with dry dressing. IDT recommendation included to follow up with Registered Dietician (RD) for recommendation. During a review of Resident 36's Nutritional Risk Review dated 10/29/24 the Nutritional Risk Assessment indicated Resident 36 had a left buttocks and sacrum ([tail bone] referring to the sacrococcyx) pressure injury. The Nutritional Risk Review indicated RD recommended to change Resident 36's G-tube feeding formula of Diabetisource AC from 50 milliliter ([ml]-unit of measurement) for 20 hours to 65 ml per hour for 20 hours. Resident 36's physician was notified but deferred RD recommendation. During a review of Resident 36's, Physician Order Summary Report dated 11/4/2024, the Physician Order Summary Report indicated Resident 36 had treatment order for Stage II pressure injury on sacrococcyx to cleanse with NS, pat dry, apply collagen powder then apply Silvadene cream cover with dry dressing x 21 days with a start date 11/5/24 and discontinued on 11/7/24 with no documentation as to why it was discontinued. During a review of Resident 36's , Treatment Administration Record (TAR) for the month of 11/2024 , the TAR indicated Resident 36 stopped receiving wound treatment (TX) to Stage II sacrococcyx pressure injury from 11/8/2024 until 11/21/2024, with no documentation to indicate the reason the pressure injury treatment was discontinued and the treatment with Zinc Oxide (medication used to treat wounds) ointment apply to sacrococcyx one time a day for skin maintenance for 21 days was started on 11/22/24. During a review of Resident 36's Care Plan titled, Resident has the potential for development of a pressure injury related to incontinence and dependency on staff for repositioning due to persistent vegetative state dated 1/28/2022 and revised on 1/7/25, the Care Plan indicated the goal for Resident 36 was not to develop avoidable Stage III (full-thickness loss of skin, dead and black tissue may be visible) or Stage IV pressure injury. The Care Plan interventions included weekly skin inspections by licensed nurse, skin inspection during ADL's and report any abnormal findings to the medical doctor (MD), and RD if indicated for nutritional review to promote pressure injury healing. During a review of Resident 36's Care plan titled, Resident has an actual Stage IV to coccyx, at risk for worsening, dated 5/31/2022 and revised on 1/9/2025, the Care Plan indicated goal for the resident was to show evidence of responding to a pressure injury treatment. The Care Plan interventions included to administer pressure injury treatments as ordered and observe for treatment effectiveness, report to physician as needed any changes in skin status appearance, color, odor, wound healing, signs and symptoms of infection, wound size, and stage of the wound. During a review of Resident 36's, COC dated 12/12/2024, the COC indicated Resident 36 had a sacrococcyx unstageable pressure injury measuring 3.0 cm in length by 1.0 cm in width with unstageable tissue damage ([UTD] a full-thickness skin loss where the extent of tissue damage is unknown)). During a review of Resident 36's IDT Conference Record Skin dated 12/12/2024, the IDT Conference Record Skin indicated Resident 36 had sacrococcyx unstageable pressure injury on 12/12/2024. The IDT Conference Record indicated the pressure injury treatment included to cleanse pressure injury with NS, pat dry, apply collagen powder then apply Silvadene cream, cover with dry dressing. During a review of Resident 36's Skin and Wound Evaluation dated 12/14/2024, the Skin and Wound Evaluation indicated Resident 36 had a facility acquired unstageable pressure injury on the sacrococcyx area developed on 12/11/2024 and was measuring 4.5 cm in length by 3.0 cm in width and 1.5 cm in depth. The Skin and Wound Evaluation indicated Resident 36's sacrococcyx pressure injury was re-assessed as Stage III pressure injury on 12/19/2024 by in-house nurse (unknown). During a review of Resident 36's Physician Order Summary Report dated 12/17/2024, the Physician Order Summary Report indicated Resident 36 had orders for a treatment to sacrococcyx unstageable pressure injury, cleanse with NS, pat dry, apply Collagen Powder then apply Silvadene cream cover with dry dressing for 21 days with a start date 12/17/2024 and was discontinued on 12/18/24. The Physician Order Summary Report also indicated on 12/19/24 Resident 36 had an order to clean sacrococcyx pressure injury with NS, pat dry, apply Silvadene cream and Collagen Powder and Calcium Alginate (absorbs moisture and promotes healing) then cover with dry dressing daily for 21 days and discontinue on 12/26/24. The Physician Order Summary Report indicated on 12/27/24 an order for wound consult for Resident 36's pressure injury to the sacrococcyx. The Physician Order Summary Report dated 12/27/2024 indicated and order to cleanse sacrococcyx pressure injury with NS, pat dry, apply Medihoney gel then cover with dry dressing daily for 21 days. During a review of Resident 36's Wound Consultant Progress note dated 1/1/2025, the Wound Consultant Progress Note indicated Resident 36 had a sacrococcyx Stage IV pressure injury measuring 4.0 cm in length by 1.5 cm in width with 0.2 cm in depth. The Wound Consultant Progress note indicated wound debridement (a medical procedure that involves removing dead or infected tissue from a wound) was done at bedside. Wound Consultant Progress note indicated removed necrotic (dead tissue) subcutaneous (under the skin) tissue, muscle tissue and viable surrounding tissue to the point of bleeding. During a review of Resident 36's Nutritional Risk Review dated 1/6/2025 the Nutritional Risk Assessment indicated Resident 36 had a Stage IV pressure injury to the sacrococcyx area with recommendations to start Resident 36 on ProStat SF (liquid protein supplement) 30 two times a day and Juven (supplement to promotes wound healing) one packet two times a day to aid in wound healing. During an observation on 2/14/2025 at 7:25 a.m. in Resident 36's room, observed Treatment Nurse (TX) 1 providing treatment with Silvadene cream and Collagen Powder to Resident 36's Stage IV sacrococcyx pressure injury as ordered. During a concurrent interview and record review on 2/15/2025 at 1:40 p.m. with TX 1, Resident 36's Skin and Wound Evaluations dated 10/13/2024 and 12/14/2024 and Change of Conditions (COC) dated 8/21/2024 and 12/12/2024were reviewed. TX 1 stated that on 8/21/2024 Resident 36 was identified to have a Stage II pressure injury to sacrococcyx measuring 5.0 cm in length by 0.5 cm in width and was superficial. TX 1 stated on 10/13/2024 Resident 36 had a weekly skin evaluation done and Resident 36 sacrococcyx pressure injury measured 2.5 cm in length by 2.0 cm in width with 0.2 cm in depth with 100% granulation tissue. TX 1 stated on 12/12/2024 (two months after the last skin and wound evaluation) Resident 36 had a COC complete identifying an unstageable pressure injury on the sacrococcyx. TX 1 stated the next Resident 36 Skin and Wound Evaluations was done on 12/14/2024 and the resident had an unstageable pressure injury to the sacrococcyx measuring 3.0 cm in length by 1.5 cm in depth with undetermined depth and slough (dead tissue that is usually yellow, tan, gray, or green in color, usually moist and stringy in texture, that may be found in wounds) present. TX 1 stated there was no other Resident 36's weekly Skin and Wound Evaluations documented to track the progression of Resident 36's pressure injury. TX 1 stated it was important to assess Resident 36's pressure injury to monitor Resident 36's pressure injury as it could change, and wound could deteriorate. TX 1 stated it was important to ensure pressure injury was assessed and monitored to ensure appropriate treatment was implemented. During a concurrent interview and record review on 2/15/2025 at 10:38 a.m. with Unit 2 Director of Nurses (UDON) 2, Resident 36's Skin and Wound Evaluations and Treatment Administration Record (TAR) were reviewed. UDON 2 stated that on 11/7/2024 treatment for the sacrococcyx Stage II pressure injury was discontinued with no documented reason for discontinuance. UDON 2 stated Resident 36 did not receive pressure injury treatment from 11/8/2024 through 1/21/2024. UDON 2 stated on 11/22/2024 the maintenance treatment with Zinc Oxide ointment application to sacrococcyx daily for 21 days was started but there was no documentation as to why the treatment was started. UDON 2 stated the last Resident 36's Skin and Wound Evaluations evaluation was done on 10/13/2024 indicating the resident had a Stage II sacrococcyx pressure injury measured 2.5 cm in length by 2.0 cm in width with 2.0 cm in depth with 100% granulation tissue in stable condition. UDON 2 stated the next Resident 36's pressure injury evaluation was done on 12/14/2024 and the resident had developed a sacrococcyx unstageable pressure injury measure at 3.0 cm in length by 1.5 cm in depth with undetermined and slough present. UDON 2 stated pressure injury needs to have weekly assessment and documentation to track the progress of pressure injury healing. UDON 2 stated Resident 36's pressure injury was avoidable if Resident 36 sacrococcyx pressure injury was assessed, monitor and appropriate treatment was implemented timely. During a phone interview on 2/15/2024 at 12:06 p.m. TX 2 stated Resident 36 had a scar (permanent mark on the skin as a result from an injury or wound) on her sacrococcyx that started as moisture associated skin damage ([MASD] caused by prolonged exposure to moisture) (unknown date). TX 2 stated the Wound Coordinator (WC) was responsible for assessing and documenting Resident 36's pressure injury. TX 2 stated pressure injury can deteriorate when not assessed, and monitored so appropriate treatment can be implemented to avoid progression of pressure injury. During a concurrent interview and record review on 2/15/2025 at 4:23 p.m. with the Minimum Data Set Coordinator ([MDSC]), Resident 36's IDT Care Conferences dated 12/12/2024, and Resident 36's Care Plans dated 1/28/2022 and 1/7/2025 were reviewed. The MDSC stated all pressure injuries need to have weekly assessment and documentation including a weekly IDT Care Conference to track the healing progress of a pressure injury as it could improve or deteriorate. The MDSC stated the only IDT Care Conference that had been done for Resident 36 was on 10/13/2024 and on 12/12/2024. The MDSC stated Care Plans are a guide for the licensed nurses when providing care to the residents and need to be followed. The MDSC stated any time there was a change in the resident's condition a care plan needs to be reviewed and updated to reflect the level of care the resident is receiving. The MDSC stated there was a potential for an adverse reaction when resident's (in general) pressure injury was not assessed regularly, and nurses were not following the plan of care. During a concurrent interview and record review on 2/15/2025 at 4:23 p.m. with the RD, Resident 36's IDT notes dated 10/13/24 and 12/12/24 were reviewed. The RD stated the IDT recommendation for RD consult were made on 10/13/24 but were completed on 10/29/2024, two weeks later. The RD stated the IDT recommendation made on 12/12/2024 was not completed until 1/6/2025. RD stated all residents with pressure injuries should have RD's assessment done right away (unspecified). RD stated it was important to have RD recommendations to ensure pressure injury would heal as quick as possible as we don't want the pressure injury to get worse. RD stated, we want the pressure injury to get better, and without proper nutrition and the right supplements pressure injury can deteriorate. During an interview on 2/15/24 at 2:42 p.m. the Director of Nursing (DON) stated she was aware of Resident 36's Stage IV pressure injury to sacrococcyx developed on 12/12/2024. The DON stated she identify a systemic issue of the WC's lack of weekly pressure injury assessment documentation. The DON stated, there was a potential for harm to Resident 36 when weekly pressure injury assessment was not done, care plans were not followed, and pressure injury treatments not provided to Resident 36. The DON stated Resident 36's pressure injury deteriorated because weekly assessments were not being done to assess and monitor progress of pressure injury toward healing. The DON stated, pressure injury was avoidable if the right interventions were implemented. During a review of the facility's policy & procedures (P&P) titled Wound Care Suggestions and Documentation dated 10/2021, indicated, wounds should be measured and reviewed weekly for improvement or decline. The wound will be observed for improvement or decline with dressing changes and treatment orders will be changed accordingly. The physician should be notified of any improvements or decline that necessitates changes in order or to update. The primary care provider and family notification of wound care shall be documented in the appropriate section in the chart. Care plans are updated accordingly to reflect current interventions for wounds and the long-term interventions to prevent further breakdown as appropriate. Assessment-Elements and documentation Each wound a resident has shall be documented on admission, upon discovery, and at least weekly thereafter until healed.

