Every finding on record at Sunray Healthcare Center

Based on observation, interview, and record review, the facility failed to implement its Abuse Prevention Program, Abuse and Neglect, and Abuse Investigation and Reporting policies and procedures (P&P) for one of three sampled residents (Resident 1) reviewed for resident abuse by failing to: - Ensure Housekeeper 1 did not physically force Resident 1's right hand to open, causing Resident 1 to scream in pain on 5/9/2026 at 4 PM. -Ensure Registered Nurse 1 (RN1) identified and reported Resident 1's Family 1's allegation of physical abuse to the facility's Administrator (ADM), the Director of Nursing (DON), the Ombudsman (an official appointed to investigate individuals' complaints against maladministration), local police, and to the California Department of Health (CDPH) on 5/9/2026 at 4 PM. -Ensure Registered Nurse 1 conducted private interviews with Resident 1 and Family 1 separately and in a private location on 5/9/2026 and did not allow Housekeeper 1 to confront Resident 1 and Family 1. -Ensure Housekeeper 1 received abuse prevention training as required. These failures caused Resident 1 to scream in pain and had the potential to increase Resident 1's risk for potential abuse.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 8/1/2023, with diagnoses that included dementia (a progressive state of decline in mental abilities), cerebral infarction (a medical emergency caused by disrupted blood flow to the brain), and transient ischemic attack (a mini-stroke, occurs when blood flow to the brain is temporarily blocked). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 1/23/2026, the MDS documented that R1 required maximum assistance (helper does more than half the effort) from staff to complete activities of daily living (ADLs, activities a person performs daily such as bathing, dressing, and toileting). The MDS documented thatR1's cognition was severely impaired (significant difficulty with memory, orientation, and recalling information). During a review of Resident 1's Care Plan Report, revised on 4/23/2026, the Care Plan Report documented that R1 was at risk for decline in range of motion (ROM, how far and in what direction you can move a joint or muscle) due to upper and lower extremity weakness. The Care Plan Report documented that nursing interventions included that staff were to monitor for signs of pain or stiffness and alert nurses of any changes. During a review of Resident 1's Progress Notes dated 5/13/2026, the Progress Notes documented that Resident 1 stated he (Resident 1) lost functioning in his right hand after a stroke. During a review of Resident 1's Occupational Therapy (OT) Evaluation and Plan of Treatment dated 5/19/2026, the OT Evaluation and Plan of Treatment documented that Resident 1 had decreased ROM in the right hand. During a review of Resident 1's Post-Event Review dated 5/20/2026, the Post-Event Review documented that Resident 1's family alleged that a housekeeper [Housekeeper1] touched the resident's hand on 5/9/2026 at 4 PM. During a review of Family 1's email sent to the facility titled, Urgent Formal Complaint - Abuse, Neglect, and Safety Concerns Regarding [Resident 1], dated 5/12/2026, the email indicated that on 5/9/2026 at 4PM Housekeeper 1 Without our permission and without any medical authorization, she [Housekeeper 1] forcefully grabbed and attempted to pry open his hand [Resident 1]. The email indicated Resident 1 Immediately screamed in pain and repeatedly told her [Housekeeper 1] he [Resident 1] could not move or open his hand himself. She [Housekeeper 1] continued despite his [Resident 1] visible pain and distress. The email indicated Witnessing a staff member [Housekeeper 1] physically force movement on a stroke patient [Resident 1] causing him [Resident 1] pain was deeply alarming and traumatic for our family. We immediately reported the incident to the manager or supervisor [RN1] on duty. During an observation on 5/21/2026 at 9:38 AM in front of Resident 1's room, Resident 1 had a splint (a firm material used for supporting and immobilizing an arm or leg) on his right arm. During a phone interview on 5/21/2026 at 10:24 AM with Housekeeper 1, Housekeeper 1 denied physically touching Resident 1 and stated she massaged her own hand to demonstrate to Family 1 how to massage Resident 1's right hand. Housekeeper 1 stated she remained at the facility to finish her shift on 5/9/2026 after the incident. Housekeeper 1 stated that her most recent abuse training was over a year ago. During a phone interview on 5/21/2026 at 11:30 AM with Family 1, Family 1 stated that on 5/9/2026 at 4PM while at the outside smoking area, Housekeeper 1 grabbed Resident 1's hands without permission which caused Resident 1 to scream in pain. Family 1 stated she immediately reported what happened to Registered Nurse1 (RN 1). Family 1 stated RN 1, Housekeeper 1, Certified Nursing Assistant 1(CNA 1) went to Resident 1's room after the incident to discuss with Family 1 and Resident 1 what happened. During a phone interview on 5/21/2026 at 12 PM with Housekeeper 1, Housekeeper 1 stated that she (Housekeeper 1) went to Resident 1's room after the incident on 5/9/2026 to confront Family 1 about the accusation. During a phone interview on 5/21/2026 at 12:39 PM with CNA 1, CNA 1 stated herself, RN 1, Housekeeper 1, Family 1, and Resident 1 were in Resident 1's room to discuss the incident. CNA 1 stated that she provided Spanish translation. During a concurrent interview and record review on 5/21/2026 at 1:16 PM with the Director of Staff Development (DSD), Housekeeper 1's employee file was reviewed. The employee file indicated Housekeeper 1's mandatory abuse prevention in-service training was past overdue since 4/30/2026. The DSD stated staff should complete in-service trainings to learn how to provide optimal care for residents. During a concurrent interview and record review on 5/21/2026 at 1:41 PM with the Maintenance Supervisor (MS) 1, Housekeeper 1's 5/2026 timesheet was reviewed. The timesheet documented that Housekeeper 1 worked full shifts on 5/9/2026 and 5/10/2026. MS 1 stated Housekeeper 1 notified him of the incident on 5/9/2026. MS 1 stated Housekeeper 1 continued to work after the incident was reported to RN 1. MS 1 stated he did not follow up with RN 1 and was not aware of an abuse allegation until 5/12/2026. During a phone interview with RN 1 on 5/21/2026 at 2:08 PM, RN 1 stated that Housekeeper 1 was not sent home after Family 1's complaint of Housekeeper 1 inappropriately touching Resident 1's hand because Family 1 did not explicitly verbalize that abuse had occurred. RN 1 stated when there was suspected staff-to-resident abuse, staff could not stay to finish his/her shift. RN 1 stated residents could feel unsafe and further abuse could be committed. RN1 stated she (RN1) did not report the incident to the ADM and or DON. RN1 stated she (RN1) did not document the incident in Resident 1's medical records. RN1 stated Resident 1's Family 1 stated they did not appreciate Housekeeper 1 touching Resident 1 and giving them medical advice. RN1 stated she (RN1) did not think the incident was considered abuse. During an interview with the DON on 5/21/2026 at 2:42 PM, the DON stated that forcibly pulling a resident's extremity (in general), causing the resident to scream was considered physical abuse. The DON stated that when there was suspected staff-to-resident abuse, staff must immediately clock out to prevent retaliation (revenge), otherwise staff could go back to intimidate the residents. The DON stated interviews between the victim and alleged abuser should have been conducted separately. The DON stated that Housekeeper 1 was on extended leave and recently came back. The DON stated Housekeeper 1 should have completed abuse prevention in-service training after returning from leave, to ensure competency. During an interview with the Administrator (ADM) on 5/21/2026 at 3:26 PM, the ADM stated Housekeeper 1 was not sent home because there was no official reported allegation of abuse on 5/9/2026, when the incident happened. The ADM stated he (ADM) was not aware that Housekeeper 1 went to confront Resident 1 and Family 1 after the incident. During a review of the facility's P&P titled, Abuse Prevention Program, revised August 2025, the P&P documented that the facility required staff training/orientation programs which would include topics such as abuse prevention, identification, and reporting of abuse. The P&P documented that the facility would protect residents during abuse investigations. During a review of the facility's P&P titled, Abuse & Neglect - Clinical Protocol, revised August 2025, the P&P documented that facility staff would help identify risk factors for abuse within the facility; for example, issues related to staff knowledge and skill. During a review of the facility's P&P titled, Abuse Investigation and Reporting, revised August 2025, the P&P documented that Each interview with be conducted separately and in a private location.

Based on observation, interview and record review the facility failed to ensure safe food storage practices in the kitchen when: 1.One bottle of thickened coffee was stored in the reach in fridge with an open date of 2/27/2026, exceeding storage period indicated in the manufacturer's instructions. 2.Bulk food (sugar) was stored inside trash bags that were not food grade (specialized bags designed for the safe storage, transportation, and packaging of food items intended for human consumption). These failures had the potential to result in harmful bacteria growth and cross contamination of food (transfer of harmful bacteria and chemicals from one place to another) that could lead to food borne illness in 67 of 75 residents (unidentified) who received food from the facility.Findings: During an observation in the facility's kitchen on 4/18/2026 at 9:15AM, an open bottle of thickened coffee with receive date of 3/20/2025 and open date of 2/27/2026 was observed stored in the reach in refrigerator (an upright, commercial-grade cooling unit designed for easy access to ingredients, featuring front doors that allow staff to reach in for items rather than entering the unit.) During a concurrent observation of the reach in refrigerator and interview with the dietary supervisor (DS) on 4/18/2026 at 9:15AM, the DS stated the thickened coffee was for residents who were on thickened liquids (beverages modified with powders or gels to increase viscosity, designed for individuals with dysphagia (swallowing difficulties) to reduce aspiration risk. By slowing the liquid's flow, these drinks allow more time for throat muscles to control swallowing.) The storage instructions on the bottle written on the manufacturer's instructions were reviewed by the DS, the instructions indicated the thickened coffee had to be refrigerated after opening and used within 14 days of opening. The DS stated that the thickened coffee should have been discarded because it had been in the refrigerator for more than 14 days. The DS said serving the thickened coffee could have been bad. The DS stated kitchen staff had not served the thickened coffee lately. The DS stated serving the thickened coffee after 14 days from opening had potential to make residents sick. The DS was then observed removing the bottle of thickened coffee from the refrigerator to discard. During a review of facility's policy and procedures (P&P) titled, Food receiving and Storage revised 11/2023, the P&P indicated Refrigerated foods are labeled, dated and monitored so they are used by their use by date, frozen or discarded. 2. During an observation in the facility's kitchen on 4/18/2026 at 9:40AM, bulk food (sugar) was observed stored in large bins that were lined with plastic bags (trash bags). During a concurrent observation in the facility kitchen and interview with the DS on 4/18/2026 at 9:40AM, the DS stated the plastic liners inside the bins were regular trash bags and were not food grade. The DS stated the facility had food grade liners, but kitchen staff used trash bags. The DS stated plastic trash bags were not good for food storage. During a follow up interview with the DS on 4/18/2026 at 4 PM, the DS stated plastic trash bags had chemicals and could contaminate the food. The DS stated staff should not have used plastic trash bags. During a review of the 2022 U.S. Food and Drug Administration Food Code titled Characteristics code 4-102.11, the code indicated, The safety and quality of food can be adversely affected through single service and single use articles that are not constructed of acceptable materials. The migration of components of those materials to food they contact could result in chemical contamination and illness to the consumer. In addition, the use of unacceptable materials could adversely affect the quality of the food because of odors, tastes, and colors transferred to the food.

Based on record review and interview, the facility failed to ensure that a licensed pharmacist performed a monthly medication regimen review (MRR, when a consultant pharmacist reviews and analyzes a resident's medication list, ensuring that the medications are appropriate, effective, and safe) to identify potential clinically significant medication issues, including unnecessary drugs, for one of 18 sampled residents (Resident 4). This failure had the potential to result in unmonitored adverse drug reactions (undesired and harmful effects that occur because of medication, treatment, or procedure) and inappropriate medication usage for Resident 4.Findings: During a review of Resident 4's admission Record, the admission Record indicated the facility admitted Resident 4 on 11/22/2024 with diagnoses that included schizophrenia (a mental illness that is characterized by disturbances in thought), hypertension (HTN-high blood pressure), and hypothyroidism (a condition where the butterfly-shaped gland in your neck doesn't produce enough hormones, causing your body's metabolism to slow down). During a review of Resident 4's Order Summary Report dated 12/3/2025, the Order Summary Report indicated Risperidone [medication used to treat schizophrenia] Oral Tablet (Risperidone) Give 1 mg [milligrams-unit of measure] by mouth two times a day for Schizophrenia M/B [manifested by] sudden angry outburst. During a review of the facility binder for Consultant Pharmacist's Medication Regimen Review [MRR] for recommendations created between 12/1/2025 and 12/12/2025, the MRR indicated Resident 4's name was listed among 35 other residents (unidentified) as medications that were reviewed by the consultant pharmacist but did not require any recommendations. During a review of Resident 4 ' s Minimum Data Set (MDS - a resident assessment tool) dated 2/13/2026, the MDS indicated Resident 4 was cognitively intact (was able to understand and make decisions independently). The MDS indicated Resident 4 required staff supervision or touching assistance for Activities of Daily Living (ADLs such as, toileting hygiene, shower/bathe self, personal hygiene, putting on/taking off footwear, personal hygiene, lower/upper body dressing). During a concurrent interview and record review of the facility binder for MRR with the Director or Nursing (DON) on 4/19/2026 at 7:12 PM, the DON was unable to locate the MRR for Resident 4's risperidone. During a follow up concurrent interview and record review with the DON on 4/19/2026 at 7:24 PM, the DON presented Resident 4's MRR for a different medication (Primidone 250 mg- an anti-seizure medication or an anticonvulsant that works by calming overactive nerves in the brain) and provided the consultant pharmacist's MRR list which did not indicate or specify which medications were reviewed. The MRR did not indicate Resident 4's response to the Risperdal. The DON stated that the importance of conducting an MRR was to ensure that residents (in general) who would take high risk medications (drugs with a heightened risk of causing significant patient harm, or even death, when used in error) such as antipsychotics (Risperdal) were monitored for side effects and checking the appropriateness of continuing therapy. The DON was unable to respond when asked what the potential effects were of not completing a pharmacy MRR monthly. During a review of the policy and procedure (P&P) titled, CONSULTANT PHARMACIST REPORTS. IIIAla: MEDICATION REGIMEN REVIEW (MONTHLY REPORT) reviewed 8/18/2025, the P&P indicated The consultant pharmacist performs a comprehensive medication regimen review (MRR) at least monthly. The MRR includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy. The P&P indicated that the consultant pharmacist had to review the MRR monthly for each resident either onsite or remotely to access clinically relevant information.

Based on observation, interview, and record review, the facility failed to ensure safe medication administration or accurate accountability of all controlled medications (medications with a high potential for abuse) for one of four sampled residents (Resident 6) by failing to:-Document the removal of Lacosamide (a medication used for seizure disorder, a condition characterized by abnormal electrical activity in the brain that leads to sudden changes in behavior, movement, feelings, or consciousness) for administration to Resident 6 on the Controlled Drug Record (CDR, a detailed record that tracks the receipt, administration, disposal, and inventory of controlled substances [use are regulated by law due to its potential for abuse, dependence, or harm]).This failure had the potential for unsafe care, treatment, and medication administration which could result in Resident 6 receiving more or less medication than needed to control seizures. This failure created a discrepancy between Resident 6's Medication Administration Record (MAR, a record of each medication given, including dosage, time, and the person administering) and the CDR on 4/2/2026 and 4/4/2026. This failure increased the risk for the licensed nurses (in general) not to be able to readily identify controlled medication loss, drug diversion (illegal distribution or use of prescription drugs), or medication errors.Findings: During a review of Resident 6's admission Record, the admission Record indicated the facility admitted Resident 6 on 10/4/2024 and readmitted Resident 6 on 1/24/2026 with diagnoses that included seizures and encounter for attention to gastrostomy tube (G-Tube, a medical device inserted through the abdomen for nutrition, fluids, or medication administration). During a review of Resident 6's Care Plan Report dated 4/5/2025, the Care Plan Report indicated Resident 6 was at risk for injury related to seizure disorder. The Care Plan Report indicated the goal was for the resident not to experience an adverse reaction (an unpleasant symptom or event that is due to or associated with a medication) to medication. The Care Plan Report indicated the nursing interventions included to administer medications as ordered and monitor for side effects. During a review of Resident 6's Minimum Data Set (MDS, a resident assessment tool) dated 12/9/2025, the MDS indicated Resident 6's cognition (ability to think, remember, and reason) was severely impaired, and Resident 6 needed substantial to maximal assistance (staff does more than half the effort) for eating and oral hygiene, and was dependent (staff does all the effort) for toileting, shower, dressing, personal hygiene, and transfer from bed to chair. During a review of Resident 6's Order Summary Report, the Order Summary Report indicated on 1/24/2026, Resident 6's physician ordered Lacosamide Oral Solution 10 milligrams (mg, unit of mass) per milliliters (ml, unit of volume), to give 20 ml via G-Tube every 12 hours for seizure disorder. During a review of Resident 6's History and Physical (H&P, a comprehensive physician's note regarding the assessment of the resident's health status) dated 1/26/2026, the H&P indicated Resident 6 did not have the capacity to understand and make decisions. During a concurrent medication area observation, record review, and interview on 4/18/2026 at 11:55 AM, with a Licensed Vocational Nurse 3 (LVN 3), on Station A at Medication Cart 1 (MedCart1), Resident 6's CDR and MAR for the Month of April 2026 were reviewed for the administration of Lacosamide. LVN 3 compared the 4/4/2026 MAR and CDR for Resident 6's Lacosamide and stated Resident' 6s MAR had two doses documented as administered on 4/4/2026 (timed at 9 AM and 9 PM) and the CDR indicated one dose of Lacosamide for Resident 6 was documented on the CDR on 4/4/2026 (timed at 9 PM). LVN 3 stated that there were no licensed nurse initials on the CDR to indicate Resident 6's Lacosamide was removed for administration on 4/4/2026 for the scheduled 9 AM dose. LVN 3 stated if the licensed nurse (unidentified) did not document then it did not happen. During a concurrent interview and record review on 4/18/2026 at 6:11 PM with the Director of Nursing (DON), Resident 6's MAR and CDR for the Month of April 2026 were reviewed. The DON stated Resident 6's MAR indicated by documentation that Resident 6 was received two doses of Lacosamide on 4/2/2026 and on 4/4/2026 each day at 9 AM and 9 PM but the licensed nurses (unidentified) did not sign for the removal of each dose on the CDR. The DON stated for Resident 6 one dose of Lacosamide was documented as removed for administration to the resident on 4/2/2026 at 9 AM and there was no CDR documentation for the scheduled 9 PM dose of Lacosamide on 4/2/2026. The DON stated for Resident 6 one dose of Lacosamide was documented as removed for administration to the resident on 4/4/2026 at 9 PM and there was no CDR documentation for the scheduled 9 AM dose of Lacosamide on 4/4/2026. The DON stated the purpose of the CDR was to reconcile (the process of reviewing and verifying a patient's medications to ensure accuracy, safety, and proper coordination across different healthcare providers) with the resident's MAR to make sure the medication was removed and administered to the resident. During a review of Resident 6's MAR and CDR for the Month of April 2026, the following discrepancies were noted:Resident 6's MAR for the Month of April 2026 indicated by documentation and licensed nurses' initials (unidentified) that the resident was administered Lacosamide as follows:a. Two doses of Lacosamide on 4/2/2026 for scheduled administration at 9 AM and 9 PMb. Two doses of Lacosamide on 4/4/2026 for scheduled administration at 9 AM and 9 PM Resident 6's CDR for the Month of April 2026 indicated by documentation and licensed nurses initials the following discrepancy with the MAR:a. One dose of Lacosamide was documented removed on the CDR for administration on 4/2/2026 at 9:00 AM for 20 ml to Resident 6. There were no licensed nurse initials on Resident 6's CDR on 4/2/2026, for the scheduled 9 PM dose of Lacosamideb. One dose of Lacosamide was documented removed on the CDR for administration on 4/4/2026 at 2100 (9:00 PM) for 20 ml for Resident 6. There were no licensed nurse initials on Resident 6's CDR on 4/4/2026, for the scheduled 9 AM dose of Lacosamide. During a review of the facility's policy and procedures (P&P) titled, Controlled Substances, review date 8/28/2025 indicated The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976).If the count is correct, an individual resident controlled substance record is made for each resident who will be receiving a controlled substance. Do not enter more than one (1) prescription per page. This record contains:Name of the residentName and strength of the medicationQuantity receivedNumber on handName of the prescriber.Time of administrationmethod of administration.signature of nursing administering medication.Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up.The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following:Records of personnel access and usageMedication administration recordsDeclining inventory recordsDestruction, waste and return to pharmacy records.If major discrepancy or a pattern of discrepancies occurs, or if there is apparent criminal activity, the director of nursing notifies the administrator and consultant pharmacist immediately.The medication regimen of residents using medication that have such discrepancies are reviewed to assure the resident has received all medications ordered and the goal of therapy is met.

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 90) reviewed for urinary indwelling catheter (a flexible tube that is inserted through the urethra [passageway between the bladder and the external part of the body, which allows urine to be excreted from the body] and into the bladder and left in place to drain urine) received the necessary urinary catheter care by failing to: -Ensure Resident 90's urinary catheter drainage bag did not touch the floor. This failure placed Resident 90 at risk for urinary tract infection (infection caused by bacteria). Findings: During a review of Resident 90's admission Record, the admission Record indicated the facility originally admitted Resident 90 on 2/7/2020 and readmitted on [DATE] with diagnoses including hydronephrosis with renal and ureteral calculous obstruction (when kidney stones are causing a blockage in the tube draining the kidney, causing the kidney to swell with trapped urine), encounter for surgical aftercare following surgery on the genitourinary system (postoperative care on keeping the urinary system clean, preventing infection, and reducing pressure on the healing area), and agoraphobia (an anxiety [nervous] disorder characterized by an intense fear of being in situations where escape might be difficult or help unavailable if a panic attack occurs). During a review of Resident 90's Minimum Data Set (MDS- a resident assessment tool) dated 2/16/2026, indicated Resident 90 required extensive assistance to total dependence from staff for activities of daily living (ADL- bed mobility, transfer, dressing, toilet use, and personal hygiene). During a review of Resident 90's History and Physical (H&P) dated 4/13/2026, the H&P indicated Resident 90 had a history of hydronephrosis and had the capacity to make medical decisions. During a facility tour observation on 4/18/2026 at 9:26 AM, the surveyor observed Resident 90's urinary catheter drainage bag hanging on the side of the bed and was touching the floor. During a concurrent observation and interview on 4/19/2026 at 12:01 PM inside Resident 90's room with Treatment Nurse 1 (TN 1), TN 1 stated Resident 90's urinary catheter drainage bag was touching the floor. TN 1 stated the urinary catheter drainage bag should not be touching the floor for infection control and prevention purposes. During an interview on 4/19/2026 at 4:57 PM with the Director of Nursing (DON), the DON stated the urinary catheter drainage bag should not touch the floor or be placed on a basin to protect residents (in general) from urinary tract infections. During a review of facility's policy and procedure (P&P), titled Catheter Care, Urinary, reviewed on 8/2025, the P&P indicated: The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. Infection Control: be sure the catheter tubing and drainage bag are kept off the floor.

Based on observation, interview, and record review, the facility staff failed to ensure one of two sampled residents (Resident 6) reviewed for activities of daily living (ADL's- activities related to personal care, including bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) and was dependent on staff (helper does all of the effort) received care in accordance with the residents' plan of care by failing to:-Ensure the nursing staff (in general) assisted Resident 6 with meals on 4/19/2026 at 8:12 AM. This failure had the potential for Resident 6's increased the risk of inadequate nutrition and aspiration due to dysphagia (difficulty swallowing). Findings:During a review of Resident 6's admission Record, the admission Record indicated the facility admitted Resident 6 on 10/4/2024 and readmitted the resident on 1/24/2026 with a diagnoses including seizures (uncontrollable electrical activity in the brain that disrupts normal function), other encephalopathy (permanent brain damage that causes severe confusion and forgetfulness), type two diabetes (a long-term condition in which the body has trouble controlling blood sugar), acute pancreatitis (inflammation of the pancreas [a gland behind the stomach] that aids digestion and blood sugar control). During a review of Resident 6's History and Physical (H&P) dated 1/26/2026, the H&P indicated Resident 6 had a history of renal failure (kidneys can no longer adequately filter waste, toxins, and excess fluid from the blood), altered metal status (change in a person's normal mental state or level of awareness), and did not have the capacity to make medical decisions. During a review of Resident 6's Minimum Data Set (MDS- a resident assessment tool) dated 3/9/2026, the MDS indicated Resident 6 had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) to make decisions on selfcare activities. The MDS indicated Resident 6 was dependent on staff for toileting hygiene, oral hygiene, transferring from bed to chair/chair to bed, shower/bath, personal hygiene, eating, sitting to lying, and sitting to stand. During a review of Resident 6's Order Summary Report dated 4/19/2026, the Order Summary indicated May participate in activities not in conflict with treatment plan. During a review of Resident 6's Care Plan Report dated 1/19/2026, the Care Plan Report indicated Resident 6 was at risk for aspiration (is when something enters the airway or lungs by accident) related to dysphagia (difficulty swallowing), the Care Plan Report indicated nursing staff was to assist Resident 6 with meals as needed and encourage the resident to eat slowly and take small bites of food. During an observation on 4/19/2026 at 8:12 AM inside Resident 6's room, Resident 6 was observed lying in bed, talking to self, not responding to verbal cue, breakfast tray on bedside table. Resident 6 was unable to feed himself, and there were no staff assisting the resident. During an interview on 4/19/2026 at 8:30 AM with Certified Nursing Assistant 5 (CNA 5), CNA 5 stated Resident 6 was dependent on staff for feeding. CNA 5 had not fed Resident 6 yet and stated, his family is the one usually feeding him. During a concurrent observation and interview on 4/19/2026 at 12:40 PM with Resident 6's Family Member 1 (FM 1) inside Resident 6's room, FM1 was observed feeding Resident 6. FM 1 stated it usually took a long time to feed Resident 6. FM 1 stated it took patience and time to provide care for Resident 6. FM 1 stated some of the CNAs (unidentified) did not take time to feed Resident 6. FM 1 stated it is stressful not knowing if they are caring for him or not when I am not here, I can't be here all the time. During an interview on 4/19/2026 at 4:10 PM with the Director of Nursing (DON), the DON stated Resident 6 was confused and was dependent on staff for care and activities. The DON stated it was the facility's staff's responsibility to ensure Resident 6's care and needs were met. During a review of the facility's Policy and Procedure (P&P) titled Activities of Daily Living (ADLs), Supporting revised on 8/26/2025, the P&P indicated Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. The P&P indicated appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care); mobility (transfer and ambulation, including walking); elimination (toileting); dining (meals and snacks); and communication (speech, language, and any functional communication systems). The P&P indicated interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice.