Based on interview and record review, the facility failed to ensure the resident, who was a high risk for falls and injuries, did not fall and sustain injury for one of three sampled residents (Resident 136). The facility failed to: 1. Ensure Certified Nurse Assistant (CNA 2) did not leave Resident 136 unsupervised in the bathroom to go to assist another resident. 2. Ensure CNA 2 followed the facility's policy and procedure (P&P) titled, Fall Prevention and Management Program dated 2/2025, which indicated the facility must ensure that each resident receives adequate supervision and assistive devices ( devices that are designed to assist a person to perform a particular task) to prevent accidents. 3. Ensure staff followed Resident 136's care plan titled The resident is at risk for falls dated 9/27/2023 to anticipate and use of assistive device front wheel walker ( [FWW ] a mobility aid with two wheels on the front and two legs on the back) as needed. These deficient practices resulted in Resident 136 falling on the floor on 12/7/2024 at 11:45 a.m., while unattended in the bathroom. and sustaining an injury. On 12/9/2024 Resident 136 was transferred to a General Acute Care Hospital (GACH) for evaluation and treatment where the resident was diagnosed with fracture (broken bone) of multiple pubic rami ( a pair of bone that form part of the lower pelvis, at the front of each hip bone) and acute to subacute (used to describe the duration and severity of a medical condition ) thoracic 12 (T12) compression fracture (a fracture of the 12th thoracic vertebra (bones of the spine) in the middle back) Findings: During a review of Resident 136's Admission Record, the Admission Record indicated Resident 136 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including osteoporosis ( a bone disease that causes bones to become weak and brittle [easy to break ], making them more prone to fracture), kyphosis (curving of the spine that causes bowing or rounding of the back) hypertension (high blood pressure), and a history of falling. During a review of Resident 136's Care Plan titled, Resident at Risk for Falls dated 9/27/2023, the Care Plan indicated the goal for Resident 136 was to reduce the risk for falls through the next review date (10/21/2024). The Care Plan's interventions including to anticipate and meet Resident 136's needs and encourage use of call light ( a device that patients use to communicate with healthcare staff). During a review of Resident 136's Care Plan titled Activities of Daily Living (ADL daily self-care activities) self-care performance deficit dated 9/27/2023, the Care Plan interventions indicated staff will provide maximal assistance to Resident 136 with ADL as needed. During a review of Resident 136's Fall Risk Assessment (a comprehensive evaluation to identify factors that may increase a resident's risk of falling), dated 10/25/2024, indicated a score of 65 (a score above 45 on the Fall Risk Assessment indicated high risk for falls). The Fall Risk Assessment indicated Resident 136 was overestimating his/her abilities and was forgetting of her limitations. The Fall Risk Assessment indicated Resident 136's gait (how a person walk) was weak. During a review of Resident 136's Nurses Progress Notes dated 12/7/2024 timed at 11:45 a.m., the Nurses Progress Notes indicated Resident 136 was found on the floor in a fetal position (laying on the side with knees bent and curled up toward the chest) in the bathroom's doorway. The Nurses Progress Notes indicated Resident 136 stated she fell backwards while trying to kick the bathroom door shut. The Nurses Progress Notes indicated Licensed Vocational Nurse (LVN-unknown) informed Resident 136 that she might be sent to GACH but Resident 136 declined. During a review of Resident 136's Minimum Data Set ([MDS]- a resident assessment tool) dated 12/9/2024, the MDS indicated Resident 136's cognition (ability to think, understand, learn, and remember) was intact. The MDS indicated Resident 136 required substantial/maximal assistance (helper does more than half the effort) with showering, bathing, and lower body dressing and partial/moderate assistance (helper does less than half the effort) with toileting, personal hygiene, and upper body dressing. The MDS indicated Resident 136 required moderate assistance with walking 10 feet ([ft]-unit of measurement) but walking 50 ft to 150 ft was not attempted due to safety concerns. The MDS indicated the resident used FWW for walking. The MDS indicated Resident 136 was occasionally incontinent (inability to control bladder (urine) and bowel (stool) functions) of urine and bowel. During a review of Resident 136's Nurses Progress Notes dated 12/9/2024 timed at 1:19 a.m., the Nurses Progress Notes indicated Resident 136 complained of bilateral (both) hips pain rated 10 out of 10 on a zero to ten pain rating scale (0 is no pain and 10 is worse possible pain). The Nursing Progress Note indicated Resident 136 was transferred to the GACH on 12/9/2024 at 1:19 a.m. During a review of Resident 136's Interdisciplinary Team ([IDT]- team members from different departments working together with a common purpose to set goals and make decisions that ensure residents receive the best care) Notes dated 12/9/2024 timed at 7:56 a.m., the IDT notes indicated on 12/7/2024, CNA 2 assisted Resident 136 to the bathroom . When Resident 136 was finished, she attempted to ambulate back to bed using her FWW . The IDT notes indicated Resident 136 attempted to kick the closed bathroom door, lost her balance and fell to the floor. The IDT Note indicated Resident 136 declined to go to GACH and refused Xray (imaging that produces pictures of the inside of the body) of the pelvis (hip) and leg initially. The IDT note indicated Resident 136 eventually agreed with the Xray of the pelvis on 12/8/2024, which indicated the resident had a non-displaced fracture of the left inferior pubic rami (a pair of bones that form part of the lower pelvis, at the front of each hip bone). During a review of Resident 136's GACH's Progress Notes dated 12/10/2024 and timed 4:45 p.m., the GACH's Progress Note indicated Resident 136's Computed Tomography ([CT]- an imaging test used to detect internal injuries) of the abdomen and pelvis done on 12/9/2024 at 8:09 a.m. indicated probable subacute (beginning to heal) fractures of the left superior and inferior pubic rami. During a review of Resident 136's GACH's Discharge Summary report dated 12/15/2024, the GACH's Discharge Summary report Resident 136 was diagnosed with fracture of multiple pubic rami and acute to subacute 12th thoracic vertebra (T12) in the middle back). The GACH's Discharge Summary report indicated Resident 136 received lumbar (lower back) epidural (injection given in the lower back that numbs the lower half of the body) injection on 12/13/2024 at 5:29 p.m. for pain management. The GACH's Discharge Summary indicated Resident 136 to receive acute physical therapy (aimed in the restoration, maintenance, and promotion of optimal physical function) and pain management. During an interview on 2/13/2025 at 1:40 p.m., CNA 2 stated Resident 136 was forgetful and tends to not call for assistance when she wants to get up. CNA 2 stated she assisted Resident 136 to the bathroom and instructed Resident 136 to call CNA 2 when she was done. CNA 2 stated she left Resident 136 by herself in the bathroom to provide an assistance to another resident (Resident 136's roommate) in the same room. CNA 2 stated when she left, Resident 136 got up, walked with her FWW to walk out of the bathroom. CNA 2 stated Resident 136 tried to kick the bathroom door and lost her balance. CNA 2 stated Resident 136's fall could have been prevented if she (CNA 2) would not have left the resident unattended in the bathroom. During an interview on 2/13/2025 at 2:05 p.m., Licensed Vocational Nurse (LVN) 9 stated CNA 2 should not have left Resident 136 unattended in the bathroom as Resident 136 was forgetful and tended not to call for assistance. LVN 9 stated Resident 136's fall was avoidable if CNA 2 did not leave Resident 136 unattended in the bathroom on 12/7/2024. During an interview on 2/13/2025 at 3:33 p.m., Registered Nurse (RN) 3 stated Resident 136 was forgetful and required assistance with ambulation. RN 3 stated CNAs should remain with a resident when assisting to the bathroom, especially to residents who were forgetful and required assistance with ambulation to prevent falls. RN 3 stated Resident 136's fall was preventable if CNA 2 did not leave Resident 136 unattended in the bathroom on 12/7/2024. During an interview on 2/13/2025 at 4:24 p.m., the Director of Staff Development (DSD) stated she was responsible for CNAs training which includes caring for forgetful and confused residents and fall prevention. The DSD stated CNAs should not leave residents unattended in the bathroom if they are forgetful because they could fall and sustain injury. During an interview on 2/13/2025 at 4:42 p.m., the Unit Director of Nursing (UDON) 3stated CNA 2 should not have left Resident 136 in the bathroom unattended. The UDON 3 stated Resident 136's fall was avoidable if CNA 2 did not leave Resident 136 unattended on 12/7/2024. During an interview on 2/13/2025 at 5:31 p.m., with Resident 136, Resident 136 stated that since her fall she was unable to walk. Resident 136 stated she had pain on her hip and lower back that keeps her from not sitting in the chair which made her feel sad. During a review of the facility's P&P titled, Fall Prevention and Management Program, dated 2/2025, the P&P indicated, To ensure the facility provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents.

Based on interview, and record review, the facility failed to ensure a resident, who was assessed at risk for wandering (moving around inside the facility without awareness of personal safety, potentially putting themselves in harm's way), did not elope (the act of leaving a facility unsupervised and without prior authorization) from the facility for one of nine sampled residents (Resident 1). The facility failed to: 1. Have a system in place to supervise and monitor Resident 1's whereabouts to prevent him from eloping from the facility. 2. Develop a care plan with interventions addressing Resident 1's risk for wandering, to ensure the resident's safety, and prevent him from eloping from the facility. 3. Ensure staff followed the facility's policy and procedure (P&P), titled Wandering Residents - No Facility Wide Wandering Notification System dated 11/2016, that indicated residents at risk for wandering shall have a care plan implemented with interventions appropriate to the resident to help prevent wandering out of the facility during the day. These deficient practices resulted in Resident 1 eloping from the facility on 10/30/2024 and was missing for over two hours before staff noticed he was gone. Resident 1 was placed at risk for exposure to harsh environmental conditions, including extremes in heat and/or cold, possible motor vehicle accidents, medical complications related to his diagnoses of diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar [b/s] control and poor wound healing), such as hyperglycemia (when b/s levels are too high [normal b/s levels range from 70 milligrams [mg]/deciliter [dl] a unit of measurement), hypoglycemia (when b/s levels are too low), and possible death. Resident 1 was eventually located on 11/6/2024 (eight days after he was found missing from the facility), in a towing yard, living in a van. On 11/6/2024 at 4:10 p.m. an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called in the presence of the facility's Executive Director (ED), Chief Clinical Officer (CCO), and RCN (RCN) due to the facility's failures to have a system in place to prevent Resident 1 from eloping from the facility and placing nine other residents, who were assessed at risk for elopement, to go missing. On 11/7/2024, the facility submitted an acceptable IJ Removal Plan ([IJRP] interventions to immediately correct the deficient practices). After onsite verification of the facility's IJRP's implementation through observation, interview, and record review, the IJ was removed on 11/7/2024 at 6:23 p.m. in the presence of the facility's ED, and the CCO. The facility's IJPR included the following immediate actions: 1. Corrective and appropriate actions to be implemented for the affected residents identified in the deficiencies. a. Immediate Action: On 10/30/2024 at approximately 4:30 p.m., the Certified Nursing Assistant (CNA) assigned to Resident 1 reported to the CCO and ED that Resident 1 was missing. Immediately a Code Orange (a message usually sent out via intercom to notify and prompt staff to search for a missing resident) was called, which initiated facility staff to conduct a thorough search within the premises of the facility and surrounding neighborhoods, but staff were unable to locate the resident. The facility also alerted local hospitals and shelters. The incident was reported to the local sheriff's office via telephone on 10/30/24 at 5:40 p.m., and notification was faxed to the California Department of Public Health (CDPH) on 10/31/24 at 3:00 p.m. The resident's roommate was interviewed and queried after staff were unable to locate Resident 1. The resident's roommate indicated that Resident 1 said he wanted to go to Pacific Coast Highway. A facility staff drove down Pacific Coast Highway to assist with locating Resident 1. An in-service for staff regarding Elopement Policy was completed on 11/1/2024. b. A door monitor (a person assigned to monitor the facility's entrance/exit doors) was assigned for the back door entrance initiated 10/30/24. The local Sheriff's office was also informed and assisted in looking for Resident 1. The local Sheriff's Office made multiple postings to social media and to other missing person's outreach. The Department of Motor Vehicle (DMV) was called to request if the facility could avail itself of any vehicle registered under Resident 1 to locate the resident and inform the sheriff's department. The DMV informed the facility that they were not allowed to disclose any vehicle information that was registered to Resident 1. The final investigation report was sent to CDPH on 11/5/2024 at 5:00 p.m. c. Immediate action: On November 6, 2024, at 2:00 p.m., the facility admission coordinator worked with the insurance case manager to locate information on a responsible party. The insurance case manager found details about Resident 1's daughter and her phone number from an entry made six months prior in their portal, related to a previous admission and discharge, which had not been relayed to the facility or included in Resident 1's current admission records. The RCN called the daughter at around 2.30 p.m. on 11/6/2024. The daughter stated she called the sheriff's office and the sheriff posted information on the patient on social media. Resident 1's daughter indicated Resident 1 did not want to stay with her but currently had a van that was parked in the lot of a towing company. On November 6, 2024, at 5:40 p.m., Resident 1 was located by the facility's RCN. The resident expressed a desire not to return to the facility, preferring to stay in his van, where he had been residing when not hospitalized or in a nursing home over the past year. Resident 1 mentioned that he had visited his doctor for an appointment earlier in the day and received his prescription. His van was parked at a towing company lot, where the owner of the towing company keeps an eye on him (Resident 1). Resident 1 reported having his own supply of food and medication and confirmed a recent visit to the social security office. Resident 1 also signed a discharge against medical advice (A.M.A) on 11/6/2024 since he insisted on not wanting to return to the facility. The Sheriff's department was notified on 11/6/24 that Resident 1 had been located and where Resident 1, they (the Sheriff's department) and also completed a wellness check on 11/7/24 and Resident 1 continued to not want to return to the facility. d. Immediate action: All exit doors are equipped with an alarm 24 hours and 7 days a week. Door monitors have been assigned to monitor two exit doors beginning 11/6/24 with the front door being monitored from 8 a.m. to 8 p.m. and the back door and back patio from 6:30 a.m. to 8 p.m. The alarms are activated after the door monitors leave for the day. 2. Governing Body (responsible for ensuring that the facility's Quality Assessment [QAPI] and Performance Improvement program is effective and ongoing) - QAPI committee a. Immediate Action: The Interdisciplinary Team ([IDT] a group of healthcare professionals with diverse specialties who collaborate closely to develop and implement a comprehensive care plan for each patient) convened on 11/6/24 to revise the wandering and elopement policy. The updated policy includes assessment updates, risk scoring with targeted interventions based on risk levels, elopement drills, and procedures to follow if a resident goes missing. Following the review and update of the policy, an ad hoc meeting of the Quality Assurance Performance Improvement (QAPI) Committee was held on 11/6/24 to review, update and approve the new wandering and elopement policy, including the wandering and elopement assessment. b. Immediate Action: During the ad hoc QAPI Committee meeting on 11/6/24, a root cause analysis (RCA) revealed key issues in the wandering and elopement process, including communication breakdowns, inconsistent documentation, and training gaps in high-risk monitoring protocols/interventions. Staff were found to lack clear guidance on monitoring frequency, specific elopement prevention protocols, and proper documentation of care plans for high-risk residents. These findings underscore the need for improved communication, consistent documentation, and targeted training to enhance care quality for residents at risk of elopement. c. The ED will oversee corrective actions initiated on 11/6/2024 and monthly thereafter during QAPI meetings which are based on the results of the RCA and plan of corrections for the findings during the survey. Any corrective actions not meeting the 100% compliance benchmark, as determined by medical records audits, wandering and elopement system audit will be reviewed and revised with the QAPI Committee for revision, further evaluation, and recommendations, with a designated person IDT member assigned to each corrective action. d. Any new issues found during medical record audits and wandering, and elopement system audit will be presented to the Wandering/Elopement IDT members for immediate action. The CCO will monitor the immediate actions for implementation of monitoring/audit needs at least monthly for the next 3 months or until compliance is 100% or is achieved. 