Based on interview and record review the facility failed to develop a care plan for range of motion (ROM, the full movement potential of a joint) for one of six sampled residents (Resident 2) reviewed for limited ROM. This failure placed Resident 2 at risk for functional decline and had the potential to affect Resident 2's care and services received. Findings:During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 to the facility on 6/9/2023 with diagnoses including; thrombocytopenia (blood clotting deficiency), alcoholic cirrhosis of the liver (severe liver injury [scarring] and the final stage of alcohol associated liver disease), dysphagia (difficulty swallowing), epilepsy (chronic neurological disorder caused by abnormal electrical activity in the brain, characterized by recurrent seizures), hypertension (HTN, high blood pressure), and vascular dementia (brain dysfunction decline in thinking, memory, and behavior caused by conditions that damage blood vessels in the brain, reducing or blocking blood flow and oxygen). During a review of Resident 2's Order Summary Report dated 12/23/2025, the Order Summary Report indicated Resident 2 had an order for Restorative Nursing Assistant (RNA-nursing aide program that helps residents maintain their function and joint mobility) program daily three times a week for active range of motion (AROM - movement of joint by individual's own power unassisted) and passive range of motion (PROM - assisted movement of joint by person or machine) to bilateral (both sides) lower extremities (legs). During a review of the Minimum Data Set (MDS - resident assessment tool) dated 4/2/2026 indicated Resident 2 had moderate cognitive impairment (ability to think, reason, learn, and remember). The MDS indicated Resident 2 required supervision or touching assistance for eating and required partial/moderate assistance to being totally dependent on staff for other activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and bed mobility. During a concurrent interview and record review on 4/19/2026 at 6:28 PM with the Minimum Data Set Nurse (MDSN) Resident 2's care plans were reviewed. The MDSN stated there was no care plan for the ROM treatments and stated the process was to highlight the orders for the residents (in general) and to develop the care plan. The MDSN stated the ROM care plan for Resident 2 was not developed. During a review of the facility's Policy and Procedures (P&P) titled Care Plans, Comprehensive Person-Centered with a review date of 8/28/2025, the P&P indicated A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights.

Based on observation, interview, and record review, the facility failed to ensure to accurately code the Minimum Data Set (MDS, a resident assessment tool) for one of two sampled residents (Resident 8) reviewed for antibiotics (medication that help stop infection caused by bacteria) by failing to: -Ensure to code Resident 6's use of antibiotics and diagnosis of cellulitis (serious bacterial infection of the deeper skin layers, causing painful, red, swollen, and hot legs or feet) of the left and right lower limbs (legs) on the MDS dated [DATE]. This failure had potential to negatively affect the provision of necessary care and services for Residents 8. Findings:During a review of Resident 8's admission Record, the admission Record indicated the facility admitted Resident 8 on 1/14/2026 with diagnosis including cellulitis of left and right lower limbs, and type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 8's Order Summary Report dated 1/15/2026, the Order Summary Report indicated for Resident 8 to receive Vancomycin solution (antibiotic used to treat severe bacterial infections that do not respond to common antibiotics) 750 milligram/150 millimeter (mg/ml - unit of measurement) - use 150 ml intravenously (IV - means delivering medication, fluids, or blood directly into a person's vein) every 12 hours for right and left foot cellulitis During a review of Resident 8's Order Summary Report dated 1/15/2026, the Order Summary Report indicated for Resident 8 to receive piperacillin tazobactam solution (a powerful, broad-spectrum intravenous (IV) antibiotic used in hospitals to treat serious bacterial infections) 3.0375 gram (gm - unit of measurement) - use 3.375 gram intravenously two times a day for right and left foot cellulitis. During a review of Resident 8's MDS dated [DATE], the MDS indicated Resident 8's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was intact. The MDS indicated Resident 8 required assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS for skin conditions indicated Resident 8 did not have any foot skin problems such as cellulitis. The MDS indicated Resident 8 was not on any antibiotic. During a concurrent observation and interview on 4/18/2026 at 10:30 AM with Resident 8, Resident 8 was observed with swollen skin and with redness on the skin on both lower limbs. Resident 8 was observed with an open wound on the left foot. Resident 8 stated he (Resident 8) had a wound on both of his legs. Resident 8 stated his left leg was swollen and tender and his left foot had an open wound. During an interview on 4/19/2026 at 11:47 AM with Treatment Nurse1 (TN 1), TN 1 stated Resident 8 had multiple skin conditions on both lower legs and foot and Resident 8 was being seen by a wound care specialist. During a concurrent interview and record review 4/19/2026 at 3:51 PM with the Minimum Data Set Nurse (MDSN), MDSN reviewed Resident 8's MDS assessment dated [DATE]. The MDSN stated Resident 8's MDSN for foot problem was coded as None and antibiotic medications coded as 0. The MDSN stated that Resident 8's diagnosis of cellulitis on both lower limbs and IV antibiotic medications were not coded. The MDSN stated that the MDS was coded incorrectly. The MDSN stated Resident 8's diagnosis of cellulitis and antibiotic medication should have been coded as yes upon assessment. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Assessments, reviewed on 8/2025, the P&P indicated, Comprehensive MDS assessments are conducted to assist in developing person-centered care plans. The facility conducts comprehensive, accurate, standardized, reproducible assessments of each resident's functional capacity using the Resident Assessment Instrument specified by [Centers for Medicare & Medicaid Services, a federal agency that administers major U.S. healthcare programs] CMS.

Based on observation, interview, and record review, the facility failed to protect the personal belongings for one of one sampled residents (Resident 90) reviewed for personal property by failing to create an inventory list of Resident 90's belongings upon admission and readmission as per the facility's policy and procedure (P&P) titled, Personal Property dated 8/2025.This failure resulted in Resident 90's missing personal belongings.Findings: During a review of Resident 90's admission Record, the admission Record indicated the facility originally admitted Resident 90 on 2/7/2020 and readmitted the resident on 4/13/2026, 3/9/2026, 2/9/2026, and on 3/3/2025 with diagnoses including hydronephrosis with renal and ureteral calculous obstruction (when kidney stones are causing a blockage in the tube draining the kidney, causing the kidney to swell with trapped urine), respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide) and agoraphobia (an anxiety disorder characterized by an intense fear of being in situations where escape might be difficult or help unavailable if a panic attack occurs). During a review of Resident 90's Resident's Clothing and Possessions (RCP) dated 3/3/2025, the RCP indicated staff documented, no belongings. During a review of Resident 90's Resident's Clothing and Possessions (RCP) dated 7/18/2025, the RCP indicated one gray + white stuffed animal dog, one blue stuffed bird with voice, one pink doll, one blue bear doll. During a review of Resident 90's Resident's Clothing and Possessions (RCP) dated 2/1/2026, the RCP indicated staff documented, None. During a review of Resident 90's Resident's Clothing and Possessions (RCP) dated 2/10/2026, the RCP indicated staff documented, Belongings at the facility. During a review of Resident 90's Minimum Data Set (MDS - a resident assessment tool) dated 2/16/2026, the MDS indicated Resident 90's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) were severely impaired for daily decision-making and required extensive assistance to total dependence from staff for activities of daily living (ADL- bed mobility, transfer, dressing, toilet use and personal hygiene). During a review of Resident 90's Resident's Clothing and Possessions (RCP) dated 3/9/2026, the RCP indicated staff documented, Resident belongings are here in the facility, see old inventory. During a review of Resident 90's Resident's Clothing and Possessions (RCP) dated 4/13/2026, the RCP indicated staff documented, please see previous inventory, all belongings are in the facility. During an interview on 4/18/2026 at 9:26 AM with Resident 90, Resident 90 stated, where is my bag? I want my bag. Resident 90 was unable to explain what the bag was and kept repeating herself asking for the bag. During a concurrent observation and interview on 4/19/2026 at 9:31 AM with Certified Nursing Assistant 6 (CNA 6) inside Resident 90's room Resident 90's closet and drawer were observed. CNA 6 stated there were no clothes and/or bags inside Resident 90's closet and drawer. CNA 6 stated that Resident 90 was moved from another room (unidentified) after hospitalization (unidentified date). During an interview on 4/19/2026 at 4:36 PM with the Social Services Director (SSD), the SSD stated Resident 90 had been recently hospitalized and was moved from another room. The SSD stated he (SSD) did not have Resident 90's personal belongings being kept at his (SSDs) office. The SSD stated during readmission, facility staff (in general) were to complete an inventory of resident's (in general) personal belongings. During a concurrent interview and record review 4/19/2026 at 4:49 PM with the Director of Nursing (DON), Resident 90's inventory lists dated 3/3/2025, 7/18/2025, 2/1/2026, 2/10/2026, 3/9/2026, and 4/13/2026 were reviewed. The DON stated Resident 90's personal belongings were not properly inventoried during admissions and readmissions because the inventory lists did not include personal belongings in detailed report. The DON stated the CNAs (in general) had to go through the residents' (in general) personal belongings and report to the licensed nurses (in general). The DON stated it was not appropriate to just document see previous inventory and the form should have been filled out completely. During a review of facility's P&P, titled Personal Property, reviewed on 8/2025, the P&P indicated that, Residents are permitted to retain and use personal possessions. The resident's personal belongings and clothing are inventoried and documented upon admission and updated as necessary.The facility promptly investigates and complaints of misappropriation or mistreatment of resident property.

Based on observation, interview, and record review, the facility failed to protect the privacy and dignity of one of two sampled residents (Resident 90) reviewed for urinary catheter (a soft hollow tube which is passed into the bladder to drain urine, for persons who cannot empty their bladder in the usual way) by failing to ensure to cover the urinary catheter drainage bag as indicated in the facility's policy and procedure (P&P) titled Dignity. This failure had the potential to affect Resident 90's sense of self-worth and self-esteem.Findings: During a review of Resident 90's admission Record, the admission Record indicated the facility originally admitted Resident 90 on 2/7/2020 and readmitted the resident on 4/13/2026 with diagnoses including hydronephrosis with renal and ureteral calculous obstruction (when kidney stones are causing a blockage in the tube draining the kidney, causing the kidney to swell with trapped urine), encounter for surgical aftercare following surgery on the genitourinary system (postoperative care on keeping the urinary system clean, preventing infection, and reducing pressure on the healing area), and agoraphobia (an anxiety disorder characterized by an intense fear of being in situations where escape might be difficult or help unavailable if a panic attack occurs). During a review of Resident 90's Minimum Data Set (MDS - a resident assessment tool) dated 2/16/2026, the MDS indicated the resident required extensive assistance to total dependence from staff for activities of daily living (ADL- bed mobility, transfer, dressing, toilet use and personal hygiene). During a facility tour observation on 4/18/2026 at 9:26 AM, Resident 90's urinary catheter drainage bag was observed hanging on the side of the bed, not covered and urine was visible from the catheter drainage bag. During a concurrent observation and interview on 4/19/2026 at 12:01 PM with Treatment Nurse 1 (TN 1) inside Resident 90's room, TN 1 stated Resident 90's urinary catheter drainage bag was not covered with a privacy bag. TN 1 stated that the urinary catheter bag needed to be covered with a privacy bag. During an interview on 4/19/2026 at 4:57 PM with the Director of Nursing (DON), the DON stated the urinary catheters bags (in general) had to be covered with privacy bags for residents' (in general) privacy and dignity. During a review of facility's P&P titled Dignity, with a reviewed date of 8/2025, the P&P indicated that, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being. Staff are expected to promote dignity and assist residents; for example: helping the resident to keep urinary catheter bags covered.

Based on observation, interview, and record review, the facility failed to ensure three of 36 resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) met the 80 square feet (sq. ft.) per resident. room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER] consisted of three-bedroom capacity. This failure had the potential to result in inadequate space to provide safe nursing care and privacy for the residents (unidentified) who resided in room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER].Findings:During a review of the facility's untiled room waiver letter dated 4/19/2026, the room waiver letter indicated the facility requested a room waiver for three resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]). The room waiver letter indicated room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER] had three resident beds and measured 231 square feet, which equaled to 77 square feet per bed (the minimum requirement for a 3 bedroom should be at least 240 square feet). The room waiver letter indicated room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER] were free of projections or other obstructions that could impede safe and independent movement of wheelchairs and /or other mobility devices. The room waiver letter indicated room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER] provided sufficient space to deliver resident care in a dignified manner while maintaining privacy. The room waiver letter indicated the individual needs of residents (unidentified) who occupied room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER] could be met safely and appropriately, with care delivered in a manner that supported each resident in achieving his or her highest practicable level of functional ability and overall well-being. During the initial tour observation of the facility on 4/18/2026 from 9:30 AM to 12:30 PM, the surveyors observed room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER] and observed that nursing staff (in general) had enough space to provide care to the residents (unidentified), there were curtains to provide privacy for each resident and the rooms had direct access to the corridors. During the group interview with the residents (Resident 11, Resident 31, Resident 38, Resident 54, Resident 58, and Resident 63) on 4/19/2026 at 11:11 AM, no concerns were brought up regarding the size of the rooms. The Department is recommending approval of the room waiver request.

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1), reviewed for behavioral health services who had a diagnosis of depression (a mood disorder that causes persistent feeling of sadness and loss of interest) received appropriate mental health services and support. On 1/1/26, R1 alleged that CNA3 abused her, and on 1/5/26, R1's physician noted that R1 had increased nighttime anxiety and was afraid to fall asleep. The facility failed to identify R1's increased anxiety and failed to implement care-planned interventions in response to R1's change in behavioral health symptoms. 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 hypertension (HTN-high blood pressure), hyperlipidemia (abnormally high levels of fats in the blood), depression, presence of colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall to allow waste to leave the body) and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 1's Order Summary dated 10/23/2025, the Order Summary indicated Resident 1 to receive a psychology (the study of mind and behavior) consult and treatment as needed. During a review of Resident 1's History and Physical (H&P) dated 10/23/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of the Minimum Data Set (MDS - resident assessment tool) dated 10/28/2025, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) was intact. The MDS indicated Resident 1 required moderate to maximum assistance from the staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1's Progress Notes dated 1/1/2026 at 2 PM, the Progress Notes indicated Resident 1 reported an allegation of abuse on 1/1/2026 at 8:40 AM. The Progress Notes indicated Resident 1 alleged that a CNA (CNA3) from the 11PM to 7AM shift showed arm gestures with two closed fists. The Progress Notes indicated Resident 1 alleged Resident 1 felt afraid towards the CNA(CNA3). The Progress Notes indicated Resident 1 alleged the CNA (CNA3) aggressively woke Resident 1 up. The Progress Notes indicated Resident 1 alleged the CNA (CNA3) threw two towels on her chest and another towel on her colostomy site. The Progress Notes Resident 1 alleged CNA 3 turned and pulled Resident 1 while changing Resident 1 and told Resident 1 if she (Resident1) would speak up about what happened she (Resident 1) would be hit with arm gestures with two closed fists. The Progress Notes indicated the facility initiated an Investigation, CNA3 suspended while the investigation was ongoing. During a review of Resident 1's Care Plan Report dated 1/2/2026, the Care Plan Report indicated Resident 1 had a psychosocial well-being problem due to a language barrier. The Care Plan Report indicated interventions with consultations with pastoral care, social services, and psych services. During a review of progress note titled MD/NP/PA Progress Note dated 1/5/2026, Resident 1's Primary Medical Doctor (PMD) wrote, resident [Resident 1] had an interaction with a staff member 2 [two] days ago during which she [Resident 1] felt threatened that the CNA [CNA 3] will hurt her. No physical contact occurred. Since then, resident [Resident 1] is afraid to fall asleep. CNA [CNA 3] was suspended. According to resident [Resident 1's] husband, resident [Resident 1] has a chronic anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety or fear that are strong enough to interfere with one's daily activities) and this incident caused a flare of nocturnal anxiety. During a review of Progress Notes dated 1/8/2026 timed 10:34 PM, the Progress Notes indicated Resident 1 stated she (Resident 1) did not feel safe. During a concurrent observation and interview on 1/15/2026 at 8:20 AM in Resident 1's room Resident 1 grimaced (frowned), shifted side to side, gagged, and stated she (Resident 1) felt nauseous (a feeling of sickness with an urge to vomit). Resident 1 stated she (Resident 1) preferred not to discuss Resident 1's allegation of abuse with CNA3. During a concurrent interview and record review on 1/15/2026 at 10:33 AM with Social Service Supervisor (SW) Resident 1's general medical records were reviewed. The SW stated his responsibilities included assessing residents' social needs (in general), arranging referrals, and supporting their mental, psychosocial, and emotional wellness in the facility. The SW stated trauma assessments were done on admission, quarterly, and at change of condition. The SW stated Resident 1 made remarks about certain people of different ethnicities being loud, harmful, and unfriendly. The SW stated Resident 1 stated not being comfortable with certain staff of a different ethnicity. The SW stated Resident 1 could possibly have a past trauma causing her reaction. The SW stated there was no behavioral assessment done for Resident 1's change of condition (COC) on 1/1/2026. The SW stated the importance of assessment and reassessment in evaluating and adjusting the resident's care plan (in general). The SW indicated that interdisciplinary team (IDT- a group of dedicated healthcare professionals who work to bring knowledge together to help residents receive the care they need) were responsible for updating the resident care plan. The SW stated that a behavior change required a COC. The SW stated the care plan interventions for Resident 1 included consultations with pastoral care, social services, and psych services. The SW stated there were no psychologist's progress notes for Resident 1. During an interview and record review on 1/15/2026 at 11:44 AM with the Minimum Data Set Coordinator (MDS), Resident 1's assessment records were reviewed. The MDS stated there were no behavioral assessments done for Resident 1 for 1/1/2026. During an interview on 1/15/2026 at 9:30 AM, with the Quality Assurance Nurse (QAN), the QAN stated steps following an abuse allegation included to reassure the resident, notify family/doctor, arrange for a psych evaluation, consult social services, initiate a COC for 72-hour emotional distress monitoring, update the care plan, and meet with the IDT (in general). The QAN stated that if after 72 hours the resident would still feel unsafe the facility needed to have a new intervention. During a concurrent interview and record review of the nursing notes with Director of Nursing (DON) on 1/15/26 at 11:44 AM, the DON stated she (DON) did not know that Resident stated she (Resident1) did not feel safe on 1/8/2026. The DON stated Registered Nurse 2 (RN 2) needed to notify the doctor that Resident 1 stated she (Resident 1) did not feel safe. During a review of the facility's policy and procedure (P&P) revised on 03/2019 titled Behavioral Assessment, Intervention and Monitoring, the P&P indicated that Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to receive the services and/or items included in the plan of care. The P & P indicated the nursing staff will identify, document, and inform the physician about specific details regarding changes in an individual's mental status, behavior, and cognition, including: a. onset, duration. intensity and frequency of behavioral symptoms; b. any recent precipitating or relevant factors or environmental triggers (e.g medication changes, infection, recent transfer from hospital); and c. appearance and alertness of the resident and related observations. The P & P also indicated the interdisciplinary team will thoroughly evaluate new or changing behavioral symptoms in order to identify underlying causes and address any modifiable factors that may have contributed to the resident's change in condition, including: physical or medical changes, emotional, psychiatric and/or psychological stressors, functional, social or environmental factors. The P & P indicated Interventions will be individualized and part of an overall care environment that supports physical, functional and psychosocial needs, and strives to understand, prevent or relieve the residents distress or loss of abilities. The IDT will monitor the progress of individuals with impaired cognition and behavior until stable. New or emergent symptoms will be documented and reported. During a review of the facility's policy and procedure (P&P) revised on 08/2022 titled Trauma Informed Care and Culturally Competent Care, the P&P indicated that resident assessments involve evaluating symptoms' presence, their link to trauma, and identifying triggers. The P&P also indicated in the Resident Care Planning which included Develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate. Identify and decrease exposure to triggers that may re-traumatize the resident. Recognize the relationship between past trauma and current health concerns. Develop individualized care plans that incorporate language needs, culture, cultural preferences, norms and values. During a review of facility's P&P revised 03/2022 titled Care Plans, Comprehensive Person-Centered, the P&P indicated that Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to: a. participate in the planning process; d. request revisions to the plan of care: g. receive the services and/or items included in the plan of care; and h. see the care plan and sign it after significant changes are made. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition: b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment.

Based on interview and record review, the facility failed to implement the facility's policy and procedure (P&P) titled, Abuse, Neglect [s the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress], Exploitation (taking advantage of a resident for personal gain through the use of manipulation, intimidation, or threats) and Misappropriation Prevention Program, for one of three sampled residents (Resident 1) reviewed for abuse by failing to: -Ensure to provide one-on-one abuse training for Certified Nurse Assistant 3 (CNA3) prior to having direct-care responsibilities for residents following a three-day suspension after an allegation of abuse. This failure had the potential to place Resident 1 at risk for abuse, neglect, and feeling intimidated. Findings: During a review of Resident 1's admission Record dated 1/15/2026, the admission Record indicated the facility admitted Resident 1 on 10/23/2025 with diagnoses including diverticulitis (infection of small pouches of the intestines causing sudden stomach pain), muscle weakness, dysphagia (difficulty swallowing), depression (persistent sadness or loss of pleasure), and colostomy status (a surgical opening in the belly that diverts stool from the colon into an external removable bag). During a review of Resident 1's History and Physical (H&P) dated 10/23/2025, the H&P documented that Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - resident assessment tool) dated10/23/2025, the MDS documented that Resident 1's cognitive skills (relating to the process of having knowledge and understanding through thought experience). The MDS documented that Resident 1 had the capacity to understand and make decisions on her own. The MDS documented that Resident 1 required moderate to maximum assistance from facility staff for activities of daily living (ADLs-routine tasks/activities such as bathing, dressing and toileting). During a review of Resident 1's Progress Notes dated 1/1/2026 at 2 PM, the Progress Notes documented that Resident 1 reported an allegation of abuse on 1/1/2026 at 8:40 AM. The Progress Notes documented that Resident 1 alleged that a CNA (CNA3) from the 11PM to 7AM shift showed arm gestures with two closed fists. The Progress Notes documented that Resident 1 alleged she felt afraid towards the CNA3. The Progress Notes documented that Resident 1 alleged that CNA3 aggressively woke Resident 1 up. The Progress Notes documented that Resident 1 alleged that CNA3 threw two towels on her chest and another towel on her colostomy site. The Progress Notes documented that Resident 1 alleged CNA 3 turned and pulled her while providing incontinence care and told her that if she (Resident1) would speak up about what happened she (Resident 1) would be hit while gesturing with her arms and two closed fists. The Progress Notes documented that the facility initiated an Investigation, and suspended CNA3 while the investigation was ongoing. During a review of the facility's 5-Day Conclusion of Facility Reported Incident dated 1/12/2026, the 5-day Conclusion of Facility Reported incident documented that CNA 3 was suspended pending investigation of the alleged abuse. During a record review of the Time sheet dated 1/15/2026. The Time sheet card indicated that CNA 3 went to the facility to work on 1/4/2026. During a record review of the Facility's Inservice Record Sheet conducted by Quality Assurance Nurse (QAN) to CNA 3 dated 1/5/2026 (after CNA3 provided resident care) summary of presentation documented to ensure all resident received a safe, respectful and dignified care at all times. During a concurrent interview on 1/15/2026 at 11:15 AM, with the QAN and the Director of Staff Development (DSD), the QAN stated CNA3 went to work on 1/4/2026 at 11 PM and CNA3's shift ended at 7 AM. The QAN stated that he (QAN) did not provide an in-service to CNA3 prior to CNA3 returning to do resident care. The DSD stated she (DSD) was responsible for providing a one-one in-service prior for CNA 3 to provide care to other residents in the facility. The DSD stated it was important to make sure CNA 3 had understood the abuse allegations that Resident 1 reported to the facility and knew how to prevent it from happening again. The DSD stated that she (DSD) did not work during week of 1/1/2026. During a concurrent interview on 1/15/2026 AT 1:30 PM with the Administrator (ADM), the ADM stated CNA3 was suspended pending investigation. The ADM stated that he (ADM) called CNA3 to report to work on 1/4/2026 as the investigation was concluded on 1/4/2026. The ADM confirmed that in-service was not done for CNA3 prior to start of her shift. During a review of the facility's P&P titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, under Resident Rights Guidelines for All Nursing Procedures, the P&P indicated to provide general guidelines for resident rights while caring for the resident. The P &P indicated Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on resident rights, including: Preventing, recognizing and reporting resident abuse; Resident dignity and respect; Resident notification of rights, services and health/medical condition; Resident's freedom of choice. The P& P indicated Implement measures to address factors that may lead to abusive situations, to adequately prepare staff for caregiving responsibilities, provide staff with opportunities to express challenges related to their job and work environment without reprimand or retaliation and Instruct staff regarding appropriate ways to address interpersonal conflicts; The P &P also indicated help staff understand how cultural, religious and ethnic differences can lead to misunderstanding and conflicts. Investigate and report any allegations within timeframes required by federal requirements.