3. Specific staff involved in implementing the corrective actions. a. Team. Members: Medical Director, ED, CCO, Director of Staff Education, and RCN. Each member will perform as follows: i. Medical Director: Through the QAPI committee, the Medical Director will monitor the system, recommend changes, and oversee corrective action plans. This role includes identifying and implementing medical interventions to reduce confusion and prevent wandering or elopement. ii. ED: The ED will oversee all corrective actions initiated on 11/6/2024 and continue monthly reviews during QAPI meetings. iii. CCO: Leading the Wandering and Elopement Team., the CCO will regularly review at-risk residents, assess intervention effectiveness, and adjust care plans as needed. This role also ensures that wandering management and elopement prevention practices are standardized, monitors staff compliance, coordinates equipment maintenance, educates staff, oversees data analysis, and conducts reviews to recommend preventive measures. iv. RCN: This role entails staying updated on regulatory changes, collaborating with the IDT to update policies, and ensuring staff adherence to these policies. It includes participating in quality improvement initiatives, analyzing compliance data, assisting with corrective actions, identifying risks, and investigating incidents to prevent recurrence. v. Director of Staff Education: This role involves educating staff on care planning, documentation, and protocols for elopement and wandering, covering incident reporting, preventive measures, and emergency responses. Responsibilities include training new hires on resident safety, conducting competency assessments, emphasizing risk assessment, and ensuring accurate documentation related to elopement and wandering prevention. 4. Identification of other residents who may need to be included (who may have been affected by the deficient practice: a. All residents who were identified as high risk for wandering/eloping were identified at risk for the identified deficient practice. A total of 5 residents were initially identified based on current assessment as high risk. All five residents were reassessed using the new wandering and elopement assessment approved by the QAPI Committee on 11/6/24. There was a total of 0 residents that scored significant/serious actual risk for wandering/elopement and 2 residents scored moderate actual risk. The care plan was updated based on the wandering/elopement assessment for frequency of routine checks for location will be as followed: i. Significant/Serious Actual Risk - frequency of routine monitoring will be every 15 minutes for location of the resident. ii. Moderate Actual Risk - frequency of routine monitoring will be every 2 hours for location of the resident. iii. Low Probable Risk - frequency of routine monitoring will be every 4 hours for location of the resident. 5. Systemic Changes and Measures: a. Immediate Action: The IDT convened on 11/6/24 to revise the wandering and elopement policy. The updated policy includes assessment updates, risk scoring with targeted interventions based on risk levels, elopement drills, and procedures to follow if a resident goes missing. Following the review and update of the policy, an ad hoc meeting of the QAPI Committee was held on 11/6/24 to review, update and approve the new wandering and elopement policy, including the wandering and elopement assessment. b. Immediate Action: The residents with identified risk will be added to the specific instructions on the Electronic Medical Record (EMR) banner for each resident beginning 11/6/24. c. System Change: The EMR's wandering, and elopement risk assessment was updated as well as the care plan library to include risk score intervention for frequency of routine checks for location on 11/7/2024 will be documented in either the Electronic Medication Administration Record (EMAR) or TASK section of the EMR and will be as followed: a. Significant/Serious Actual Risk - frequency of routine monitoring will be every 15 minutes for location of the resident. b. Moderate Actual Risk - frequency of routine monitoring will be every 2 hours for location of the resident. c. Low Probable Risk - frequency of routine monitoring will be every 4 hours for location of the resident. d. Immediate Action: The elopement/wandering binder that already contained the list of all the residents with moderate/ serious significant risk for wandering and elopement was reviewed on 11/6/24. The elopement binder will be updated at least weekly by each Unit Director of Nursing (DON) and/or with new admissions that meet the significant/serious risk score. The wandering/elopement binder will be audited for completion and verification of list of patients every week by Medical Records Designee and any inconsistencies from the list will be provided to CCO to update and make corrections. e. System Change: Wandering and elopement risk assessment and missing resident policy has been updated on 11/6/24. f. System Change: Starting November 7, 2024, the Medical Records Department will use a monitoring tool to audit the documented frequency of routine checks/location for residents identified with a risk for wandering or elopement, based on their established care plans. Audits will be conducted daily for three days, then weekly for two weeks, and monthly thereafter. Immediately after completion of the audit, the Medical Records Designee will submit the findings of the audits to the CCO. Issues found by the CCO will be referred to the Wandering and Elopement IDT for further review and revision of the action plan and/or to determine any further training needed for staff involved. g. System Change: The Wandering/Elopement IDT will review post elopement events within 24-72 hours of incident for any revision of assessment need and/or plan of care interventions. 6. Training and Education Started on 11/6/24 by Director of Staff Education and/or Designee. a. Immediate action: Inservice training for staff license nurses was started on 11/6/24 on updating comprehensive care plans for residents that have been identified as wandering/elopement risk. A total of 11 nurses have been trained and will continue training until all staff nurses have attended and will continue training until all staff nurses have attended by 11/08/24. b. Immediate action: Inservice training for staff nurses was started on 11/6/24 on how to assess residents with elopement/wandering risk. A total of 11 nurses have been trained and will continue training until all staff nurses have attended and will continue training until all staff nurses have attended by 11/08/24. c. Immediate action: Inservice training for staff nurses was started on 11/6/24 on how to determine frequent monitoring needs based on elopement/wandering episodes and how to document the monitoring in the electronic medical records. A total of 27 clinical staff have been trained and will continue training until all staff nurses have attended and will continue training until all staff nurses have attended by 11/08/24. d. Immediate action: Inservice training on staff nurses was started on 11/6/24 on how to recognize behaviors that place residents at risk for elopement and who to report and how to follow up with residents. A total of 27 clinical staff have been trained and will continue training until all staff nurses have attended and will continue training until all staff nurses have attended by 11/08/24. e. Immediate action: Inservice training for staff nurses was started on 11/6/24 on how to identify residents that are at high risk for wandering using an orange band (a band placed on residents' wrist to indicate they are at risk for wandering). A total of 27 nurses have been trained and will continue training until all staff nurses have attended and will continue training until all staff nurses have attended by 11/08/24. f. Immediate action: Inservice training for staff nurses was started on 11/6/24 on elopement drill and what to do for missing residents. A total of 27 clinical staff have been trained and will continue training until all staff nurses have attended and will continue training until all staff nurses have attended by 11/08/24. g. Immediate action: The assigned door monitors were provided in-service training on how to monitor residents based on elopement binder list on 11/7/24. A total of 2 have already been training and will continue until all have attended by 11/8/24. Findings: During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including wedge compression fracture (a break or crack in the spine that usually occurs from too much pressure) of the thoracic vertebra (the 12 bones in the middle section of the spine between the neck and the bottom of the ribs), DM, and mild cognitive (ability to think and reason) impairment. The Face Sheet indicated Resident 1 prior to admission to the facility was unsheltered/homeless (when someone's primary night time residence is in a place that is not designed for sleeping such as a car). During a review of Resident 1's Minimum Data Set ([MDS] a federally mandated resident assessment tool) dated 9/16/2024, the MDS indicated Resident 1's cognition (ability to think and reason) was mildly impaired. The MDS indicated Resident 1 had no functional limitations in range of motion ([ROM] the direction a joint can move to its full potential) to his upper or lower extremities (arms/legs) and he required moderate assistance (helper does less than half the effort) for showering and dressing the lower body and he required supervision for toileting hygiene. During a review of Resident 1's Wandering Risk Scale assessment dated [DATE], the Wandering Risk Scale Assessment indicated Resident 1 was at risk for wandering due to his diagnosis of cognitive impairment. During a review of the Care Plan section of Resident 1's clinical records, the Care Plan section indicated there was no care plan developed for Resident 1's risk for wandering, based on his Wandering Risk Scale Assessment conducted 9/7/2024 . During a review of Resident 1's Physician's Order dated 9/7/2024, the Physician's Order indicated Resident 1 was to receive Regular Insulin (a short-acting injected medication, used to treat DM, that helps the body metabolize sugar) subcutaneously (administered under the skin) before meals and at bedtime per a sliding scale (pre-meal insulin dosage based on the b/s level before set intervals) as follows: For a b/s of 121 mg/dl -150 mg/dl give one unit of Regular Insulin For a b/s of 151 mg/dl - 200 mg/dl give two units of Regular Insulin For a b/s of 201 mg/dl - 250 mg/dl give three units of Regular Insulin For a b/s of 301 mg/dl - 350 mg/dl give six units of Regular Insulin For a b/s of 351 mg/dl - 400 mg/dl give eight units of Regular Insulin For a b/s greater than 400 mg/dl give eight units of Regular Insulin and call the Medical Doctor (MD). During a review of Resident 1's Change in Condition (COC) Evaluation note dated 10/30/2024, the COC indicated on 10/30/2024 at 4:30 p.m., Resident 1 could not be located by facility staff and a Code Orange was called. During an interview on 11/1/2024 at 12:23 p.m., Certified Nursing Assistant (CNA 1) stated on 10/30/2024, she worked a double shift beginning 7 a.m. to 3 p.m., and continued 3 p.m. to 11 p.m., but was only assigned to Resident 1 from 3 p.m. to 11 p.m. CNA 1 stated the last time she saw Resident 1 was in his room, lying in bed awake after lunch around 1 p.m. CNA 1 stated she did not see Resident 1 on her next shift when she started at 3 p.m. CNA 1 stated at 3:40 p.m., she spoke to Resident 1's roommate (Resident 4), who told her Resident 1 informed him (Resident 4) that Resident 1 was upset because his room was being deep cleaned (a cleaning process where all furniture is removed from the residents room). CNA 1 stated she believed Resident 1 left through the front exit because he liked to sit on the couch and hang out in the front lobby. CNA 1 stated Resident 1 was able to walk holding onto a wheelchair and pushing the wheelchair in front of him. CNA 1 stated she reported to the Assistant Director of Nursing (ADON) at 4:15 p.m., that Resident 1 was missing, and the ADON called a Code Orange at 4:45 p.m., but they were unable to locate Resident 1 after searching the facility. During an interview on 11/1/2024 at 3:02 p.m., CNA 2 stated on 10/30/2024 she was assigned to Resident 1 for the first time from 7 a.m. to 3 p.m. and was not told when she was given report that Resident 1 was a wandering risk. CNA 2 stated the last time she saw Resident 1 on 10/30/2024 was before lunch, around 11 a.m., in the front lobby near the front door of the facility. CNA 2 stated she normally made rounds three times on her eight-hour shift, between 7:30 a.m. to 8 a.m., 12:30 p.m. to 1 p.m. and at 2:45 p.m., before her shift ended at 3 p.m. CNA 2 stated on 10/30/2024 it was busier than usual, residents' rooms were being deep cleaned, including Resident 1's room, and she had to take residents to the facility's Halloween event after lunch. CNA 2 stated she was unable to stick to her normal routine and forgot to check on Resident 1. During an interview on 11/1/2024 at 3:30 p.m., the MDS Nurse (MDSN) 1 stated, the admitting nurse was responsible for creating an initial care plan for residents at risk for wandering, based on the resident's Wandering Risk Scale assessment, which was completed on admission. MDSN 1 stated the Wandering Risk Scale assessment was completed for all newly admitted residents and if a resident was determined to be at risk for wandering, a care plan should be created. MDSN 1 stated the nursing staff and MDS department does not specify on the care plan how often a resident who was at risk for wandering should be monitored. MDSN 1 stated in her professional opinion a resident with mild cognitive impairment should be monitored every 1 to 2 hours, and more frequently for a more confused resident. MDSN 1 stated nurses should have communicated that Resident 1 was at risk for wandering during their huddle (a meeting discussing residents). During an interview on 11/5/2024 at 9:40 a.m., Registered Nurse (RN 1) stated during admission, if a wandering risk assessment indicated a resident was at risk for wandering, a care plan should be created with interventions to monitor the resident at least once every 2 hours. RN 1 stated even if the resident does not exhibit wandering behaviors but was mildly confused, the resident could have impaired judgement and should be monitored. RN 1 stated during huddle, residents who need to be monitored closer due to wandering or confusion should be discussed amongst staff. During an interview on 11/5/2024 at 10:14 a.m., the Director of Staff Development (DSD) stated residents should be visually checked at a minimum of once every two hours and more as needed, which is determined by any licensed nurse. The DSD stated monitoring frequency for residents at risk for wandering was at the discretion of the licensed nurse who should communicate the frequency needed to monitor the resident to the CNAs during their huddle, then the licensed nurse should oversee the CNA to make sure the residents were being monitored. During an interview on 11/5/2024 at 10:59 a.m., Licensed Vocational Nurse (LVN 1) stated Resident 1 was ambulatory (able to walk) and would often walk through the facility pushing his wheelchair daily. LVN 1 stated Resident 1 was not in his room most of the day on the day he eloped from the facility (10/30/2024) because his room was being deep cleaned from 10:15 a.m. to 3 p.m. LVN 1 stated she last saw Resident 1 before lunch when she attempted to take Resident 1's b/s, and she assumed he was at the facility's Halloween event. LVN 1 stated Resident 1 was not discussed in their huddle at the beginning of the shift on 10/30/2024, she was not aware Resident 1 was at risk for wandering, and she was not sure if Resident 1 had a care plan related to his at risk for wandering. LVN 1 stated, normally CNAs make rounds to monitor residents three times on an eight-hour shift but for residents at risk for wandering she instructed the CNAs to do rounds every 1 to 2 hours. During an interview on 11/5/2024 at 11:59 a.m., the ADON stated the purpose of completing a wandering risk assessment was to identify residents who were at risk for elopement, and the purpose of creating a care plan, based on the wandering risk assessment, was to ensure all staff were aware to monitor the resident. The ADON stated charge nurses were responsible to familiarize themselves with a resident's care plan and communicate those needs to the CNAs. The ADON stated residents who were at risk for wandering should be monitored once an hour or more. The ADON stated care plans should be clear and not left open for interpretation so goals could be measured to know if the goals were being met or not. During an interview on 11/6/2024 at 12:38 p.m., the Director of Quality Assurance (DOA) stated the last time she saw Resident 1 was in the facility's front lobby near the front door at 2 p.m., on 10/30/2024. The DOA stated a wandering risk assessment should be completed for all residents, and a care plan should be created if a resident was at risk for wandering, in order to document the care needed for a resident and implement it. The DOA stated a care plan should have been created for Resident 1's risk of wandering by the admitting nurse. The DOA stated Resident 1 should have been monitored at least four times during an eight-hour shift based on his mild cognitive impairment and ability to walk. During an interview on 11/6/2024 at 10:36 a.m., the DON stated per their policy when a resident was assessed as a wandering risk, a care plan should be created to make everyone aware of the resident's specific care needs. The DON stated for residents at risk for wandering, monitoring should be done at least six times during an eight-hour shift. The DON stated the reason why a wandering/elopement care plan was not created for Resident 1 was because he did not exhibit any actual wandering behaviors. The DON stated different frequencies of monitoring were dependent on the resident. During an interview on 11/6/2024 at 1:22 p.m., the DON stated the purpose of a care plan was to identify appropriate care for residents based on their needs and preferences. The DON stated a care plan should have been developed to address Resident 1's risk for wandering and documentation should have been completed to monitor Resident 1's location to prevent him from eloping from the facility and potentially getting hurt. The DON stated Resident 1 was diabetic and required insulin depending on his b/s levels and could suffer a medical emergency if he did not get his medication as prescribed. The DON stated Resident 1 was living in his van prior to admission to the facility and he voiced wanting to be discharged from the facility to go back to his van, but the physician stated it was unsafe for him to leave at that time. During an interview on 11/12/2024 at 1:14 p.m., Admission Nurse Assistant (ANA 1) stated she had been an ANA at the facility for six months and part of her duties included completing the wandering risk assessment for newly admitted residents. ANA1 stated she was not instructed to complete a care plan for residents who were assessed at risk for wandering. ANA 1 stated her understanding was that wandering care plans were to be completed by the MDS department. During a review of facility's P&P titled Wandering Residents - No Facility Wide Wandering Notification System dated 11/2016, the P&P indicated residents at risk for wandering shall have a care plan implemented with interventions appropriate to the resident to help prevent wandering out of the facility during the day. During a review of facility P&P titled Care Plans - Baseline and Summary dated 10/2024, the P&P indicated a baseline care plan should be developed for each resident within 48 hours of admission to provide instructions for the provision of effective and person-centered care to each resident, striking a balance between conditions and risks affecting the residents' health and safety. During a review of facility's P&P titled Routine Resident Checks dated 10/2024, the P&P indicated to ensure the safety and well-being of residents nursing staff shall make a routine resident check on each unit at least once per 8-hour shift, but frequency adjustments will be made according to individual needs.