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) reviewed for pureed diet (a pudding-like texture that is smooth, blended) diet received food consistent with the ordered diet by failing to: -Ensure staff (in general) implemented accident-prevention measures by requiring visitors to notify nursing staff when food was brought into resident care area on 12/31/2025, so staff could supervise and prevent unsafe food from creating an accident hazard.-Ensure staff provided adequate supervision and environmental safeguards to prevent visitors (Family Member 3, FAM3) from providing unsafe food (non-pureed chocolate chip cookie/unidentified size) on 12/31/2025 at approximately 1 PM to Resident 1 who had a diagnosis of dysphagia oropharyngeal phase (inability/difficulty swallowing food or drink, can also cause breathing difficulties, choking, and drooling), and was on a pureed (a pudding-like texture that is smooth, blended) gratification (providing pleasurable oral taste) diet, severe cognitive impairment, and high aspiration risk (when something enters the airway or lungs by accident). -Ensure licensed nurses (in general) implemented supervision and environmental controls to prevent unsafe food from entering the resident environment and creating an accident hazard for Resident 1's who had a diagnosis of dysphagia oropharyngeal phase, including supervision, positioning, monitoring, and restriction of access to unsafe food. -Ensure licensed nurses (in general) implement accident-prevention measures by informing and directing visitors, including FAM3, residents, residents' representatives (in general) to notify staff when food was brought into the facility, so staff could supervise and prevent unsafe food from creating an accident hazard. On 12/31/2025 at approximately 1 PM, FAM3 gave a chocolate chip cookie (unidentified size) to Resident 1 while Resident 1 was in bed. At approximately 1:05 PM to 1:10PM, FAM3 saw Resident 1 shaking, choking, pale, and FAM3 called for help. Certified Nursing Assistant 1 (CNA1) went inside Resident 1's room and saw Resident 1 in bed with no mobility, with no reaction, with his mouth a little open, and saw food running down from Resident 1's mouth. Restorative Nursing Assistant 1 (RNA1) then went inside Resident 1's room and performed a Heimlich maneuver (a lifesaving first-aid technique used to remove an object [like food] stuck in a person's throat or windpipe) while Resident 1 was on his bed. Licensed Vocational Nurse 1 (LVN1) went inside Resident 1's room and asked CNA1 and RNA 1 to place Resident 1 on a foldable metal chair. Respiratory therapist 1 (RT1) identified Resident 1 did not have a pulse, Resident 1 looked lifeless, and instructed CNA1, RNA1, and LVN1 to place Resident 1 back to bed to perform cardiopulmonary resuscitation (CPR, an emergency treatment that is done when someone's breathing or heartbeat has stopped). The facility called 911 (phone number for emergency services) at 1:20PM, and the paramedics (a person trained to give emergency medical care) to people who are seriously ill declared Resident 1 dead on 12/31/20/2025 at 1:34 PM. As a result, Resident 1 received food inconsistent with the ordered diet, choked, and died on12/31/2025 at 1:34 PM. On 1/5/2026 at 5:22 PM, the Department called 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) in the presence of the facility's Administrator (ADM) related to the failure to implement the Foods Brought by Family/Visitors policy and procedure to ensure the facility staff (in general) asked visitors (in general, including FAM3) to inform the nursing staff (in general) when visitors (in general, including FAM3) would bring outside food to the facility to ensure compliance with an ordered diet, and had the potential to place other residents (Resident 2, Resident 3, Resident 4, Resident 8, Resident 9, Resident 10, Resident 11, Resident 12, Resident 13, Resident 14, and Resident 15) with pureed diets at risk for choking and death. On 1/8/2025 at 5:25 pm, the Department removed the IJ situation while onsite after the surveyor verified the facility's implementation of the IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely) through observation, interview,On 1/8/2025 at 5:25 pm, the Department removed the IJ situation while onsite after the surveyor verified the facility's implementation of the IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely) through observation, interview, and record review, wherein the nursing staff updated the care plans of eleven residents who had mechanically altered diets (changes food consistency to be soft, moist, and easy to chew and swallow, used for issues like poor teeth or dysphagia), all staff received training on the policy regarding Food Brought by Family/Visitors and residents, and families were informed of the policy. The scope and severity was lowered to a G. The IJ removal plan included: -On 12/31/2025, the Administrative Consultant educated the ADM and the Director of Nursing (DON) on the policy regarding Food Brought by Family/Visitors. -On 1/5/2026 and on 1/6/2026, the DON conducted in-services for all staff on the policy regarding Food Brought by Family/Visitors. -On 1/5/2026, a third-party software sent messages via text and email to all the facility's residents and their responsible parties (someone legally designated or acting as the person accountable for an entity) educating them to inform the facility's nursing staff when foods are brought to the facility for a resident, as well as instructing them not to share with or distribute to other residents.-On 1/5/2026, the facility posted a signage throughout the facility regarding the policy for the Food Brought by Family/Visitor. -On 1/5/2026, the facility's receptionist or designee encouraged visitors to sign in on the facility's Visitor Log and to indicate whether they (visitors) brought food/drinks. If the visitors brought food/drinks, the Licensed Vocational Nurses (LVNs, in general) ensured the food/drinks were appropriate with the residents' (in general) prescribed diet. The LVNs educated the visitors to not to share food/drinks with other residents. -On 1/5/2026, the facility's Registered Dietitian posted a Dietary Log outside the kitchen allowing the staff to cross-check special requests from residents/staff/family to ensure all special requests are following doctor's dietary orders which were posted in the kitchen. -On 1/5/2026 the facility's Interdisciplinary Team (IDT, group of diverse health care professionals from different fields) identified eleven residents (unidentified) with mechanically altered diets (changes food consistency to be soft, moist, and easy to chew and swallow, used for issues like poor teeth or dysphagia) and the care plans were updated, and no negative outcomes were noted.Cross Reference F656 and F678Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 9/10/2025 with diagnoses that included dysphagia, oropharyngeal phase, dementia (a progressive state of decline in mental abilities), encounter for attention to gastrostomy (care needed for gastrostomy tube [GT] a tube through the abdomen and into the stomach used for feeding, usually via a feeding tube), pneumonitis (inflammation of the lungs) due to inhalation (breathing in) of food and vomit, and chronic obstructive pulmonary disease (COPD, a disease that damages the lungs in ways that make it hard to breathe). During a review of Resident 1's History and Physical (H&P) dated 9/10/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. The H&P indicated Resident 1 was hospitalized prior to the facility's admission due to Resident 1 ingested Lysol (cleaning solution product). During a review of Resident 1's Care Plan Report dated 9/15/2025, the Care Plan Report indicated Resident 1 was at risk aspiration related to dysphagia. The Care Plan Report indicated no nursing interventions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 9/15/2025, the MDS indicated Resident had severe cognitive (ability to think, read, learn, remember, reason, express thoughts, and make decisions) impairment. The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort) with eating. During a review of Resident 1's Order Summary Report dated 10/30/2025, the Order Summary Report indicated for Resident 1 to receive enteral feeding (getting liquid nutrition directly into stomach via a tube) Jevity (nutritional formula) 1.5 (1.5 calories per milliliter [ml, unit of measurement]) at 65 ml/hr (hour) for 20 hours. During a review of Resident 1's Order Summary Report dated 12/22/2025, the Order Summary Report indicated Resident 1 to receive a pureed texture regular diet for oral gratification (providing pleasurable oral taste) . During a review of Resident 1's Progress Notes dated 12/31/2025 at 2:45 PM, the Progress Notes indicated that on 12/31/2025 at 1:15 PM, a code blue (alert for a life-threatening medical emergency) was called. The Progress Notes indicated Resident 1 was seated on a chair across Resident 1's bed and RNA1 was performing a Heimlich maneuver while licensed staff (LVN1) and Respiratory Therapist 1 (RT1) suctioned Resident 1's secretions (mucus/fluids) from Resident 1's mouth. The Progress Notes indicated FAM 3 gave a chocolate chip cookie to Resident 1 and to Resident 4. The Progress Notes indicated Resident 1 was pale and Resident 1 did not have a pulse. The Progress Notes indicated Resident 1 was transferred back to bed and staff-initiated CPR and called 911 at around 1:20 PM. The Progress Notes indicated the paramedics declared the time of Resident 1's death at 1:34 PM. During a review of Reside's Progress Notes dated 12/31/2025 at 8:30 PM indicated FAM3 told the Social Services Designee (SSD) that she (FAM3) gave a chocolate cookie (unidentified size) around 1PM to Resident 1 because Resident 1 asked for the cookie. During an interview on 1/5/2026 at 12:54 PM with CNA 1, CNA 1 stated that on 12/31/2025 at around 1:10 PM to 1:15 PM she (CNA1) was in the hallway when FAM3 called for her attention saying come in, come in to Resident 1's room. CNA 1 stated when she (CNA1) entered Resident 1's room she (CNA1) saw Resident 1 sitting upright in bed with no mobility, with no reaction, with his mouth a little open, and saw food running down from Resident 1's mouth. CNA 1 stated Resident 1 was not moving. CNA 1 stated Resident 1's face was pale. CNA 1 stated she (CNA1) asked Resident 1 are you okay? twice but Resident 1 did not respond. CNA 1 stated that she (CNA1) performed a sweep in Resident 1's mouth with her finger and removed pieces of cookie from Resident 1's mouth. CNA 1 stated FAM 3 stated she (FAM3) gave Resident 1 a cookie. CNA1 stated she (CNA1) told FAM 3 to call for help. CNA 1 stated RNA 1 and LVN 1 came to Resident 1's room. CNA 1 stated RNA 1 helped her (CNA1) transfer Resident 1 from the bed to a chair to perform the Heimlich maneuver. During a telephone interview on 1/5/2026 at 1:10 PM, FAM1 stated Resident 1 had dementia and was forgetful and had poor safety awareness and required constant supervision. FAM1 stated Resident 1 was admitted to the facility after being hospitalized for swallowing laundry detergent thinking it was milk. FAM1 stated the facility did not hold any meeting with FAM1 to discuss Resident 1's plan of care. FAM1 stated she (FAM1) would frequently express concerns to facility staff (unidentified) about Resident 1 eating or being fed when Resident 1 was not supposed to because Resident 1 had such poor memory and would put things in his mouth. FAM1 stated there were no signs or anything in place to help Resident 1 remember not to eat or tell people not to feed him. FAM1 stated she (FAM1) had asked the staff (unidentified) for signs to be put up (unidentified date). FAM1 stated on 12/31/2025 (unidentified time) the facility called to inform FAM1 that a visitor (FAM3) took cookies for Resident 4 and fed a cookie to Resident 1. FAM1 stated Resident 1 was very forgetful and would not remember that he (Resident 1) was not allowed to eat food. FAM1 stated Resident 1 could not safely swallow solid foods and was supposed to be on a pureed diet. FAM1 stated she (FAM1) was not informed of the policy for outside food or what steps would be taken to prevent Resident 1 from being fed food from outside. FAM1 stated outside food was not communicated in any plan of care. FAM1 stated there were no meetings held to discuss the plan of care. FAM1 stated she (FAM1) would worry very much that Resident 1 would accidentally eat something or drink something that he (Resident 1) was not supposed to. During a concurrent interview and record review on 1/5/2026 at 2:08 PM, with the Director of Nursing (DON), Resident 1's admission Record and Resident 1's Care Plan Reports (in general) were reviewed. The DON stated Resident 1 had a diagnosis of dysphagia on admission and Resident 1 was at risk for aspiration. The DON stated staff (in general) were informed of the residents (unidentified) who were on aspiration precautions (specialized safety measures, often termed dysphagia precautions or feeding precautions, designed to prevent food, fluids, saliva, or vomit from entering the airway and lungs, reducing the risk of choking) verbally at morning huddles (brief meetings). The DON stated each diagnosis needed a specific care plan (in general) to have interventions such as aspiration precautions, type of diet, monitor swallowing, and proper positioning. The DON stated Resident 1's care plan did not have nursing interventions to address dysphagia and the pureed diet. During a concurrent interview and record review on 1/5/2026 at 2:15 PM with DON, the facility's Foods Brought by Family /Visitors policy and procedure dated 8/29/2025 was reviewed. The DON stated the policy indicated food brought by family/visitors were not to be shared with or distributed to other residents. The DON stated the staff (in general) needed to tell the family/visitors to check with the nurses (in general) when bringing food to the residents. The DON stated that visitors were told to check with the nurses when bringing food to the residents. The DON stated there was no documentation of licensed nurses checking visitor's food brought from outside (in general). The DON stated there was no education given to visitors regarding food from outside. The DON stated there were no signs posted for visitors regarding food brought by family and not to share and distributed to other residents. The DON stated there was potential for harm to the residents if the visitors were not aware of the policy. During a telephone interview on 1/5/2026 at 3:30 PM, with FAM3, FAM3 stated that on 12/31/2025 she (FAM3) visited Resident 4 who was Resident 1's roommate. FAM3 stated she (FAM3) would often visit Resident 4 and would take food to Resident 4 weekly. FAM3 stated Resident 4 had requested cookies and FAM3 purchased chocolate chip and oatmeal cookies and took the cookies inside the facility. FAM3 stated when she (FAM3) saw Resident 4, she (FAM3) told Resident 4 I got your cookies, Resident 1 overheard and Resident 1 stated, I want a cookie too. FAM3 stated she (FAM3) was feeding Resident 4 a cookie inside the room, Resident 1 kept repeating can I get a cookie, I want a cookie. FAM3 stated after she (FAM3) fed Resident 4 a cookie, she (FAM3) asked Resident 1 if he (Resident 1) wanted a cookie and Resident 1 said yes. FAM3 stated she (FM3) gave Resident 1 a cookie at around 1PM. FAM3 stated she (FAM3) then sat down and started talking with Resident 4 for approximately five to ten minutes, then looked over at Resident 1 and saw Resident 1 shaking, pale, and choking. FAM3 stated she (FAM3) then went to call the nurse (unidentified). FAM3 stated a nurse (unidentified) went into the room and told FAM3 to call for help. FAM3 stated she (FAM3) then went to the hallway and called for help and multiple staff (unidentified) entered the room. FAM3 stated facility staff (unidentified) were trying to revive Resident 1 and called the paramedics, but Resident 1 passed away. FAM3 stated she (FAM3) did not ask a staff (in general) if it was ok to give Resident 1 a cookie. FAM3 stated she (FAM3) gave the cookie to Resident1 because Resident 1 kept asking for a cookie. FAM3 stated she (FM3) made a mistake and should not have given Resident 1 a cookie. FAM3 stated there were no signs above Resident 4 or Resident 1's bed or by the door indicating not to give the residents food or to ask staff prior to giving residents food. FAM3 stated the facility staff (unidentified) saw FAM3 take food into the facility almost weekly and never said anything to FAM3. FAM3 stated the facility would let FAM3 take whatever food she (FAM3) wanted to Resident 4. FAM3 stated facility staff (in general) did not explain the rules or policy on taking outside food to the facility and did not tell FAM3 what foods were safe or unsafe to take to Resident 4. During an interview on 1/6/2026 at 12:16 PM with the Registered Dietitian (RD), the RD stated she (RD) was aware of the choking incident that happened with Resident 1 on 12/31/2025. The RD stated a visitor (FAM3) in Resident 1 and Resident 4's room gave Resident 1 a cookie and Resident 1 choked and passed away. The RD stated Resident 1 was on a pureed texture diet for oral gratification. The RD stated Resident 1 was on a pureed textured diet for safety to ensure Resident 1 could swallow food without complications and/or chewing issues. The RD stated pureed textured food should be blended to ensure a smooth texture that was not runny and without lumps. The RD stated pureed textured food was not solid. The RD stated a cookie was regular textured not pureed textured. The RD stated if a resident who was on a pureed textured diet (in general) was given regular textured food to eat it could cause the resident to choke, have an airway blockage, develop aspiration pneumonia (a lung infection from inhaling foreign substances like food, vomit, or saliva, often due to swallowing problems), and could lead to death. During an interview on 1/7/2026 at 10:38 AM with RNA 1, RNA 1 stated Resident 1 was unresponsive when he (RNA1) got to Resident 1's room on 12/31/2025 (unidentified time). RNA 1 stated CNA 1 informed him (RNA1) Resident 1 was choking so he (RNA1) immediately did the Heimlich maneuver. During an interview on 1/7/2026 at 11:44 AM, with RT 1, RT1 stated that on 12/31/2025 at around 1 PM, he (RT1) heard a CNA (CNA1) call out for help. RT 1 stated when he (RT1) went to Resident 1's room, Resident 1 was sitting in a foldable metal chair. RT 1 stated RNA 1 was doing the Heimlich maneuver. RT 1 stated a CNA (CNA1) was next to Resident 1 and told him (RT 1) that Resident 1 was choking. RT 1 stated Resident 1 was not alert and did not have the universal sign of choking (clutching the throat with one or both hands). RT 1 stated Resident 1 looked as if he (Resident 1) was not breathing. RT 1 stated Resident 1 looked lifeless. RT 1 stated he (RT1) checked Resident 1's pulse. RT 1 stated Resident 1 did not have a pulse. RT 1 stated he (RT1) told the CNA (CNA1), RNA 1, and LVN (LVN1) who were in Resident 1's room to put Resident 1 back in bed to start CPR. During a follow up interview on 1/7/2026 at 2:20 pm with FAM3, FAM3 stated that on 12/31/2025 after she (FAM3) gave Resident 1 a cookie, Resident 1 was not making any noise and just looked like he (Resident 1) was choking on something. During an interview on 1/8/2026 at 12:51 PM with the Medical Director 1 (MD 1), MD 1 stated he (MD1) was informed that FAM3 gave a cookie to Resident 1 without consulting a nurse. MD 1 stated Resident 1 choked and passed away. MD 1 stated Resident 1 was ordered a pureed textured diet. MD 1 stated pureed textured diets were ordered for residents (in general) who had trouble swallowing textures of a higher consistency like solids and cookies. MD 1 stated pureed textured diets were ordered for residents (in general) who have dysphagia. MD 1 stated it was the expectation that when a pureed texture diet was ordered for a resident (in general), that the resident would only be given pureed foods. MD 1 stated it was the expectation of the facility that families would be educated on pureed diets and family would not give food to the resident without consulting the nurses. MD 1 stated that a resident (in general) could aspirate, choke, and die if the resident was given regular textured food when the resident had orders for a puree textured diet. During a review of the facility's Food Brought by Family/Visitors policy and procedure (P&P) dated 8/29/2025, the P&P indicated family members and visitors were asked to inform the nursing staff when foods were brought for a resident. The P&P indicated foods brought by family/visitors for individual residents were not shared with or distributed to other residents. During a review of the facility's Dysphagia-Clinical Protocol P&P, dated 8/29/2025, the P&P indicated the staff and the physician would identify individuals with a history of swallowing difficulties or related diagnoses such as dysphagia and will implement interventions to manage the situation; for example, cutting food into smaller pieces allowing the individual to eat more slowly.