Based on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), who could not bear weight on her left leg, was transferred using a mechanical lift according to the care plan and Kardex (a communication tool to access important and resident data regarding care). Resident 1 was transferred from her bed using two staff to physically lift Resident 1 from her bed and fell . This deficient practice resulted in Resident 1 being lifted from her bed by two Certified Nursing Assistants (CNA 1 and CNA 2) who used Resident 1's underarms to attempt to transfer Resident 1 from her bed to a wheelchair. The two CNAs lost control of Resident 1 who slid from her bed and landed on her knees on the floor. Resident 1 was later found with swelling, bruising and an abrasion (a scrape) to her left knee. Resident 1 sustained swelling and effusion (a buildup of fluid inside a joint such as a swollen ankle or knee) to her left knee with an order to apply a topical antibiotic to her left knee abrasion for 14 days. Findings: During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated, Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The Face Sheet indicated Resident 1's diagnoses included hemiplegia (paralysis on one side of the body), hemiparesis (weakness or inability to move on one side of the body) affecting Resident 1's left nondominant side, a history of falling, age related osteoporosis (a medical condition in which the bones become brittle and fragile), and foot drop (difficulty lifting the front part of the foot) of Resident 1's left foot. During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 9/11/2023, the MDS indicated Resident 1 made independent decisions that were reasonable and consistent. The MDS indicated, Resident 1 required extensive one-person physical assist for bed mobility and transfers and was totally dependent on nursing staff requiring a two-person physical assist for surface-to-surface transfers. The MDS indicated Resident 1 was not steady during surface-to-surface transfers (transfers between bed and chair or wheelchair) and was only able to stabilize with staff assistance and Resident 1 had a functional limitation in range of motion ([ROM] the direction a joint can move to its full potential) to one leg and one arm. During a review of Resident 1's Care Plan, dated 12/16/2020 the Care Plan indicated, Resident 1 required total assistance by two staff to move between surfaces and Resident 1 utilized a mechanical lift (a device used to move residents who are unable to stand on their own or whose weight makes it unsafe to move or lift them manually) for transfer. During a review of Resident 1's undated Kardex, the Kardex indicated to utilize assistive devices as needed for transfers, and to use a mechanical lift during transfers to provide a safe transfer. During a review of Resident 1's Change in Condition (COC) Evaluation, dated 10/18/2023, and timed at 8:45 p.m., the COC indicated, at 8:40 p.m., (10/18/2023) a Certified Nurse Assistant (CNA 1) reported that Resident 1 had an abrasion with swelling to her left knee. The COC indicated Resident 1's left knee was noted with a greenish discoloration measuring 13 centimeters ([cm] a unit of measurement) and an abrasion measuring 1.5 cm x 2.0 cm. The COC indicated Registered Nurse Supervisor (RNS) 1 obtained an order from Resident 1's physician ' s Nurse Practitioner (NP) for a stat (immediate) x-ray for Resident 1's left knee and to apply a topical antibiotic daily for 14 days. During a review of Resident 1's Radiology Results Report, dated 10/18/2023, the Radiology Report indicated Resident 1's left knee had swelling, and effusion. During an interview on 11/2/2023, at 3:58 p.m., with CNA 3, CNA 3 stated, Resident 1 had always been transferred using a mechanical lift. CNA 3 stated, CNA 1 told her that she (CNA 1) transferred Resident 1 (10/18/2023 around dinner time) to a shower chair with the assistance of CNA 2. CNA 1 thought Resident 1 could stand, so CNA 1 and CNA 2 tried to stand Resident 1 up and Resident 1 slid out of her bed. During an interview on 11/2/2023, at 5:52 p.m., with CNA 1, CA 1 stated CNA 2 asked her for assistance to transfer Resident 1 to a shower chair (10/18/2023). CNA 1 stated she and CNA 2 sat Resident 1 on her bed, then she (CNA 1) and CNA 2 stood on each side of Resident 1 and placed one arm under each of Resident 1's arms then they (CNA 1 and CNA 2) lifted Resident 1 up, that's when Resident 1 slid off the bed. CNA 1 stated she did not recall if Resident 1's feet or knees touched the floor. CNA 1 stated she and CNA 2 lifted Resident 1 and placed her back in her bed. CNA 1 stated she asked Resident 1 if she was in pain and Resident 1 stated no. CNA 1 stated, at 7 p.m., when she tried to turn Resident 1 to her side in order to change her adult brief Resident 1 complained of pain to her left knee. CNA 1 stated she informed the charge nurse (LVN 1), who informed the RNS 1, and an x-ray was ordered. CNA 1 stated residents don ' t get up on evening shift, so she did not check the Activities of Daily Living ([ADL] task such as eating, bathing, dressing, grooming and toileting) sheet to see how Resident 1 should have been transferred. CNA 1 stated it was important to know how Resident 1 should be transferred so Resident 1 does not get injured or fall. During an interview on 11/3/23, at 1:45 p.m., with LVN 1, LVN 1 stated, CNA 3 notified her that she (CNA 3) noticed swelling and discoloration on Resident 1's left knee (10/18/2023). LVN 1 stated she checked on Resident 1 and Resident 1 told her that she (Resident 1) slid down the bed when she was transferred from her bed to a shower chair around 5 p.m., (10/18/2023) and bumped both of her knees on the floor causing her pain in her left knee. LVN 1 stated, she assessed Resident 1 and gave her pain medication, and informed RNS 1. LVN 1 stated Resident 1 could not bend her left leg, so staff uses a mechanical lift to transfer Resident 1 for her safety. During an interview on 11/8/2023, at 11:10 a.m., the Director of Rehab (DR) stated, Resident 1 was dependent and required a mechanical lift for transfers. The DR stated staff should use a mechanical lift to transfer Resident 1 from her bed to a chair or a shower chair so Resident 1 does not fall or injure herself. The DR stated Physical Therapists are highly skilled and trained to perform a safe two person transfer from a bed to a wheelchair, whereas nursing did not receive that type of training. During an interview on 11/8/2023, at 11:57 a.m., the Director of Staff Development (DSD) stated, CNAs should know how a resident should be transferred because the information on transfers is located on the Resident's Kardex, and plan of care. The CNAs should ask the charge nurse or RNS how the resident should be transferred. The DSD stated, if a resident cannot stand, pivot, or bear weight on their leg(s) then a mechanical lift should be used. The CNAs should not lift a resident by placing their arms underneath the resident arms because the CNA can injure the resident, pull a joint out of socket, or the resident can slip and fall. During an interview on 11/21/2023 at 3 p.m., the Treatment Nurse, LVN 2, LVN 2 stated Resident 1did not have any discoloration to her knees prior to her fall (10/18/2023). LVN 2 stated Resident 1 has pain in her knees all the time and Voltaren cream (a gel/cream used to treat pain) is applied to her knees, which causes her skin to become dry and scaley but there was no discoloration. LVN 2 stated she saw the discoloration to Resident 1's knees two days after it was documented, and Resident 1 told her she (Resident 1) fell when she was transferred from her bed to a shower chair. During an interview and record review on 11/21/2023, at 4:11 p.m., with the Senior Nurse Executive, the facility's policy, and procedure (P/P), titled, Safe Lifting and Movement of Residents dated 7/2017, was reviewed. The P/P indicated manual lifting of residents shall be eliminated when feasible. The Senior Nurse Executive stated, when feasible is when the resident is not safe to be transferred based upon the resident functional status. The Senior Nurse Executive stated the two CNAs (CNA 1 and CNA 2) should have used a mechanical lift, when transferring Resident 1 based on her functional status and the CNAs should have accessed the Point of Care (a system that provides the ability for clinicians to document patient finding and assessments, as well as plans of care) Kardex to see how Resident 1 was to be transferred. During an interview on 11/21/2023, at 5:07 p.m., with the Unit Director of Nursing (UDON), the UDON stated Resident 1 was being transferred using a mechanical lift prior to her fall to ensure the safety of Resident 1. During an interview on 11/22/2023, at 5:42 p.m., with the Clinical Director (CN), the CN stated the Kardex is a clinical tool used by the CNAs to see how residents are transferred and the CNAs are taught to access the Kardex on hire. During a review of the facility's policy and procedure (P/P) titled, Safe Lifting and Movement of Residents, dated 7/2017, the P/P indicated, in order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and movement of residents. Manual lifting of residents shall be eliminated when feasible. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis.

Based on interview and record review, the facility failed to: 1. Ensure a resident, who had a diagnosis of a diabetes mellitus (DM) type 2 [a chronic disease characterized by elevated levels of blood glucose (or blood sugar) in a bloodstream] and was receiving Insulin [a hormone that lowers the level of glucose [a type of sugar in blood]) based on sliding scale (the increasing administration of pre-meal insulin dose based on the blood sugar [b/s] level before meals) coverage, did not have their b/s monitoring and insulin administration abruptly discontinued for one of six sampled residents (Resident 5). 2. Ensure a resident, who had a physician's order for monthly laboratory test of a complete blood count with differential ([CBC] a laboratory test which gives information about the production of all blood cells in the body) and a basic metabolic panel ([BMP] a group of blood tests which provide information about the body's metabolism [chemical reaction in the body's cells which change food into energy]) was carried out as ordered for one of five sampled (Resident 5). 3. Ensure staff followed the facility's policy and procedure (P/P) titled, Lab and Diagnostic Test Results - Clinical Protocol, to process test requisitions and arrange for Resident 5's tests for CBC and BMP as ordered. These deficient practices resulted in Resident 5's b/s obtained via her CMP and BMP in 9/2023 being unknown and not reported to Resident 1's physician. On 10/1/2023, Resident 1 was assessed with tachypnea (abnormally rapid breathing over 20 breaths per minute), tachycardia (a rapid heart rate over 100 beats per minute), and an unobtainable blood glucose reading, when the Accu-Check device (a blood glucose level monitoring device ) used to obtain Resident 1's b/s, read Error, indicating Resident 5's b/s was too high and above the Accu-Check device measuring range. On 10/1/2023 Resident 5 was transferred to a General Acute Care Hospital (GACH) for evaluation and treatment. At the GACH the resident was found to have a critically high b/s of 1199 milligrams [(mg)/deciliter (dl) a unit of measurement; b/s reference range is from 70-100 mg/dl] with significant hypernatremia (high concentration of sodium [salt] in the blood which is indicative of dehydration [when the body loses more fluid than what is taken in]. According to Cleveland Clinic article titled, Hyperglycemia (a condition when the b/s is higher than 180 mg/dl) any b/s reading above 250 mg/dl is a critical medical emergency due to high blood sugar levels are jeopardizing a person health and life and requires immediate medical intervention to lower b/s safely. https://my.clevelandclinic.org/health/diseases/9815-hyperglycemia-high-blood-sugar On 10/1/2023, Resident 5 was admitted to the GACH's Intensive Care Unit ([ICU] a unit with specialized staff, equipment, and standards to handle severe, potentially life-threatening illness) after endotracheal intubation (a medical procedure which a tube is placed into the windpipe (trachea) though the mouth aid with breathing) due to respiratory failure (a serious condition which makes it difficult for someone to breathe on their own). Findings: A review of Resident 5's Admission Record (Face Sheet), indicated Resident 5 was admitted to the facility on [DATE] with diagnosis including diabetes mellitus type 2, hemiparesis (a slight paralysis or weakness on one side of the body) following a cerebral infarction (a stroke), right side hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body) with the gastrostomy tube ([GT] soft flexible tube surgically placed into the stomach through the abdominal wall to provide nutrition and/or medication) in place. A review of Resident 5's History and Physical (H/P), dated 4/28/2023, indicated Resident 5 did not have the capacity to understand and make decisions. A review of Resident 5's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 5/4/2023, indicated Resident 5's cognitive skills for daily decision-making were severely impaired. The MDS indicated Resident 5 had DM and was receiving insulin. A review of Resident 5's Care Plan (untitled), dated 7/3/2023 indicated Resident 1 was at risk for hyperglycemia due to Resident 5's diagnosis of type 2 DM. The Care Plan indicated the goal for Resident 1 was to maintain blood glucose control in range as evidenced by no hyperglycemic events that required treatment outside the facility. A review of Resident 5's Order Summary Report ([OSR] physician's orders), dated 4/28/2023, indicated a physician's order for administration of regular Insulin (short acting medication used to treat elevated b/s levels) every six hours for DM, per the sliding scale as follows: 1. For b/s between 70-120 mg/dl no insulin required. 2. For b/s between 121-150 mg/dl administer two units of regular Insulin. 3. For b/s of 151-200 mg/dl administer four units of regular Insulin. 4. For b/s of 201-250 mg/dl administer six units of regular Insulin. 5. For b/s of 251-300 mg/dl administer eight units of regular Insulin. 6. For b/s of 301-350 mg/dl administer 10 units of regular Insulin. 7. For b/s of 351-400 mg/dl administer 12 units of regular Insulin. 8. Notify the physician if Resident 5's b/s is less than 70 mg/dl or greater than 400 mg/dl. A review of Resident 5's Order Audit Report, dated 7/6/2023 indicated via a verbal communication to discontinued Resident 5's b/s monitoring. A review of Resident 5's Medication Administration Record (MAR), dated 6/2023 and 7/2023 indicated the following b/s results and the amount of regular Insulin administered: 1. On 6/1/2023 at 12 a.m., Resident 5's b/s was 225 mg/dL, and six units of regular Insulin was administered. 2. On 6/2/2023, at 6 p.m., Resident 5's b/s was 136 mg/dL, and two units of regular Insulin was administered. 3. On 6/3/2023, at 12 a.m., Resident 5's b/s was 223 mg/dL, and six units of regular Insulin was administered. 4. On 6/4/2023, at 12 a.m., Resident 5's b/s was 121 mg/dL, and two units of regular Insulin was administered. 5. On 6/6/2023, at 6 a.m., Resident 5's b/s was 129 mg/dL, and two units of regular Insulin was administered. 6. On 6/7/2023, at 6 p.m., Resident 5's b/s was 161 mg/dL, and four units of regular insulin was administered. 7. On 6/9/2023, at 12 a.m., Resident 5's b/s was 179 mg/dL, and four units of regular Insulin was administered. 8. On 6/10/2023, at 12 a.m., Resident 5's b/s was 202 mg/dL, and six units of regular insulin was administered. 9. On 6/12/2023, at 12 p.m., Resident 5's b/s was 129 mg/dL, and two units of regular Insulin was administered. 10. On 6/13/2023, at 12 p.m., Resident 5's b/s was 123 mg/dL, and two units of regular Insulin was administered. 11. On 6/13/2023, at 6 p.m., Resident 5's b/s was 145 mg/dL, and two units of regular Insulin was administered. 12. On 6/15/2023, at 6 p.m., Resident 5's b/s was 152 mg/dL, and wo units of regular Insulin was administered. 13. On 6/16/2023, at 12 a.m., Resident 5's b/s was 136 mg/dL, and two units of regular Insulin was administered. 14. On 6/16/2023, at 6 a.m., Resident 5's b/s was 122 mg/dL, and two units of regular Insulin was administered. 15. On 6/16/2023, at 6 p.m., Resident 5's b/s was 166 mg/dL, and four units of regular insulin was administered. 16. On 6/17/2023, at 12 a.m., Resident 5's b/s was 180 mg/dL, and four units of regular Insulin was administered. 17. On 6/19/2023, at 12 p.m., Resident 5's b/s was 123 mg/dL, and two units of regular Insulin was administered. 18. On 6/20/2023, at 12 a.m., Resident 5's b/s was 134 mg/dL, and two units of regular Insulin was administered. 19. On 6/20/2023, at 6 p.m., Resident 5's b/s was 185 mg/dL, and four units of regular insulin was administered. 20. On 6/21/2023, at 12 a.m., Resident 5's b/s was 143 mg/dL, and two units of regular Insulin was administered. 21. On 6/21/2023, at 6 p.m., Resident 5's b/s was 123 mg/dL, and two units of regular Insulin was administered. 22. On 6/22/2023, at 6 p.m., Resident 5's b/s was 168 mg/dL, and four units of regular Insulin was administered. 23. On 6/23/2023, at 6 p.m., Resident 5's b/s was 142 mg/dL, and two units of regular Insulin was administered. 24. On 6/24/2023, at 12 a.m., Resident 5's b/s was 143 mg/dL, and two units of regular Insulin was administered. 25. On 6/27/2023, at 12 a.m., Resident 5's b/s was 223 mg/dL, and six units of regular Insulin was administered. 26. On 6/29/2023, at 6 p.m., Resident 5's b/s was 185 mg/dL, and four units of regular Insulin was administered. 27. On 7/1/2023 at 12 a.m., Resident 5's b/s was 132 mg/dL, and two units of regular Insulin was administered. 28. On 7/2/2023 at 12 a.m., Resident 5's b/s was 216 mg/dL, and six units of regular Insulin was administered. 29. On 7/5/2023 at 12 p.m., Resident 5's b/s was 219 mg/dL, and six units of regular Insulin was administered. A review of Resident 5's physician's order dated 8/9/2023, indicated to obtain a CBC with differential and a BMP every month. A review of Resident 5's laboratory results, dated 9/2023, indicated the CBC and BMP results were not available for review. A review of Resident 5's Consultant Pharmacist's Medication Regimen Review (MRR), dated 6/23/2023, indicated the Consultant Pharmacist recommended to decrease Resident 5's b/s monitoring from every six hours to every 12 hours. A review of Resident 5's Nursing Progress Notes, dated 7/6/2023, indicated Licensed Vocational Nurse 1 (LVN 1) documented she received a verbal order from Resident 5's physician to discontinue administration of insulin on sliding scale. A review of Resident 5's Laboratory Report results of Resident 5's random b/s ([RBS] a random glucose test that measures the amount of glucose circulating in a person's blood, the test is taken any time of the day whether you have eaten or not and is conducted in a laboratory) dated 7/2023 and 8/2023, indicated the following: 1. On 7/10/2023 Resident 5's RBS was 180 mg/dl. 2. On 7/19/2023 Resident 5's RBS was 143 mg/dl. 3. On 7/31/2023 Resident 5's RBS was 220 mg/dl. 4. On 8/14/2023 Resident 5's RBS was 198 mg/dl. 5. On 8/21/2023 Resident 5's RBS was 234 mg/dl. A review of Resident 5's laboratory report forms, for 7/10/2023, 7/19/2023, 7/31/2023, 8/14/2023 and 8/21/2023, indicated there was documentation on the form, by the licensed nurses (unidentified staff as well as LVN 1 and the Unit Director of Nursing 1 [UDON 1] that Resident 5's elevated RBS was reported to Resident 5's physician on 7/10/2023, 7/19/2023, 7/31/2023, 8/14/2023 and 8/21/2023. The licensed nurses' documentation on the laboratory report forms indicated Resident 5's physician gave no new orders on 7/10/2023, 7/31/2023, 8/14/2023 and 8/21/2023. A review of Resident 5's Nurse Practitioner Progress Notes, dated 7/11/2023, indicated Resident 5's Hemoglobin A1C ([HbA1c] a blood test which measures the average b/s level over the past three months from the date of the test) was 6.0 (a level of 5.7 to 6.4 indicates pre-diabetes). The Nurse Practitioner's Progress Notes dated 7/11/2023, 7/25/2023 and, 8/1/2023 indicated no documentation that the Nurse Practitioner was aware of Resident 5's elevated RBS on 7/10/2023, 7/19/2023 and 7/31/2023. A review of Resident 5's medical record indicated the resident's b/s level and insulin administration was not done starting from 7/8/2023 until 10/1/2023, a total of three months. A review of Resident 5's Change of Condition Evaluation Form ([COCE] a sudden clinically important change from a patient's baseline in physical, cognitive, behavioral, or functional status which without intervention, the change could lead to clinically significant complications up to and including death) dated 10/1/2023, indicated Resident 5 had a heart rate between 134-144 beats per minute, respirations of 26 breaths per minute, had cold and clammy skin, and an unobtainable b/s reading. A review of Resident 5's Nurse Progress Notes, dated 10/1/2023, indicated Resident 5's physician was notified of Resident 5's change in condition (COC), and the physician ordered to transfer Resident 5 to a GACH emergency department (ED) via 911. A review of Resident 5's Incident Report (used by emergency medical responders ([EMRs] to provide immediate lifesaving care to critical patients who are not in the hospital), dated 10/1/2023, indicated Resident 5 had a heart rate ranging between 132 and 138 beats per minute, a respiratory rate ranging between 44 and 60 breaths per minute, and a b/s level of High. The Incident Report indicated Resident 1 was transferred to a GACH due to tachypnea and tachycardia secondary to hyperglycemia. A review of Resident 5's GACH ED's Intake/Triage documentation dated 10/1/2023, indicated Resident 5 presented to the ED obtunded (depressed level of consciousness and could not be fully aroused), unresponsive to stimuli (an individual whose level of consciousness is such that he/she is not responsive to a stimulus [a thing or event which evokes a specific functional reaction in an organ or tissue]), with dry mucous membranes (decreased level of mucous that keeps the nose, mouth, and eyes moist and can indicate if a person is dehydrated [when the body loses more fluid than what is taken in]), delayed capillary refill (quick test done on a person's nail beds used to monitor dehydration and the amount of blood flow to the tissues), tachypneic and tachycardic. The ED's Intake/Triage documentation indicated Resident 5 required endotracheal intubation due to respiratory failure. A review of the GACH's laboratory results, dated 10/1/2023, indicated Resident 5's critical (such a difference from normal, as to be life-threatening unless something is done promptly and for which some corrective action could be taken) laboratory results were as follows: 1. Sodium (a type of electrolyte in the body which if elevated can be indicative of dehydration) level to 170 milliosmoles ([mmol] a unit of measurement)/liter ([L] a unit of measurement). The sodium reference range is between 136-144. 2. Potassium (a type of electrolyte in the body which if elevated can result in abnormal heart rhythms [improper beating of the heart, whether irregular, too fast, or too slow] level of 6.2 mmol/L. The Potassium reference range is between 3.6-5.1 mmol/L. 3. Chloride (a type of electrolyte in the body which if elevated can be indicative of dehydration) level of 126 mmol/L. The Chloride reference ranges are between 101-111 mmol/L. 4. Anion Gap (a blood test which checks the electrolyte balance of the blood, a high anion gap can be indicative of too much acid in the blood which can be caused by dehydration and diabetes) of 15. The Anion Gap reference range is between 4-12. 5. Blood Urea Nitrogen ([BUN] a blood test which measures the amount of urea nitrogen [waste product when the liver breaks down protein] in the blood which if elevated can be indicative of poor kidney function or damage) level of 81 mg/dL. The BUN reference range is between 8-20 mg/dL. 6. Creatinine level (a blood test used to check how well the kidneys are filtering the blood which if elevated can be indicative of dehydration, kidney damage or kidney failure) of 1.42 mg/dL. The Creatinine level reference range is between 0.44-1.03 mg/dL. 7. Glucose level of 1199 mg/dL. The reference range is 70-100 mg/dl. A review of Resident 5's GACH's records indicated Resident 5 was admitted to the Intensive Care Unit on 10/1/2023 with a diagnosis including a hyperosmolar hyperglycemic state ([HHS] a life threatening complication of type 2 DM when the b/s levels are too high [between [PHONE NUMBER] mg/dL] for a long period, leading to severe dehydration, confusion and if left untreated can lead to death), hypernatremia, and acute kidney injury (a condition which develops rapidly over a few hours or days in which the kidneys suddenly can't filter waste from the blood). The ICU records indicated Resident 5 required an insulin drip (continuous infusion of insulin intravenously [IV]) in the vein) to bring down Resident 5's high b/s, to control Resident 5's HHS and for fluid resuscitation (aggressive IV fluid replacement to prevent cardiovascular collapse [circulatory failure] and help restore renal (kidney) perfusion [the blood flow that passes through a unit mass of renal tissue withing a given time). A review of the GACH's laboratory results dated [DATE], indicated Resident 5's HbA1c was 8.5. During an interview on 10/4/2023 at 12:08 p.m., LVN 1 stated she was the one who reviewed Resident 5's Medication Record Review (MRR) with Resident 5's physician and received a verbal order to discontinue Resident 5's sliding scale, including b/s monitoring and Insulin administration. LVN 1 stated Resident 5's admitting diagnoses included type 2 DM and any b/s under 200 mg/dL was considered normal. LVN 1 stated Resident 5's b/s fluctuated and b/s monitoring should not have been discontinued. LVN 1 stated looking back, she should have recommended to Resident 5's physician to only discontinue the sliding scale and continue to monitor Resident 5's b/s levels, especially since Resident 5 had a diagnosis of type 2 DM. During an interview on 10/5/2023 at 10:53 a.m., the Pharmacist Consultant (PC) stated a resident with a diagnosis of type 2 DM should not have b/s monitoring and sliding scale coverage discontinued abruptly. The PC stated, if the physician decided to discontinue the sliding scale coverage, then the physician should have at least continued checking the resident's b/s to see how the resident's b/s levels were trending and hold the Insulin coverage. The PC stated a resident with a diagnosis of type 2 DM without b/s being monitored is at risk for unrecognized hyperglycemia, unnecessary hospitalization s, and possible death. During an interview on 10/5/2023 at 12:37 p.m., the UDON 1 stated on 8/21/2023 she notified Resident 5's physician that Resident 5's RBS was 234 mg/dL. However, the b/s laboratory results were abbreviated as RBS and at the time of her report to Resident 5's physician she did not know what RBS meant. The UDON 1 stated had she known what RBS stood for, she would have made a recommendation to Resident 5's physician to order additional labs or to monitor Resident 5's b/s with insulin coverage as needed. The UDON 1 stated it was the responsibility of all licensed nurses to ensure laboratory tests (labs) ordered by the physician were carried out. The UDON 1 stated it was ultimately her responsibility to oversee that labs were being done. The UDON 1 stated she was also responsible for notifying Resident 5's physician of Resident 5's labs results and acknowledge that Resident 5's CBC and BMP for the month of September 2023 were completely missed. The UDON 1 stated it was the standard of practice (the usual thing which is done in a particular situation) to monitor b/s levels of residents with DM. The UDON 1 stated the licensed nurses should have advocated for Resident 5 and obtained an order for b/s monitoring. The UDON 1 stated it was important to monitor Resident 5's b/s, especially since Resident 5 had elevated RBS levels. The UDON 1 stated Resident 5's hospitalization could have been prevented by reminding Resident 5's physician that Resident 5 had DM and Resident 5's b/s was no longer being monitored. The UDON 1 stated unknown and uncontrolled b/s levels placed Resident 5 at risk for kidney failure, comatose (a period of prolonged unconsciousness brought on by illness or injury), impaired cognition, and death. According to the undated American Diabetes Association article titled, The Big Picture: Checking Your Blood Glucose, the blood glucose monitoring is the primary tool to find out if a person's blood glucose levels are within the target range. https://diabetes.org/living-with-diabetes/treatment-care/checking-your-blood-sugar According to the Centers for Disease Control and Prevention (CDC) article titled, Monitoring Your Blood Sugar, dated 12/30/2022, the regular blood sugar monitoring is the most important thing a person can do to manage diabetes. https://www.cdc.gov/diabetes/managing/managing-blood-sugar/bloodglucosemonitoring.html A review of the facility's LVN Charge Nurse Job Description, revised 4/2013, indicated the LVN charge nurse responsibilities included verifying residents' care plans accurately reflect appropriate goals, problems, approaches, and revisions based on resident needs. The Job Description indicated the LVN charge nurse is responsible for requisition and arranging for diagnostic tests as ordered by the physician. A review of the facility's Registered Nurse (RN) Job Description, revised 2017, indicated the RN responsibilities included verifying assigned residents' care plans accurately reflect appropriate goals, problems, approaches, and revisions based on resident needs. The Job Description indicated the RN is responsible for requisition and arranging for diagnostic tests as ordered by the physician. A review of the facility's policy and procedure (P/P) titled, Lab and Diagnostic Test Results - Clinical Protocol, revised 11/2018, indicated the staff will process test requisitions and arrange for tests. The person who is to communicate results to a physician will gather, review, and organize the information which includes major diagnosis, and any pertinent lab work. A review of the facility's P/P titled, Nursing Care of the Older Adult with Diabetes Mellitus, revised 11/2020, indicated symptoms associated with diabetes include hyperglycemia. Older adults with diabetes are at higher risk for functional impairment, cognitive decline, muscle loss than other older adults.