Based on interview and record review the facility failed to ensure Licensed Vocational Nurse1 (LVN1), Certified Nursing Assistant 1 (CNA1), and Restorative Assistant 1 (RNA1) performed cardiopulmonary resuscitation (CPR, a life-saving procedure used when someone's heart or breathing has stopped) with no delays to one of four sampled residents (Resident 1), who was found with no mobility (movement), no reaction, not responding, and lifeless, on 12/31/2025 at approximately 1:10 PM to 1:15PM by failing to: -Ensure LVN1, CNA1, and RNA1 implemented the facility's Policy and Procedure (P&P) titled Emergency Procedure - Cardiopulmonary Resuscitation dated 8/28/2025 when LVN1, CNA1, and RNA1 failed to check Resident 1's pulse, checked for breathing, and failed to begin CPR when CNA1, LVN1, and RNA1 found Resident 1 who was a full code (resident who chooses to be resuscitated [saved] if he or she stops breathing of if the heart stops beating or wishes to have full treatment in life-threatening situations to do CPR) with no mobility, not responding, and with no reaction in bed inside Resident 1's room on 12/31/2025 at approximately 1:10 PM to 1:15PM. -Ensure CNA1, LVN1, and RNA1 had the competencies necessary to perform Basic Life Support (BLS, is the foundational level of emergency medical care focused on maintaining a resident's airway, breathing, and circulation until advanced care arrives, primarily through high-quality CPR, and clearing airway obstructions [like choking] for victims of cardiac arrest [loss of heart function] or respiratory distress [trouble breathing] measures). As a result, the paramedics pronounced Resident 1 dead on 12/31/2025 at 1:34 PM. This failure had the potential for other unidentified full code residents (68 residents) not to receive life-saving measures during an emergency that could lead to harm and death. On 1/7/2026 at 5 pm, the Department called 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), Director of Nursing (DON), and Administrative Consultant due to the facility's failure to ensure LVN1, CNA1, and RNA1 performed CPR without delays after finding Resident 1 unresponsive, with no mobility and no reaction. Resident 1 died and placed other unidentified full code residents at risk not to receive life-saving measures during an emergency that could lead to harm and death. On 1/8/2025 at 8:54 PM, the Department removed the IJ situation while onsite in the presence of the ADM and the Director of Nursing (DON) after the surveyor verified the facility's implementation of the IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely) through observation, interview, and record review, wherein all nurses would receive CPR training to ensure 68 residents who were full code would receive BLS in case of an emergency The scope and severity was lowered to a G. The IJ removal plan included: -On 1/7/2026, the facility implemented a Quality Assurance (is the specification of standards for quality of service and outcomes, and a process throughout the organization for assuring that care is maintained at acceptable levels in relation to those standards) Performance Improvement (QAPI) Performance Improvement Project (PIP is the continuous study and improvement of processes with the intent to better services or outcomes, and prevent or decrease the likelihood of problems, by identifying areas of opportunity and testing new approaches to fix underlying causes) regarding CPR with return demonstrations. -On 1/8/2026, a third-party vendor educated all nurses on the procedure for initiating CPR and received certifications. CPR drills were conducted. -On 1/8/2026, nurses would not be permitted to work without a CPR card until a certification was completed. -On 1/8/2026, the Medical Records Director audited 80 residents' medical charts and identified two residents (unidentified) who did not have a Physician Orders for Life-Sustaining Treatment (POLST is a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency). Cross reference F656 and F689Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 9/10/2025 with diagnoses that included dysphagia, oropharyngeal phase, dementia (a progressive state of decline in mental abilities), encounter for attention to gastrostomy (care needed for gastrostomy tube [GT] a tube through the abdomen and into the stomach used for feeding, usually via a feeding tube), pneumonitis (inflammation of the lungs) due to inhalation of food and vomit, and chronic obstructive pulmonary disease (COPD, a disease that damages the lungs in ways that make it hard to breathe). During a review of Resident 1's History and Physical (H&P) dated 9/10/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. The H&P indicated Resident 1 was hospitalized prior to the facility's admission due to Resident 1 ingested Lysol (cleaning solution product). During a review of Resident 1's POLST dated 9/11/2025, the POLST indicated to attempt CPR. The POLST indicated to provide full treatment to Resident 1 with the primary goal to prolong life by all medically effective means. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 9/15/2025, the MDS indicated the resident had severe cognitive (ability to think, read, learn, remember, reason, express thoughts, and make decisions) impairment. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) for eating, oral hygiene, lower body dressing, personal hygiene, putting on footwear, and taking off footwear. The MDS indicated Resident 1 was dependent on help for toileting hygiene, showering, and bathing himself. The MDS indicated Resident 1 had a feeding tube. During a review of Resident 1's Care Plan Report dated 9/19/2025, the Care Plan Report indicated the resident's POLST specified to attempt resuscitation. The Care Plan Report indicated to provide full treatment to Resident 1 with the primary goal of prolonging life by all medically effective means. The Care Plan Report indicated an intervention to respect Resident 1 and Resident 1's family's wishes. During a review of Resident 1's Order Summary Report, the Order Summary Report indicated the resident had a physician order dated 9/23/2025 to provide CPR and attempt resuscitation (is an emergency, life-saving procedure designed to restore spontaneous breathing and heartbeat) according to the resident's POLST. During a review of Resident 1's Progress Notes dated 12/31/2025 at 2:45 PM, the Progress Notes indicated that on 12/31/2025 at around 1:15 PM there was a page for a code blue (alert for a life-threatening medical emergency). The Progress Notes indicated Resident 1 was seated on a chair across Resident 1's bed and an RNA (RNA1) was performing a Heimlich maneuver while licensed staff (LVN1) and Respiratory Therapist 1 (RT1) suctioned (draw out) Resident 1's secretions (mucus/fluids) from Resident 1's mouth. The Progress Notes indicated FAM 3 gave a chocolate chip cookie to Resident 1 and to Resident 4. The Progress Notes indicated Resident 1 was pale and Resident 1 did not have a pulse. The Progress Notes indicated Resident 1 was transferred back to bed and staff-initiated CPR and called 911 at around 1:20 PM. The Progress Notes indicated the paramedics declared the time of Resident 1's death at 1:34 PM. During a review of Resident 1's Progress Notes dated 12/31/2025 at 8:30 PM, the Progress Notes indicated FAM3 told the Social Services Designee (SSD) that she (FAM3) gave a chocolate cookie (unidentified size) to Resident 1 because Resident 1 asked for the cookie. The Progress Notes indicated the local police officers (unidentified) arrived at the facility before 2 PM and the coroner (investigates sudden, unexpected, violent, or suspicious deaths to determine the cause and manner of death) picked up Resident 1's body at around 5:30 PM. During an interview on 1/5/2026 at 12:54 PM with CNA 1, CNA 1 stated that on 12/31/2025 at around 1:10 PM to 1:15 PM she (CNA1) was in the hallway when FAM3 called for her attention saying come in, come in to Resident 1's room. CNA 1 stated when she (CNA1) entered Resident 1's room, Resident 1 was looking in front, was sitting straight up in bed, not moving, and with his mouth a little open. CNA 1 stated she (CNA1) saw food running down from Resident 1's mouth. CNA 1 stated she told Resident 1 to spit out, spit out. CNA 1 stated Resident 1 looked very scary; the resident's eyes were open and big. CNA1 stated Resident 1 did not move, was not gasping, and was not trying to spit out. CNA 1 stated Resident 1 was pale and had no reaction when CNA 1 touched him. CNA 1 stated she (CNA1) tried to bring out the food in Resident 1's mouth by using her finger to clean his mouth, but Resident did not blink, did not move, did not react, and did not push her (CNA1's) hand. CNA 1 stated Resident 1 did not push back or cough when she (CNA1) put her finger in Resident 1's mouth. CNA 1 stated Resident 1's lips were pale to bluish in color. CNA 1 stated FAM 3 stated she (FAM3) gave Resident 1 a cookie. CNA 1 stated she (CNA1) told FAM 3 to call for help. CNA 1 stated she (CNA1) started to do the Heimlich maneuver because she (CNA1) saw food in Resident's mouth. CNA 1 stated Resident 1 did not react or show any movement during or after the Heimlich maneuver. CNA 1 stated Resident 1 did not have any rise and fall of his chest. CNA 1 stated she (CNA1) did the Heimlich two to three times on Resident 1.CNA 1 stated RNA 1 and LVN 1 came to Resident 1's room. CNA 1 stated RNA 1 helped her (CNA1) transfer Resident 1 from the bed to a chair to perform the Heimlich maneuver. CNA 1 stated RNA 1 told her (CNA1) to call a code blue. CNA 1 stated when she (CNA1) left Resident 1's room Resident 1 was still not moving and not reacting to touch. During a telephone interview on 1/5/2026 at 1:10 PM, with FAM 1, FAM1 stated on 12/31/2025 the facility called to inform FAM1 that a visitor took cookies to Resident 1's roommate (Resident 4) and fed a cookie to Resident 1. FAM1 stated Resident 1 could not safely swallow solid foods. FAM1 stated Resident 1 was supposed to be on a pureed diet so when Resident 1 ate the cookie he (Resident 1) choked and passed away. During a telephone interview on 1/5/2026 at 3:30 PM, with FAM3, FAM3 stated that on 12/31/2025 she (FAM3) visited Resident 4 who was Resident 1's roommate. FAM3 stated she (FAM3) would often visit Resident 4 and would take food to Resident 4 weekly. FAM3 stated Resident 4 had requested cookies and FAM3 purchased chocolate chip and oatmeal cookies and took the cookies inside the facility. FAM3 stated when she (FAM3) saw Resident 4, she (FAM3) told Resident 4 I got your cookies, Resident 1 overheard and Resident 1 stated, I want a cookie too. FAM3 stated she (FAM3) was feeding Resident 4 a cookie inside the room, Resident 1 kept repeating can I get a cookie, I want a cookie. FAM3 stated after she (FAM3) fed Resident 4 a cookie, she (FAM3) asked Resident 1 if he (Resident 1) wanted a cookie and Resident 1 said yes. FAM3 stated she (FAM3) gave Resident 1 a cookie at around 1PM. FAM3 stated she (FAM3) then sat down and started talking with Resident 4 for approximately five to ten minutes, then looked over at Resident 1 and saw Resident 1 shaking, pale, and choking. FAM3 stated she (FAM3) then went to call the nurse (unidentified). FAM3 stated a nurse (unidentified) went into the room and told FAM3 to call for help. FAM3 stated she (FAM3) then went to the hallway and called for help and multiple staff (unidentified) entered the room. FAM3 stated facility staff (unidentified) were trying to revive Resident 1 and called the paramedics, but Resident 1 passed away. FAM3 stated she (FAM3) did not ask a staff (in general) if it was ok to give Resident 1 a cookie. FAM3 stated she (FAM3) gave the cookie to Resident1 because Resident 1 kept asking for a cookie. FAM3 stated she (FAM3) made a mistake and should not have given Resident 1 a cookie. During an interview on 1/6/2026 at 2 PM with RNA 1, RNA 1 stated that on 12/31/2025 at 1 PM he was in the hallway by the nurse's station when he (RNA1) heard there was a resident (unidentified) who was choking. RNA 1 stated he (RNA1) ran towards a voice stating, Patient is choking, patient is choking and was able to identify the voice was coming from Resident 1's room. RNA 1 stated when he (RNA1) entered Resident 1's room and saw Resident 1 sitting at a 45-degree angle (head of the bed elevated) with Resident 1's head tilted towards the front. RNA 1 stated CNA 1 was with Resident 1. RNA 1 stated he (RNA1) did not have time to check if Resident 1 had a pulse. RNA 1 stated he (RNA1) did not check if Resident 1 was responsive. RNA 1 stated he (RNA1) positioned Resident 1 in bed to lean on him (RNA 1) to perform the Heimlich maneuver. RNA 1 stated he (RNA1) performed a couple of blows of the Heimlich maneuver while Resident 1 was in bed then LVN 1 came to Resident 1's room. RNA 1 stated that both he and LVN 1 agreed to transfer Resident 1 to a chair to better position Resident 1 to perform the Heimlich maneuver. RNA 1 stated that he (RNA1) and LVN 1 did not check if Resident 1 had a pulse or if Resident 1 was responsive. RNA 1 stated that it was RT 1 who said that Resident 1 did not have a pulse. RNA 1 stated that RT 1 stated to put Resident 1 back in bed and initiate CPR. During a concurrent interview and record review on 1/6/2026 at 2:37 PM, with CNA 1, CNA 1's BLS certificate dated 3/10/2023 and 1/2/2026 were reviewed. CNA 1 stated she (CNA1) was certified to perform BLS and CPR. CNA 1 stated she (CNA1) last took the BLS Certification class in 2023 as indicated on CNA 1's BLS Certificate dated 