Based on observation, interview, and record review, the facility failed to ensure the resident received all the necessary care and services in accordance with professional standards of practice to prevent a surgical wound infection for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure the licensed nurses changed a post-surgical (after surgery) dressing to Resident 1's left hip surgical wound for 34 days. 2. Ensure the licensed nurses clarified physician 2's order for wound care with orthopedic (doctor dealing with the correction of deformities of bones or muscles) surgeon and Resident 1's physician. 3. Ensure the licensed nurses implemented a plan of care titled 'Skin Integrity' to prevent infection of Resident 1's left hip surgical would. 4. Ensure the licensed nurses conducted Resident 1's left hip surgical wound site inspection for color, [CONDITION(S)] (swelling caused by excess fluid trapped in the body's tissues), drains, exudate (fluid that has seeped out of vessels or organs) and odor per facility's policy Dressing Change, Sterile, and to document findings in accordance with facility's policy titled Wound Care Suggestions and Documentation. 5. Ensure nursing staff arranged a follow up Resident 1's appointment with the orthopedic surgeon in 6 weeks from 12/21/22 as ordered. These deficient practices resulted in Resident 1 to develop a left hip wound infection, be admitted to a general acute care hospital (GACH) and receive treatment with two antibiotics (medication that fights bacterial infections) intravenously [(IV)directly in the vein/bloodstream] for infected wound. Findings: During a review of Resident 1's Admission Record dated 12/30/2021, the record indicated Resident 1 was admitted to the facility from the GACH with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 sustained a fall while at home. Resident 1 was discharged from the facility on 2/2/22 to the assisted living facility. During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care-screening tool, the MDS indicated the resident had an intact cognitive (conscious intellectual reasoning or thinking) skill for daily decision making. The MDS Section M indicated Resident 1 had a surgical wound and was at risk for developing a pressure ulcer (localized injury to the skin and underlying tissue resulting from prolonged pressure). On 2/11/22 the photographs of Resident 1's left hip surgical site and dressing were viewed. Resident 1's left hip dressing photograph was taken on 2/2/22 by the assisted living facility. The photograph was taken 2/2/22, on the day the resident discharged from the skilled nursing facility. The dressing on the photograph appeared black in color throughout with small areas of dried red fluid on the gauze. On 2/4/22, a home health nurse (HHN) had taken a photograph of Resident 1`s left hip wound at the assisted living facility. On the photograph Resident 1's left hip depicted with an opening in the skin and measured 3.7 centimeters [(cm) a unit of measurement] by 2.5 cm. The photograph depicted surrounding tissue of Resident 1's left hip surgical wound (referenced to skin opening) as dark purple in color and edematous (swollen), with drainage reddish in color. The area around the wound appeared bruised and mottled (patchy with irregular color) in color. During a review of Resident 1's Physician 2's Order dated 12/30/2021, the order indicated not to remove surgical dressing until the resident seen by the orthopedic surgeon. During a review of the facility's weekly wound report titled 'Non-Pressure Sore Skin Problem Report,' the report indicated, Resident 1's dressing to left hip surgical site was clean, dry, and intact with no signs and symptoms of infection at the site on the following dates: 1/6/22, 1/13/22, 1/20/22, 1/21/22 and 1/28/22. During a review of Resident 1's care plan titled 'Skin Integrity' dated 12/31/2021, the care plan indicated, Resident 1 had the potential for skin impairment related to the surgical incision and the interventions included: 1. Observe and document location, size, and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Keep left hip skin surgical wound clean and dry and minimize excessive moisture. 3. Weekly documentation to include any exudate and any other notable changes or observations. During a review of Resident 1's Treatment Administration Record (TAR) dated 1/1/22, the TAR indicated, that there was a physician's order with directions Do not remove surgical dressing until seen by orthopedic surgeon with a start date of 12/31/21. The TAR had a licensed nurses initials daily from 1/1/22 through 2/2/22 indicating the physician's order was followed and Resident 1's left hip surgical wound dressing was not changed since Resident 1's admission on 12/30/21. During a review of the Discharge Nursing Note (DNN) dated 2/2/22 at 4:35 p.m., DNN indicated, there was no current order to remove surgical dressing until seen by orthopedic doctor. The Discharge Note indicated that Resident 1 dressing was not changed on discharge from the skilled nursing facility. During a review of Admission Record from GACH dated 2/4/22 at 1:44 p.m., the admission record indicated, Resident 1 was admitted to GACH for a post operative wound infection of the left hip. A review of Emergency Department (ED) Documentation note from GACH dated 2/4/22 at 3:24 p.m., indicated Resident 1's chief complaint was redness at the left hip surgical site. The ED Documentation note indicated Resident 1 was admitted to the assisted living facility on 2/2/22 and on 2/4/22 was sent to GACH for evaluation of worsening infection of the left hip with bloody, foul-smelling drainage, ongoing pain involving the left hip thigh and left lower leg. The ED Documentation note indicated Resident 1 reported to have chills and believed she had a fever but was unsure. While in the Emergency Department, Resident 1 received two IV antibiotics [MEDICATION(S)] 1 gram (gm) and [MEDICATION(S)] 3.375 gm. During a review of ED Documentation from GACH dated 2/4/22 and timed 5:19 p.m., section titled 'Medical Decision Making' indicated Resident 1 presented to emergency department with nonhealing left hip surgical wound site draining foul-smelling drainage and wound culture (a test to find germs) was notable for Gram stain (a laboratory test that checks for bacteria at the site of a suspected infection or in certain bodily fluids) showing WBC [(white blood cells)- blood cells are frequently present with an infection] , GNR ([gram-negative rods]-bacteria resistant to multiple drugs and are increasingly resistant to most available antibiotics) and GPC ([gram-positive cocci]-bacteria). In the section titled 'Medical Decision Making' was documented that wound culture was suspicious for wound infection. During a review of the Microbiology (microorganism report) laboratory report from GACH dated 2/6/22 at 11:40 a.m., the report indicated the left hip surgical wound site was growing (unit of measurement) Proteus Mirabilis (bacteria) and Enterococcus Faecalis (bacteria found in human intestine). During a review of the GACH 'Discharge Summary' dated 2/8/22 at 2:49 p.m., the summary indicated Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Discharge Summary indicated that Resident 1 will remain on IV antibiotics until 2/26/22 for the left hip surgical wound infection. During a concurrent interview and record review on 3/3/22 at 12:30 p.m. Licensed Vocational Nurse (LVN1) stated the treatment nurse needs to assess a resident's skin before a resident discharged and stated if it looks infected, notify the doctor immediately. LVN 1 stated there should have been an order to monitor the surgical site every day for signs and symptoms of infection documented on TAR. LVN 1 stated, a surgical dressing can stay on from 14 to 21 days without being changed and normally nurses observe skin around the dressing and not the actual wound for signs and symptoms of infection. LVN 1 confirmed that a care plan for prevention of infection at Resident 1's lift hip surgical wound and for wound care was not implemented. LVN 1 stated, a surgical wound should have been monitored every shift for signs and symptoms of infection and notify the doctor if noted. LVN 1 confirmed Resident 1's left hip surgical wound dressing was not changed while the resident was at the facility. According to website https://wtcs.pressbooks.pub/nursingskills/chapter/20-5-wound-dressings/ Wound dressing changed every 24-48 hours to prevent drying and adherence to the wound bed. During a concurrent interview and treatment record review on 3/3/21 at 1:52 p.m. the Registered Nurse Supervisor (RNS) stated the treatment nurse inspects surgical wound dressing daily and if there was a physician's order not to change the dressing the nurses would not change the dressing. RNS stated nurses will inspect skin around the dressing for signs of infection and the dressing for any drainage on it. RNS confirmed that if the was a dressing over the surgical wound the nurses would not see the actual wound and if the wound was infected. RNS stated that nurses should document the condition of the wound and dressing upon the resident's discharge, including the presence or absence of infection. RNS confirmed there was no documentation of Resident 1's left hip surgical wound condition assessment and dressing at the time of resident's discharge from the facility. RNS confirmed that a care plan for Resident 1's left hip surgical wound infection prevention and care was not developed and not implemented and was not located in the resident's clinical record. During a concurrent interview and record review on 3/3/22 at 2:35 p.m. LVN 1 confirmed Resident 1's Discharge Summary report did not have left hip surgical wound site and dressing description. LVN 1 stated the treatment nurse must complete Discharge Summary assessment upon a resident discharge. During an interview on 3/7/22 at 2:31 p.m. the Administrator (ADM) of the assisted living facility stated Resident 1 was admitted on [DATE] from the skilled nursing facility (SNF). ADM stated Resident 1 was sent to her facility with a filthy, soiled, and saturated dressing on the left hip. ADM stated Resident 1 informed her that the dressing was not changed since she was admitted to the Skilled Nursing Facility on 12/30/21. The ADM stated that as soon as they undressed Resident 1, they smelled the foul odor from the dressing site on the left hip. ADM stated even though staff had on face masks, they were able to smell the foul odor through the masks. ADM stated that she called SNF and spoke with the DON and stated she should have advocated for Resident 1. ADM stated the nurses at SNF should have also smelled the wound before discharging the resident and even though they had on mask, they were able to smell the foul odor through the mask. ADM stated that she called the Home Health agency to come out and assess the wound. During an interview on 4/11/22 at 11:21 a.m. with the Home Health Nurse (HHN), the HHN stated that Resident 1 came into the assisted living facility on 2/2/22 after being discharged from SNF on the same day. HHN stated Resident 1 was alert and oriented. HHN stated Resident 1 informed her the nurses at the SNF only looked at her dressing but never changed it, they only put tape over it to keep the dressing in place. HHN stated, when she took off dressing from Resident 1 left hip surgical wound, she thought she was going to vomit. HHN stated that the dressing appeared to be in place on the resident's surgical wound for a very long time. HHN stated the dressing was black in color on the inside and the wound site was red. HHN stated it looked like there was an abscess around the wound and that the wound smelled like a dead body. HHN stated, that she told the assisted living facility to call 911 immediately and they took Resident 1 to GACH. HHN stated Resident 1 could have gotten [CONDITION(S)] (infection in the blood) from the infected wound and it could lead to the resident's death. HHN also stated a surgical wound site should be assessed daily and if there was a physician's order not to change the dressing, a nurse should have clarified the order with the physician. During an interview on 4/11/22 at 2:05 p.m. LVN 2 stated the residents usually come in from a hospital with doctor's orders to change their dressings after surgery and if they do not, then the facility contacts the physician. LVN 2 stated that sometimes it takes up to two weeks for the resident to see orthopedic doctor for the follow up after surgery. LVN 2 stated there is no time frame for the dressing to be on a resident after surgery and that the surrounding skin area of the dressing is inspected for strikethrough drainage or for signs and symptoms of infection if the physician order stated, do not change the dressing. LVN 2 stated I have seen dressings without being changed for about a month after the surgery, depending on the incision closure after surgery, like derma-bond (liquid glue). LVN 2 stated, that some potential complications of surgery could be an infection at the site, [CONDITION(S)], or pain. LVN 2 also stated if the orthopedic doctor says to keep the dressing on and do not change it, the nurse will keep the dressing in place without changing it. During an interview on 4/11/22 at 1:42 p.m. the Director of Nurses (DON), stated that dressing changes after surgery depends on the surgeon. DON stated, on admission Resident 1 had an order not to change the dressing until seen by the orthopedic surgeon. The DON stated the treatment nurse was to monitor for soiled dressing and signs and symptoms of infection. The DON stated other residents may have an order to change the dressing and then it is changed, but if there was an order specifically not to change the dressing, then the nurses must follow the order. The DON stated that she would not remove the dressing even if it was on for 30 days if there was an order from the surgeon not to remove it but not familiar with this case off hand. DON stated Resident 1 had an appointment for follow up on 2/2/2022 with the orthopedic surgeon. However, the resident was discharge from SNF on 2/2/22 and the follow up appointment was not arranged. During the interview on 4/12/22 at 4:03 p.m., the Orthopedic Surgeon (OS) stated that his usual protocol is to change surgical dressings after hip surgeries daily with [MEDICATION(S)] and a dry dressing. OS stated he did not write the order do not change the surgical dressing until seen by orthopedic surgeon. The order dated 12/30/21 was ordered by SNF physician. The OS stated hip surgery dressing are changed two days after the surgery and then it must be changed daily until followed up by the surgeon which is usually 14 days after surgery when the surgical site is healed to prevent infection. OS stated the facility nurses should have clarified SNF's physician order dated 12/30/21. OS stated some hip surgical sites can drain, so you need to change the dressing daily otherwise it could become infected. OS also stated that the surgical wound should be inspected daily to make sure that it is healed and that there are no signs and symptoms of infection. During a review of the facility's treatment nurse job description dated April 2013, the job description stated that the treatment nurse should: 1. Complete a dermatologic (skin disorders) examination of residents within a reasonable time after admission and as otherwise necessary based on resident needs and record the results with the assessment in accordance with the facility documentation policy. 2. Provide assessment and diagnostic services to residents. Perform an assessment evaluation using techniques including observation, inspection, and palpation (touch a body part). 3. Make written and oral reports/recommendations to the attending physician, Medical Director, or the Director of Nurses (DON) concerning the status and care of the residents During a review of the facility policy Dressing Change, Sterile, dated November 2016, the policy indicated the nurse should visually inspect the wound site for color, [CONDITION(S)], drains, exudate, odor, and integrity. During a review of the facility's policy titled Wound Care Suggestions and Documentation dated November 2016, the policy indicated a physician's order for wound care should not exceed 21 days. It also indicated that all residents would have a complete skin assessment performed by licensed staff at minimum of weekly and document findings on the Weekly Summary form.

Based on interview and record review, the facility failed to implement safety measures to prevent a fall with injury for one of three sampled residents (Resident 1). Resident 1, a newly admitted resident, who had a high risk for falls with a history of two subdural hematomas (a collection of blood outside the brain), and impulsive behaviors of ambulating without assistance, was not provided with adequate supervision to prevent further falls. This deficient practice resulted in Resident 1 falling on [DATE], two days after admission, while sitting at the nursing station for close supervision and three (3) nurses were supposed to be monitoring Resident 1 and she got up and fell . Resident 1 sustained a right [MEDICAL CONDITION] (broken bone) and shattered pelvis (multiple breaks of the bones that make up the pelvis) and required a transfer to a general acute care hospital (GACH) and underwent a surgical repair of right [MEDICAL CONDITION]. Findings: A review of Resident 1's discharge summary from the GACH dated [DATE] and timed at 2:26 p.m. indicated the resident had a history of [REDACTED]. The discharge summary indicated Resident 1's orders were approved by the former Director of Nursing (FDON) dated [DATE]. A review of Resident 1's Admission Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Resident Admission form, dated [DATE] indicated Resident 1 was disoriented (confused) to place, time, and situation. The resident admission form indicated Resident 1 had weakness and required assistive devices such as a walker for mobility. The resident admission form indicated under initial fall screen risk a score of 24. According to the resident admission form initial fall risk screen Resident 1 had a score of 24, according to the assessment a total score of 8 and more required a care plan to address risks, prevention, and minimizing risks. The resident admission form indicated Resident 1 had a history of [REDACTED]. A review of Resident 1's Morse Fall scale, dated [DATE] indicated Resident 1 had a score of 80, the Morse Fall scale indicated a total score of 45 or higher was at high risk for falls, scores of ,[DATE] at moderate risk and ,[DATE] at low risk for falls. According to the Morse Fall scale, Resident 1 had a history of [REDACTED]. A review of Resident 1's physician order, dated [DATE] indicated an order for [REDACTED]. A review of Resident 1's care plan initiated on [DATE] identified a problem with risk for fall secondary to admission risk assessment greater than 8. The goal indicated Resident 1 would have no falls with significant injury for 30 days. The staff's interventions included to keep call light in reach, provide adequate lighting, keep environment free from clutter as possible, assist with activities of daily living and transfers as indicated, and provide a 1:1 sitter. A review of Resident 1's Physical Therapy plan of care identified a problem with fall risk due to resident being impulsive (acting or done without forethought). A review of Resident 1's Skilled Nursing Facility (SNF) History and Physical (H/P), dated [DATE] and completed by Resident 1's primary care physician (Physician 1) indicated status [REDACTED]. Subsequent transfer to a SNF [DATE] to [DATE], Resident 1 was noted to have left foot dragging (weakness or paralysis of the muscles involved in lifting the front part of the foot). Resident 1 was transferred to another GACH on [DATE] and received a CT scan ((computed tomography) procedure that uses a computer linked to an x-ray machine to make a series of detailed pictures of areas inside the body) which showed worsening of the subdural hematoma larger with a 1.3 centimeter (cm) shift. The SNF H/P indicated Resident 1 was sent to a GACH emergently on [DATE] to [DATE] and received a burr hole (small hole that a neurosurgeon makes in the skull to help relieve pressure on the brain when fluid, such as blood, builds up and compresses brain tissue) with a drainage tube (flexible plastic tube implanted in the brain or skull to drain away the excess fluid). According to the SNF H/P Resident 1 had a repeat CT scan on [DATE], which showed a stable bleed (hematoma) with limited cognition (thought process), and on [DATE] Resident 1 was transferred to the current SNF to continue rehabilitation (action of restoring someone to health or normal life through training and therapy). A review of Resident 1's SNF progress note, dated [DATE] and completed by Physician 1, indicated there were no complaints, or reports of Resident 1 trying to get up by self. The SNF progress note indicated to discontinue sitter as no reports of trying to get up by self. A review of Resident 1's physician telephone order, dated [DATE] and timed at 2:20 p.m. indicated to discontinue 1:1 sitter. A recording of a voicemail (VM) left for Resident 1's Family member (FM 1), on [DATE] and timed at 7:59 p.m., Licensed Vocational Nurse 1 (LVN) gave the name of Resident 1 from the facility and stated it was not an emergency, but a call back was needed to the facility from Resident 1's FM 1 regarding Resident 1. A review of Resident 1's physician telephone order after Resident 1's fall, dated [DATE] and timed at 8 p.m. indicated to reinstate the 1:1 sitter s/p fall with neurological check (an assessment of sensory neuron and motor responses, especially reflexes, to determine if the nervous system was impaired). A review of Resident 1's investigation incident report, dated [DATE] and timed at 11 p.m. indicated the resident was found on the floor at the nursing station with straight legs facing the nursing station entrance. The incident report indicated Resident 1 was on the right side lying position, and propped up on right forearm. A review of an untimed Investigation worksheet, dated [DATE] indicated a specific incident was of Resident 1 found on the floor. The investigation worksheet indicated LVN 1's statement of Resident 1 was found on the floor by nursing station while LVN 1 was washing her hands. The investigation worksheet indicated the desk nurse LVN 2's statement Resident 1 was found on the floor when LVN 2 turned around to put away medical charts. LVN 2's statement indicated Resident 1 was assessed and put back into wheelchair. The investigation worksheet indicated a statement by a Certified Nursing Assistant (CNA 1) stated the 1:1 sitter was discontinued at 7pm, and according to CNA 1's statement the licensed nurses were asked to help monitor Resident 1 because CNA 1 was answering call lights. A review of Resident 1's Change of Condition (COC) evaluation, dated [DATE] and timed at 2:56 a.m. written by LVN 1 indicated Resident 1 had a fall on [DATE] at night and was associated with none or minor injury. The COC evaluation indicated Resident 1 was able to move the lower and upper extremities slowly. The COC evaluation indicated a 1:1 sitter would make the condition or symptoms better, and treatment for [REDACTED]. A review of Resident 1's GACH Emergency Department (ED) report, dated [DATE] and timed at 6:15 a.m. indicated Resident 1 arrived at the ED with chief complaint of a fall the day prior. The ED note indicated Resident 1 had right hip pain with a physical exam consistent with a right [MEDICAL CONDITION] and displacement. The GACH ED report indicated Resident 1 had discomfort to the right hip on internal (inside) and external (outside) rotation. Upon examination the hip was foreshortened (prematurely or dramatically shortened or reduced) on the involved right side. A review of Resident 1's GACH ED provider report, dated [DATE] and timed at 7:39 a.m. indicated an X-ray of the right hip with the reason listed as exam trauma. The GACH ED provider report x-ray findings indicated an intertrochanteric (broken bone of the proximal femur (thigh bone)) of the right hip with angulation (abnormal bend or curve) with multiple fractures of the superior and inferior pubic (pelvis) rami on the right. The ED provider report indicated Resident 1 was a candidate for surgical repair of the fractured pubic rami and right femur (thigh bone) with an anticipated surgery date of [DATE]. A review of Resident 1's GACH ED provider report, dated [DATE] and timed at 8:33 a.m. indicated CT scan of the brain was stable with chronic left-sided subdural hematoma and chronic microvascular ischemic gliosis (changes to the small blood vessels in the brain impairing brain function). A review of Resident 1's SNF nursing progress note, dated [DATE] and timed at 10:47 a.m. indicated the ambulance company estimated time of arrival was one hour. A review of Resident 1's SNF nursing progress note, dated [DATE] and timed at 3:57 p.m. indicated a new order was received for discontinuation was 1:1 sitter, as per physician Resident 1 had not had any episodes of standing up while sitter was present at bedside. A review of Resident 1's GACH's operative notes, dated [DATE] and timed at 3:35. p.m. indicated Resident 1's preoperative (before surgery) [DIAGNOSES REDACTED]. A review of Resident 1's GACH's operative notes, dated [DATE] and timed at 4:38 p.m., indicated Resident 1 postoperative diagnosis (after surgery) was s/p ORIF (an open reduction and internal fixation (ORIF) pieces of a broken bone are repaired using surgical screws, plates, sutures, or rods to hold in place) to the right hip. A review of an Interdisciplinary team ((IDT) a group of health care professionals from diverse fields who work together toward a common goal for resident care) conference record titled, Falls dated [DATE] indicated IDT acknowledge Resident 1 had impaired cognition, unsteady gait, history of falls, poor safety judgement and awareness, with decreased physical functioning. The IDT conference record indicated [DIAGNOSES REDACTED]. The IDT conference record indicated other factors considered by the team included the resident does not ask for assistance, tries to function beyond physical limitation as well as Resident 1's attempts to get out of bed unassisted with episodes of impulsiveness. Additional comments included, Resident 1's fall dated [DATE] at 7:30 p.m., found in the nursing station upon assessment no pain, swelling, bruising, bleeding, discomfort, and no head injury. The IDT conference record indicated Resident 1 was observed to move upper and lower extremities without pain. According to the IDT conference record Resident 1 was observed attempting to get out of bed unassisted and was brought to the nurses' station for visual monitoring. A review of an untimed Investigation worksheet addendum dated [DATE] indicated LVN 2 stated she heard something and turned around to find Resident 1 on the floor and called the charge nurse for help. According to the investigation worksheet addendum CNA 1 stated Resident 1 was observed attempting to get out of bed while CNA 1 was conducting room rounds. According to CNA 1's statement Resident 1 was brought to the nursing station for the nurses to watch her (Resident 1). The investigation worksheet addendum indicated a statement from Physician 1 regarding telephone order to discontinue the 1:1 sitter; Physician 1 stated Resident 1 seemed calm and quiet. The statement from Physician 1 indicated she had spoken to nursing but was unable to recall which nurse. The investigation worksheet indicated all nurses denied speaking to Physician 1. A review of Resident 1's nursing progress notes dated [DATE] and timed at 1:50 a.m., (late entry) written by LVN 1 indicates entry for [DATE] at 7:00 p.m. resident (Resident 1) was at the nurses station, at approximately 7:30 p.m. advised resident (Resident 1) not to stand up. Desk nurse found resident (Resident 1) on floor with straight legs facing nursing station entrance, right side lying position, propped on right forearm. Assessed head to toe, resident denies pain and discomfort upon assessment. No noted swelling, bruising bleeding, head injury or skin tear at this time. Resident was able to move upper and lower extremities without complaint of pain. Helped resident (Resident 1) safely transfer back into wheelchair with three-person assist. Placed hospitality aide to watch resident (Resident 1), reported incident to on-call physician (Physician 2) including vital signs and recommended x-ray. Physician (Physician 2) ordered neurological check (assessment of sensory neuron and motor responses, especially reflexes, to determine whether the nervous system is impaired) for 72 hours per facility protocol and reinstate 1:1 sitter (hospitality aide) On [DATE] at 12:22 p.m., during a telephone interview, Resident 1's FM 1 stated, while tearful, a missed call was received from the facility and the nurse (LVN 1) left a VM. FM 1 stated a call was made back to the facility and LVN 1 stated the facility nurses were waiting for a call back from Resident 1's physician to obtain an order for [REDACTED]. FM 1 stated upon speaking with Resident 1's assigned Hospitality Aide ((HA1) a nurse aide who works under the supervision of licensed nurses, who complete numerous non-medical tasks for patients, including serving meals, cleaning rooms and watching patients) it was discovered Resident 1's physician order [REDACTED]. On [DATE] at 1:10 p.m., during a telephone interview, HA1 stated Resident 1 was confused at times and would attempt to get up from bed unassisted about four times during an eight-hour shift and with very high risk for falls. According to HA1, the facility's nursing staff were aware of Resident 1's repeated attempts to get up from bed unassisted to use the restroom. HA1 stated the charge nurse on duty (LVN 1) would inquire at the end of each shift about Resident 1's attempts to get out of bed unassisted. HA1 stated the facility's staff were informed of Resident 1's mood swings and attempts to get up from bed multiple times on the first shift. HA1 stated prior to the conclusion of the second shift a text message was received from the nursing agency indicating the facility discontinued the 1:1 sitter (hospitality aide) for Resident 1. On [DATE] at 12:45 p.m., during an interview and concurrent record review of Resident 1's nursing progress notes the facility's Director of Nursing (DON) acknowledged Resident 1 did not receive an x-ray after the fall. The DON stated an outside medical vender provided the 1:1 sitter for Resident 1. The DON stated the nursing staff should assess a new resident within 24 hours and if necessary, will enroll the resident on the Falling Star Program (a variety of actions to help reduce the number of accidental falls suffered by at risk residents). The DON stated the nursing staff should complete monitoring for new resident admissions into the facility for 72 hours, monitor resident's behavior, conduct a physical assessment, and review medications. The DON stated the facility is unaware of which nursing staff member gave the wrong information regarding Resident 1's attempts to get out of bed unassisted because it was too soon to discontinue Resident 1's 1:1 sitter. The DON acknowledged there was no nursing documentation for monitoring Resident 1's attempts to get up unassisted and should have been, as well as closely monitored by the facility's staff due to history of falls with injury. The DON acknowledged the IDT conference record, dated [DATE] indicating Resident 1's attempts to get out of bed unassisted with episodes of impulsiveness. The DON stated Resident 1 was observed by the nursing staff attempting to get up from bed unassisted and documented in the IDT conference record and was the reason the resident was placed at the nursing station for monitoring. The DON acknowledged the nursing staff should have called Physician 1 to have the 1:1 sitter reinstated. The DON stated the x-ray was not ordered because Resident 1's fracture was obvious, and Resident 1 was transferred to the hospital. The DON stated a physical assessment was not completed immediately after the fall because Resident 1 was in the wheelchair and refused to go back to bed. The DON stated the nursing staff involved with Resident 1's fall no longer work at the facility and should have documented regarding the fall within the time of their shift. On [DATE] at 2:24 p.m., during a telephone interview, Physician 1 stated there were no reports from the facility's nursing staff of Resident 1 attempting to get up without assistance and stated an order to discontinue the 1:1 sitter would not have been given if the nursing staff would had reported Resident 1's attempts to get up unassisted. According to Physician 1, when Resident 1 fell she was not on call at the time and was not was notified until the following day of the incident. Physician 1 stated the nursing staff should have been supervising Resident 1 since she had a history of [REDACTED]. A review of the facility's policy and procedures (P/P) titled, Fall/ Accident Mitigation and intervention last reviewed ,[DATE] indicated it was the policy to minimize the risk of fall or accidents and minimize the risk of serious injury associated with falls or accidents. After a fall or similar accident or occurrence, the resident shall have a physical assessment documented in the nursing notes in accordance with the facility documentation policy. A review of the facility's P/P titled, Emergency care, General Guidelines last reviewed ,[DATE] indicated it is the policy of the facility to provide emergency care which may include, but not limited to CPR (cardiopulmonary resuscitation) and /or calling 911 for transfer to an acute care facility for more definitive treatment. Notify the physician and report changes in condition pursuant to the policy. If attending physician is not available, call medical director or alternate physician for guidance.

Based on interview and record review, the facility failed to develop and implement a resident-centered comprehensive care plan to ensure a resident, who had a history of [REDACTED]. Resident 1, who was impaired in cognition (thought process) with dementia (brain disorder destroys memory and thinking skills), was admitted to the facility for rehabilitation (restoring health or normal life through training and therapy) status [REDACTED]. Resident 1 had two falls while in the facility within two weeks, one with a fracture left shoulder and the facility failed to develop a comprehensive care plan to address Resident 1's behavior and needs to prevent falls with injuries. This deficient practice resulted in Resident 1 falling twice on 8/23/19 and on 9/7/19 fell and sustained a fractured left shoulder. Resident 1 required three transfers to the general acute care hospital (GACH) for evaluation and treatment. Resident 1 had a delay in treatment (surgery repair of fractured shoulder) resulting in pain requiring narcotic pain medication and the shoulder fracture worsening. Resident 1 underwent another surgery to repair the fracture left shoulder, which required a 20-day hospitalization for care and treatment. Resident 1 had a physical decline after the fall with fracture. Findings: A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. slowly destroys memory and thinking skills), difficulty in walking with a history of repeated falls. A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 7/25/19, indicated Resident 1's cognition (ability to reason and make decisions) was impaired. According to the MDS, Resident 1 required an extensive to being totally dependent with activities of daily living ((ADLs) daily care activities) and required a two-person physical assist for bed mobility, transferring, dressing and hygiene. Resident 1 required a one-person assist for eating. A review of Resident 1's History and Physical (H/P), dated 7/21/19, indicated Resident 1 does not have the capacity to understand and make decisions. A review of Resident 1's Fall Risk Assessment, dated 7/18/19 indicated Resident 1 was assessed as a high risk for fall and had an impaired gait (walk) and a history of falls. According to the Fall Risk Assessment, Resident 1 used crutches, cane, or a walker for mobility. A review of Resident 1's Care Plan, dated 7/29/19 and titled, At risk for fall or Injury, secondary to: poor safety awareness, impaired cognition, and impaired vision. The staff's interventions were vague (unclear character or meaning) and indicated they would keep the resident's environment free of slip/trip/fall hazards and provide eye/hearing/vision consult as indicated. A review of the facility's document titled, 'Investigation worksheet, dated 8/23/19 indicated Resident 1 was found on the floor at 1:08 a.m., on 8/23/19, after attempting to transfer to the bedside commode (portable toilet) alone. A review of Resident 1's Care Plan, dated 8/23/19 and titled, Actual Fall, the resident was found sitting on the floor (first fall). The staff's interventions included to do neuro checks (an assessment on someone with a head injury, cervical injury, nerve function in injury/surgery, or stroke) for 48 hours, place mats on the floor for safety, and post a sign on the wall that reads Call don't fall, push the red button. The care plan was vague and was not person-centered, as Resident 1's cognition and eyesight were impaired and Resident 1 had dementia. A review of Resident 1's care plans indicated there was no care plan to address Resident 1's need for close supervision due to Resident 1's dementia, confusion and inability to follow directives and inability to care for self. A review of the Interdisciplinary Team Conference Record ((IDT) coordinated group of experts from different fields who work together toward a common goal), dated 8/23/19 and titled, Falls indicated impaired cognition and non-compliance of the resident (Resident 1) to not activate the call button for assistance was the result of the fall. A review of Resident 1's change of condition (C[NAME]), dated 8/23/19, indicated Resident 1 had a fall but was stable (without injury). A review of Resident 1's physician's orders [REDACTED]. A review of Resident 1's GACH emergency room (ER) note, dated 8/23/19 indicated Resident 1 was seen at 8:14 a.m. on 8/23/19 and had no acute findings from the fall. Resident 1's history and physical (H/P) indicated Resident 1 fell at a SNF (skilled nursing facility) and had a history of [REDACTED]. Resident 1 had bilateral hip and pelvis x-ray done in the ER that were negative, without any fractures (broken bones). A review of Resident 1's GACH Discharge Summary, dated 8/23/19 indicated Resident 1 had a [DIAGNOSES REDACTED]. A review of Resident 1's Nursing progress note, dated 8/23/19 and timed at 2 p.m. indicated Resident 1 was readmitted to the SNF from the GACH. A review of Resident 1's Nursing Progress note, dated 8/24/19 and timed at 2:30 p.m., indicated Resident 1 was found unsupervised and decannulated ([MEDICAL CONDITION] pulled out) sitting upright in the bed and holding [MEDICAL CONDITION] in her hand. According to the Nursing progress note, Resident 1 could not recall how [MEDICAL CONDITION] came out and a [MEDICAL CONDITION] was placed by the respiratory therapist (a specialized healthcare practitioner trained in [MEDICAL CONDITION] ((relating to lungs) medicine in order to work therapeutically with people suffering from [MEDICAL CONDITION] disease). A review of the facility's document titled, 'Investigation worksheet, dated 9/7/19 indicated Resident 1 was found lying on the floor at 12:15 a.m., on 9/7/19, on her left side and complained of left shoulder pain with swelling. A review of Resident 1's physician's orders [REDACTED]. A review of Resident 1's second GACH transfer ER note, dated 9/7/19 indicated Resident 1's vital signs (are a group of the four to six most important medical signs that indicate the status of the body's vital (life-sustaining) functions) were as follow; blood pressure was 94/77 (normal reference range (NRR) is 120/80), pulse was at 77 beats per minute ((bpm) NRR is 60-100), and respiration was 18 (NRR is 12-20). Resident 1 was placed on a 100 percent (%) oxygen [MEDICAL CONDITION] (a medical device used to secure [MEDICAL CONDITION] in its position). Resident 1's ER H/P indicated Resident 1 had an unwitnessed fall to the floor with a swollen painful left shoulder. Resident 1 had a head computerized tomography ((CT scan) combines a series of x-ray images taken from different angles and uses a computer processing to create cross-sectional images) that was negative and an x-ray of the left shoulder that was positive for a [MEDICAL CONDITION] left humerus. A review of the GACH's Discharge Summary, dated 9/7/19 indicated Resident 1 had a [DIAGNOSES REDACTED]. 1. Return to emergency department symptoms such as loss of motor function, uncontrolled pain, or vomiting. 2. Follow-up with primary care physician within two-three days 3. Prescription for pain meds: [MEDICATION NAME] (narcotic pain medication (5 mg of [MEDICATION NAME] and 325 mg of [MEDICATION NAME])) and [MEDICATION NAME] (stool softener) 4. Ice packs as needed for pain A review of an electronic nurse's note dated 9/7/19 and timed at 11:55 a.m., Resident 1 was readmitted to the facility with a [DIAGNOSES REDACTED]. A review of Resident 1's Medication Administration Record [REDACTED]. A review of Resident 1's physician's orders [REDACTED]. A review of Resident 1's physician's orders [REDACTED]. According to the physician's orders [REDACTED]. A review of Resident 1's physician order, dated 9/9/19 indicated for Resident 1 to have a torso (trunk of the human body) belt left immobilizer (immobilizes (restrict movement) a part of the body to allow healing) on at all time for left humeral fracture. A review of an x-ray report, dated, 9/10/19 indicated Resident 1 had a left shoulder fracture with severe internal rotation (turning of a limb about its axis of rotation toward the midline of the body). On 9/11/19 at 11:22 a.m., during an interview, Resident 1's caregiver stated she was being paid by the family to come and sit with Resident 1 from 11 a.m. until 7 p.m. every day to monitor Resident 1 because the resident had two falls within two weeks. The caregiver stated Resident 1 was admitted to the facility for rehabilitation for a broken femur. Resident 1's caregiver stated although there was a sign posted to remind Resident 1 to push the call light, Resident 1 had impaired cognition, vision and cannot always remember to read the posted sign. Resident 1's caregiver stated while she was on duty, Resident 1 had not experienced any falls or incidents. The caregiver stated Resident 1's falls occurred after she left for the evening. On 10/17/19 at 8:30 a.m., during an interview, Resident 1's family member (FM1) stated she was very upset about Resident 1 falling twice since she has been in the facility. FM1 stated Resident 1 was placed in the facility for rehabilitation of a femur fracture. FM1 stated she was afraid Resident 1 could not endure another surgery due to her old age. FM1 stated she had asked the facility's director of nursing (DON), after the first fall, if Resident 1 could be assigned a 1:1 sitter to monitor her since she was forgetful and since most falls occurred after the paid caregiver was gone. FM1 stated she was told it had to be approved by the insurance company. FM1 stated Resident 1 was left-handed (dominant hand) and now that she has a broken her dominant arm, she was not able to do much of anything, such as feeding herself and was in pain. FM1 stated she had been renovating her home to make it wheelchair assessible, including a ramp so that Resident 1 could come home soon, but now she has a decline. FM1 stated after Resident 1 fell and fractured her shoulder she was transferred from the GACH back to the facility with an order for [REDACTED]. FM1 stated Resident 1 was admitted to the GACH (third admission to a GACH) and had a left arm ORIF surgery. A review of Resident 1's GACH orthopedic consultation, dated 9/13/19 indicated Resident 1 had a three-part acute left shoulder fracture with pain that was unstable and significantly displaced (to move, shift, or force from the usual place or position). A review of GACH's Discharge Summary, dated 10/3/19 indicated Resident 1 was diagnosed with [REDACTED]. 1. Follow-up with primary care physician within a week, suggesting physical therapy and occupational therapy 2. Follow- up with cardiologist (a physician with special training and skill in finding, treating and preventing diseases of the heart and blood vessels) as instructed. 3. Follow-up with orthopedic surgeon within a week 4. Non-weightbearing to left upper extremity 5. Administer prescribed anticoagulant (medicines that increase the time it takes for blood to clot). On 10/17/19 at 11:20 a.m., during an interview, the facility's DON stated although he was aware Resident 1 had impaired cognition, he could not think of anything else he could have put in place to prevent Resident 1 from falling and risking an injury. The DON stated 1:1 sitter was ordered after Resident 1's second fall. The DON was asked about a policy regarding supervision and he stated the facility did not have a policy/procedure for resident supervision. During an interview on 10/19/19 at 6:30 a.m., Certified Nursing Assistant 1 (CNA 1) stated she was assigned to Resident 1 the night she fell (9/7/19) and injured her shoulder. CNA 1 stated she was not made aware of Resident 1 having a previous fall. CNA 1 stated Resident 1 was forgetful and usually would not use the call light, but would sometimes beat on the bedside table if she needed assistance because she had a [MEDICAL CONDITION] and could not speak. CNA1 stated the facility would sometimes assign a volunteer to sit at Resident 1's bedside to monitor Resident 1 at night, but none was available the night Resident 1 fell . A review of the facility's policy and procedure dated 11/2017 and titled, Fall/Accident Mitigation and Intervention, indicated residents at risk for falls shall have a care plan that identifies the risk factors for that individual resident and appropriate intervention based on the risk factors. A review of the facility's policy titled, Health Information Record Manual, with a revision 2/11/19 for Care Plan/Plan of Care indicated a comprehensive plan of care will be developed for each resident that included measurable objective and timetables to meet the residents medical, nursing, mental and psychosocial needs. The policy also indicated the care plan should be updated throughout the resident's stay.

Based on observation, interview and record review, the facility failed to ensure food was served in a sanitary manner to one of 30 sampled residents (Resident 18) and nine randomly selected residents (Residents 33, 34, 35, 36, 37, 38, 39, 40 and 41) when unpasteurized shell eggs were used for the preparation and service of over easy eggs to residents. This had the potential of subjecting the residents to acquiring Salmonella, a foodborne illness commonly associated with the service of unpasteurized, undercooked eggs, especially to a highly susceptible population such as the elderly. On August 21, 2013, at 1:20 pm, the facility administrator and assistant administrator were notified Immediate Jeopardy was being declared in response to the potential of foodborne illness associated with the service of undercooked, unpasteurized eggs to facility residents. The Immediate Jeopardy was abated on August 22, 2013, at 2:30 pm., following a review of the facility's plan of correction for the removal of Immediate Jeopardy, review of resident's clinical record and staff interview. The administrator and assistant administrator were informed the Immediate Jeopardy was abated. Findings: According to the Food and Drug Administration (FDA) Food Code 2009, Section 3-801.11 Pasteurized Foods, Prohibited Re-Service, and Prohibited Food, "In a food establishment that serves a highly susceptible population: (B) Pasteurized eggs or egg products shall be substituted for raw eggs in the preparation of: (1) Foods such as Caesar salad, hollandaise or Bearnaise sauce, mayonnaise, meringue, eggnog, ice cream, and egg-fortified beverages, and (C) The following foods may not be served or offered for sale in a ready-to-eat form: (2) A partially cooked animal food such as lightly cooked fish, rare meat, soft-cooked eggs that are made from raw eggs, and meringue." On August 20, 2012, at 8:30 am, and 10 am, during an inspection of the facility kitchen, only unpasteurized shell eggs were noted to be available for the preparation of items such as over easy eggs. Pasteurized shell eggs are uniquely identified via a red letter "P" that is stamped on each egg. There was no red letter "P" stamped on any of the shell eggs observed in the facility kitchen, nor did the carton in which the eggs were delivered identify the eggs as pasteurized. On August 20, 2013, at 9:20 am, observation of the list of food substitutes available to residents, posted on the facility bulletin board, indicated sunnyside up and over easy eggs were available food substitutes. On August 21, 2013, at 8:40 am, during an observation of the breakfast meal, Resident 18 was noted to be served and consumed two over easy eggs, characterized by runny yolks that smeared the plate. On August 21, 2013, at 9 am, in an interview with cook 1, in the presence of the food service director (FSD), Cook 1 was asked if she prepared over easy eggs for residents on a regular basis. Cook 1 stated she prepared over easy eggs for "Nine to ten residents every day". Cook 1 was asked to demonstrate the process for the preparation of over easy eggs. Cook 1 proceeded to place some oil in a sauce pan, heat the oil on the stove and crack a shell egg into the hot oil. The shell egg was noted to not be imprinted with a red "P". Cook 1 then cooked the egg until she felt it was the appropriate consistency for an "over easy" egg request. Cook 1 then placed the egg on a plate, and the FSD was asked to take an internal temperature of the egg. Upon piercing the egg yolk, the yolk was noted to run out of the egg and onto the plate. The internal temperature of the egg yolk was noted to be 127 degrees Fahrenheit (F). Cook 1 and the FSD stated the over easy eggs were placed in the oven after preparation for holding purposes and not served to residents until the temperature measured 135 degrees F. On August 21, 2013, at 10 am, in an interview with the FSD, she stated she did not approve of the service of over easy eggs to residents, but, "They allow that in this facility". The FSD acknowledged the availability of pasteurized liquid eggs at the facility, but did not know about the existence of pasteurized shell eggs. The FSD did not know if there was a facility policy addressing the temperature to which unpasteurized shell eggs should be cooked, but stated references she had at home indicated eggs should be cooked to 160 degrees F. Concurrent review of the facility policy titled, "General Food Preparation and Handling" dated 2005, indicated, "No raw eggs are to be served. They must be cooked. Pasteurized eggs are the exception (these may be served soft cooked)." The facility policy titled, "Meat and Vegetable Cookery" dated 2005, indicated, "Eggs (pasteurized are preferred) must be cooked to an internal temperature of 155 degrees F (Fahrenheit). Only pasteurized eggs may be used for soft cooked eggs." On August 21, 2013, at 1 pm, review of the facility invoices of food items purchased from January 2013 through July 2013, revealed only unpasteurized shell eggs were noted to have been purchased. On August 21, 2013, at 1:20 pm, the facility administrator and assistant administrator were notified immediate jeopardy was being declared in response to the potential of foodborne illness associated with the service of undercooked, unpasteurized eggs to facility residents. On August 21, 2013, at 2:40 pm, in an interview with the registered dietitian (RD), she stated she does not make rounds in the kitchen and had not been aware pasteurized shell eggs were not being utilized for the preparation of undercooked eggs. On August 21, 2013, at 4:30 pm, the facility provided an acceptable plan of correction in response to the immediate jeopardy declared, that included: Removal of all unpasteurized shell eggs from the facility, and the purchase of pasteurized shell eggs from a local grocery store until delivery of pasteurized eggs was made through the facility's food vendor. Identification of all residents who had consumed undercooked, unpasteurized shell eggs and notification of the residents' physician and responsible party of such. Updating identified residents' care plans of the problem of consumption of undercooked, unpasteurized shell eggs, and monitoring the residents for a period of 72 hours for symptoms associated with foodborne illness (FBI) such as abdominal pain, vomiting, diarrhea. Inservice training on the proper manner to prepare eggs to the staff members involved in the cooking of eggs. Education of certified nursing assistants on monitoring for signs and symptoms associated with foodborne illness. Enforcing the facility policy titled, "General Food Preparation and Handling" which identified only pasteurized eggs should be used for the service of soft cooked eggs. At the direction of the Quality Assurance Committee, monitoring for compliance by the Dietary Service Supervisor under the oversight of the Registered Dietitian via routine audits for three months and then quarterly thereafter. On August 22, 2013, at 8:20 am, a list of residents who had been identified to have regularly consumed over easy eggs was provided. The list included residents 18, 34, 35, 36, 37, 38, 39, 40 and 41. On August 22, 2013, the registered dietitian (RD) was asked to print out the tray slip for Resident 33. Review of the tray slip indicated Resident 33 was to be served over easy eggs during the lunch meal on Wednesdays, Fridays and Sundays. August 21, 2013, was a Wednesday. Resident 33 had not been identified as one of the residents who had received undercooked eggs and was to be monitored for possible symptoms of foodborne illness such as nausea, vomiting and diarrhea. On August 22, 2013, at 8:30 am, review of the medical record for Resident 40 revealed the resident's care plan had not been updated to reflect monitoring for FBI related to the consumption of unpasteurized, undercooked shell eggs. This was confirmed in an interview with registered nurse (RN) 1 on August 22, 2013, at 8:35 am. On August 22, 2013, at 8:50 am, review of the medical record for Resident 35 revealed the resident had complained of diarrhea on August 21, 2013, and the physician was notified and ordered a stool culture. There was no documentation indicating the physician was notified the resident consumed undercooked, unpasteurized eggs. This was confirmed in a concurrent interview with licensed vocational nurse (LVN) 2. On August 22, 2013, at 9:45 am, review of the facility plan of correction revealed inservice training was conducted with certified nursing assistants, on identifying the signs and symptoms of gastrointestinal distress (nausea, vomiting and diarrhea) through August 22, 2013. The facility provided an invoice indicating the delivery of pasteurized eggs from the food vendor on August 22, 2013, at 2:20 pm.