3/10/2023. Upon review, CNA 1's BLS certificate dated 3/10/2023 indicated the BLS certificate needed to be renewed by 3/2025. CNA 1 stated she (CNA1) had a BLS Certificate dated 1/2/2026, however, CNA 1 stated she (CNA1) did not take the BLS Certification class as indicated on her BLS Certificate dated 1/2/2026. CNA 1 stated she (CNA1) called the instructor (unidentified) listed on the BLS Certificate dated 1/2/2026 and the instructor gave her (CNA1) the BLS Certification without taking the BLS class. CNA 1 stated the first step for CPR was to check for responsiveness by asking the resident (in general) if the resident (in general) was ok. CNA 1 stated the next step for CPR was to check the resident's (in general) pulse. CNA 1 stated if the resident (in general) had no pulse, she (CNA1) would give the resident (in general) breaths, and then do chest compressions (giving strong, rapid pushes to the chest to keep blood moving through the body). CNA1 stated she (CNA1) did not check for a pulse and did not perform CPR. CNA 1 stated for CPR she (CNA1) would do 20 compressions and then she (CNA1) would give one breath. CNA 1 stated it was important to take the BLS classes because there could be updates and changes in the steps to provide CPR. CNA 1 stated if classes were not taken to get the certification for BLS, she (CNA1) would not know how to do the updated CPR steps to revive a resident, which could lead to the resident's death (in general). During an interview on 1/6/2026 at 3:28 PM, with LVN 1, LVN1 stated that on 12/31/2025 at around 1 PM FAM3 was in the hallway saying help, help and called LVN 1 to Resident 1's room. LVN 1 stated when she (LVN1) entered Resident 1's room, she (LVN1) saw Resident 1 sitting on a chair. LVN 1 stated Resident 1's lips were slightly blue. LVN 1 stated Resident 1's eyes were open. LVN 1 stated Resident 1 did not appear to be choking. LVN 1 stated she (LVN1) did not check if Resident 1 was responsive, did not check if Resident 1 was breathing or if Resident 1 had a pulse. LVN 1 stated she (LVN1) performed the Heimlich maneuver on Resident 1 because she (LVN1) was told Resident 1 was choking. During a concurrent interview and record review on 1/7/2026 at 8:42 AM with the DON, CNA 1's BLS certificate dated 3/10/2023 and 1/2/2026 were reviewed. The DON stated on 12/31/2025 at around 1:10 PM to 1:15 PM she (DON) heard a code blue (an alert for a life-threatening medical emergency) paged and was informed there was a choking incident in Resident 1's room. The DON stated she (DON) went to Resident 1's room and when she (DON) got there, Resident 1 was in a chair and RNA 1 was doing the Heimlich maneuver on Resident 1. The DON stated LVN 1 was suctioning Resident 1. The DON stated RT 1 was also in Resident 1's room assisting with suctioning. The DON stated RT 1 checked Resident 1's pulse because Resident 1 was pale. The DON stated RT 1 said Resident 1 did not have a pulse and put Resident1 back in bed. The DON stated CPR was started. The DON stated whoever was the first to come into a resident's room (in general) needed to initiate the CPR steps when the resident (in general) was unresponsive and had no pulse. The DON stated it was strongly recommended that CNAs were certified (in general) for BLS. The DON stated CNAs with a BLS certificate (in general) were expected to know and perform the CPR steps until a licensed nurse went in. The DON stated a BLS/CPR certificate was good for two years. The DON stated to become BLS/CPR certified the individual must be trained to do CPR through a class. The DON stated it was important to take a BLS class to ensure the staff (in general) had an understanding of how to do CPR. The DON stated the CPR steps were to first check the resident (in general) for responsiveness, check the resident's pulse (in general), and if the resident had no pulse and was not responsive, to start CPR (in general). The DON stated if someone was given a BLS certificate without having to take the BLS class they would not know what to do when a resident had an emergency (in general), and that resident (in general) was at risk for not getting the proper emergency care that could lead to death. During an interview on 1/7/2026 at 10:38 AM with RNA 1, RNA 1 stated that on 12/31/2025 at around 1PM to 1:15 PM, he (RNA1) suddenly heard someone say, a patient is choking. RNA 1 stated LVN 1 was on her way to Resident 1's room but he passed her because he (RNA1) was moving fast. RNA 1 stated when he (RNA1) got to Resident 1's room, he (RNA1) saw people in the room and one nurse (unidentified) was with Resident 1. RNA 1 stated he (RNA1) saw Resident 1 sitting up in bed at 45 degrees. RNA 1 stated Resident 1 was leaning forward and slumped forward not moving not responding. RNA 1 stated he (RNA1) saw a staff member (CNA1) performing the Heimlich maneuver and took over the task. RNA 1 stated he (RNA1) took a bed sheet which was covering Resident 1's legs and used it to place Resident 1's legs on the side of the bed and down onto the floor. RNA 1 stated he (RNA1) was behind Resident 1 and then leaned Resident 1's body on to himself to start the Heimlich maneuver because he (RNA1) was told Resident 1 was choking. RNA 1 stated Resident 1's lips were pale to bluish in color. RNA 1 stated Resident 1 did not react or did not show any movement when he (RNA1) was doing the Heimlich maneuver. RNA 1 stated he (RNA1) did a couple of Heimlich maneuvers. RNA 1 stated LVN 1 pulled a chair next to Resident 1's bed and he (RNA1) and LVN 1 put Resident1 onto the chair and started the Heimlich maneuver on Resident 1. RNA 1 stated RT 1 came and suctioned Resident1, checked Resident1 and said, No Pulse, put him back in bed. RNA 1 stated he (RNA1) lifted Resident1's shoulder and RT 1 lifted Resident 1's legs. RNA 1 stated RT 1 then started CPR. During an interview on 1/7/2026 at 11:04 AM with LVN 1, LVN 1 stated when she (LVN1) entered Resident 1's room on 12/31/2025 Resident 1 was unresponsive (not moving, not responding). LVN 1 stated she (LVN1) was told Resident 1 was choking and her immediate action was to perform the Heimlich maneuver on Resident 1. LVN 1 stated she (LVN1) did not check Resident 1's pulse. LVN 1 stated CPR might have been delayed on Resident 1 because Resident 1's pulse was not checked. LVN 1 stated if Resident 1's pulse was checked and no pulse was felt, the immediate step would be to initiate CPR on Resident 1. During an interview on 1/7/2026 at 11:44 AM, RT 1 stated that on 12/31/2025 at around 1 PM, he (RT1) heard a CNA (unidentified) call out for help. RT 1 stated when he (RT1) went to Resident 1's room, Resident 1 was sitting in a foldable metal chair. RT 1 stated RNA 1 was doing the Heimlich maneuver. RT 1 stated a CNA (unidentified) was next to Resident 1 and told him (RT 1) that Resident 1 was choking. RT 1 stated Resident 1 was not alert and did not have the universal sign of choking (clutching the throat with one or both hands). RT 1 stated it did not look like Resident 1 was breathing. RT 1 stated Resident 1 looked lifeless. RT 1 stated he (RT1) checked Resident 1's pulse. RT 1 stated Resident 1 did not have a pulse. RT 1 stated he (RT1) told the CNA (unidentified), RNA 1, and LVN (unidentified) who were in Resident 1's room to put Resident 1 back to bed to start CPR. RT 1 stated that if a resident was found unresponsive (in general) the staff (in general) needed to immediately (no delay) check the resident's pulse first (in general) and immediately start CPR if the resident had no pulse (in general). RT 1 stated that there could have been a delay in initiating CPR for Resident 1. RT 1 stated Resident 1's pulse should have been checked sooner when Resident 1 was initially found unresponsive (not moving and not responding). During an interview on 1/7/2026 at 12:18 PM with CNA 2, CNA 2 stated on 12/31/2025 at around 1 PM, she (CNA2) heard there was a code blue in Resident 1's room. CNA 2 stated she (CNA2) went to Resident 1's room and saw RNA 1 already in Resident 1's room. CNA 2 stated RNA 1 was doing the Heimlich maneuver on Resident 1. CNA 2 stated Resident 1's whole face looked purple. CNA 2 stated she (CNA2) offered to help with Heimlich maneuver. CNA 2 stated she (CNA2) performed the Heimlich maneuver for 1 minute and then LVN 1 took over. During an interview on 1/7/2026 at 1:33 PM with the DON, the DON stated when she (DON) went into Resident 1's Room on 12/31/2026 at around 1:10 PM to 1:15 PM Resident 1 was sitting on a chair and RNA 1 was doing the Heimlich maneuver on Resident 1. The DON stated Resident 1 was not moving. The DON stated Resident 1 was pale. The DON stated she (DON) did not assess Resident 1 for responsiveness. The DON stated RT 1 came and assisted with suctioning and setting up oxygen from the crash cart (a cart stocked with emergency medical equipment, supplies, and drugs for use by medical personnel especially during efforts to resuscitate a resident). The DON stated RT 1 said Resident 1 did not have a pulse and to put Resident 1 back in bed. The DON stated CPR was then started. The DON stated CPR continued until the paramedics came to the facility at around 1:20 PM. The DON stated the first staff to respond to the incident with Resident 1 was CNA 1. The DON stated CNA 1 did not perform the step of checking Resident 1's pulse. The DON stated checking Resident 1's pulse should have been done first if Resident 1 was found unresponsive. The DON stated the steps for CPR were to check Resident 1's vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions), assess Resident 1 for responsiveness, if Resident 1 was not responsive, then CNA1 needed to check Resident 1's pulse and breathing, and then start CPR if there was no pulse. The DON stated if CNA 1 checked Resident 1's pulse first when she (CNA1) found Resident unresponsive, CNA 1 would have known which step to take next. The DON stated if Resident 1 had no pulse the immediate intervention would be to initiate CPR. The DON stated there was a delay in CPR for Resident 1 because Resident's pulse was not checked when Resident was initially found unresponsive (not responding and not moving). During an interview on 1/8/2026 at 12:51 PM with Medical Director 1 (MD 1), MD 1 stated the facility informed him of the incident that happened with Resident 1 on 12/31/2025. MD 1 stated he (MD1) was informed that FAM3 gave a cookie to Resident 1 without consulting a nurse. MD 1 stated Resident 1 choked and passed away. MD 1 stated he (MD1) was also informed that CPR protocol was not followed for Resident 1 when a CNA (unidentified) did not check Resident 1's pulse. MD 1 stated the steps for CPR (in general) were to first check the resident (in general) for responsiveness, check the resident's pulse and airways, and if the resident did not have a pulse initiate chest compressions. MD 1 stated if Resident 1 was unresponsive (not moving and not reacting) then Resident 1's pulse should have been checked first and if Resident 1 did not have a pulse, CPR should have been initiated immediately. MD 1 stated because Resident 1's pulse was not checked there was a delay in initiating CPR. During a review of the facility's undated job description titled Certified Nurse Assistant, the job description indicated it was a requirement for the Certified Nurse Assistants (in general) to have a CPR certificate. During a review of the facility's Policy and Procedure (P&P) titled CPR Certification dated 8/28/2025, the P&P indicated It is the policy of the facility that all licensed nurses maintain current CPR Certification through nationally recognized certify organizations (i.e., American Red Cross, American Heart Association), and strongly recommended that C.N.A.'s maintain certification. During a review of the facility's P&P titled Emergency Procedure - Cardiopulmonary Resuscitation dated 8/28/2025 the P&P indicated It is the policy of the facility that residents will receive cardio pulmonary resuscitation to maintain cardiac and/or respiratory function, in the absence of a physician's order to withhold CPR .Upon finding an unconscious resident, attempt to arouse resident. If unable to arouse, assess presence of respirations and heartbeat. Absence of breath sounds or air movement through the mouth, establish airways. Perform chest thrust maneuver if airway obstructed or suction resident as appropriate. Activate emergency medical services - call 911. Absence of palpable carotid or femoral pulse, call for help, active overhead paging Code Blue to room #. Initiate CPR (Cardio Pulmonary Resuscitation) based on the identified clinical needs of the patient. During a review of the American Heart Association guidelines titled 2025 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care dated 2025, the guidelines indicated Verify scene safety. Check for responsiveness, shout for nearby help, activate the emergency response system, send someone to get AED/defibrillator, look for breathing or only gasping and check pulse (simultaneously). No breathing or only gasping, pulse not felt, start CPR. Perform cycles of 30 compressions and 2 breaths.If an adult is unconscious/unresponsive, with absent or abnormal breathing (ie, only gasping), the lay rescuer should assume the person is in cardiac arrest. If an adult is unconscious/unresponsive, with absent or abnormal breathing (ie, only gasping), the health care professional should check for a pulse for no more than 10s and, if no definite pulse is felt, should assume the person is in cardiac arrest. Reference: https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines

Based on interview and record review, the facility failed to develop a specific and individualized person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition, and current treatments) for dysphagia (difficulty swallowing) for four of four sampled Residents (Resident 1, Resident 2, Resident 3, and Resident 4) reviewed for care plans. This failure placed Resident 1, Resident 2, Resident 3, and Resident 4 at an increased risk for aspiration (when something enters the airway or lungs by accident) and choking.Cross Reference F678 and F689.Findings:a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 9/10/2025 with diagnoses that included dysphagia, oropharyngeal phase, dementia (a progressive state of decline in mental abilities), encounter for attention to gastrostomy (care needed for gastrostomy tube [GT] a tube through the abdomen and into the stomach used for feeding, usually via a feeding tube), pneumonitis (inflammation of the lungs) due to inhalation of food and vomit, and chronic obstructive pulmonary disease (COPD, a disease that damages the lungs in ways that make it hard to breathe). During a review of Resident 1's History and Physical (H&P) dated 9/10/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. The H&P indicated Resident 1 was hospitalized prior to the facility's admission due to Resident 1 ingested Lysol (cleaning solution product). During a review of Resident 1's Care Plan Report dated 9/15/2025, the Care Plan Report indicated Resident 1 was at risk aspiration related to dysphagia. The Care Plan Report indicated no nursing interventions. During a review of Resident 1's Order Summary Report dated 10/30/2025, the Order Summary Report indicated for Resident 1 to receive enteral feeding (getting liquid nutrition directly into stomach via a tube) Jevity (nutritional formula) 1.5 (1.5 calories per milliliter [ml, unit of measurement]) at 65 ml/hr (hour) for 20 hours. During a review of Resident 1's Order Summary Report dated 12/22/2025, the Order Summary Report indicated for Resident 1 to receive a pureed (a pudding-like texture that is smooth, blended) texture regular diet for oral gratification (providing pleasurable oral taste). During a concurrent interview and record review on 1/5/2026 at 2:08 PM, with the Director of Nursing (DON), Resident 1's admission Record and Resident 1's Care Plan Reports (in general) were reviewed. The DON stated Resident 1 had a diagnosis of dysphagia on admission and Resident 1 was at risk for aspiration. The DON stated staff (in general) were informed of the residents (unidentified) who were on aspiration precautions verbally at morning huddles (brief meetings). The DON stated each diagnosis needed a specific care plan (in general) to have interventions such as aspiration precautions, type of diet, monitor swallowing, and proper positioning. The DON stated Resident 1's care plan did not have nursing interventions to address dysphagia and the pureed diet. b. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident on 7/22/2024 with diagnoses that included aphasia (a disorder that makes it difficult to speak), dysphagia following cerebral infarction (stroke, loss of blood flow to a part of the brain), dementia, and adult failure to thrive (a decline in older adults that manifests as a downward spiral of health and ability). During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool) dated 3/20/2025, the MDS indicated the resident had severe cognitive (ability to think, read, learn, remember, reason, express thoughts, and make decisions) impairment. The MDS indicated Resident 1 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) for eating. The MDS indicated Resident 2 required partial/moderate assistance (helper does less than half the effort) for personal hygiene. The MDS indicated Resident 2 required substantial/maximal assistance (helper does more than half the effort) for oral hygiene and upper body dressing. The MDS indicated Resident 2 was dependent on help for toileting hygiene, showering/bathing himself, lower body dressing, and putting on/taking off footwear. During a review of Resident 2's Order Summary Report, the Order Summary Report indicated Resident 2 had a physician order dated 9/16/2025 that indicated the resident was to have a controlled carbohydrate (a diet that focuses on eating consistent amounts of carbohydrates at meals to stabilize blood sugar), pureed texture, thin consistency diet. c. During a review of Resident 3's admission Record, the admission Record indicated the facility admitted the resident on 6/28/2025 with diagnoses that included gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), dysphagia, and dementia. During a review of Resident 3's MDS dated [DATE], the MDS indicated the resident had moderate cognitive impairment. The MDS indicated Resident 3 was dependent on help with eating, oral hygiene, toileting hygiene, showering/bathing himself, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated Resident 3 was on a mechanically altered diet (a diet in which the food texture is modified by chopping, griding, mashing, or pureeing to make the food soft, moist, and easy to chew and swallow). During a review of Resident 3's Order Summary Report, the Order Summary Report indicated the resident had a physician order dated 12/8/2025 for fortified (a diet with added vitamins, minerals, calories, and/or protein), pureed texture, thin consistency diet d. During a review of Resident 4's admission Record, the admission Record indicated the facility re-admitted the resident on 9/23/2025 with diagnoses that included aphasia and dysphagia following cerebral infarction. During a review of Resident 4's Order Summary Report, the Order Summary Report indicated the resident had a physician order dated 9/30/2025 for a fortified/high protein no added salt pureed texture thin consistency diet. During a review of Resident 4's MDS dated [DATE], the MDS indicated the resident had moderate cognitive impairment. The MDS indicated Resident 4 required substantial/maximal assistance for eating. The MDS indicated Resident 4 was dependent on help for oral hygiene, toileting hygiene, showering/bathing himself, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated Resident 4 had a mechanically altered and therapeutic diet (a medically prescribed meal plan that modifies a normal diet to treat a specific health condition). During an interview on 1/5/2026 at 2:08 PM with the Director of Nursing (DON), the DON stated a care plan was a plan of care that was written specifically for a resident (in general) so the nurses (in general) would be able to know how to take care of the resident. The DON stated each resident diagnosis and identified problem needed a care plan. The DON stated the care plan addressed each resident's specific needs. The DON stated the care plan was created upon admission, quarterly (every three months), and as needed when a situation would arise, such as when there was a change of condition and when new physician orders were received. The DON stated the diagnosis of dysphagia should have a specific care plan. The DON stated a care plan for dysphagia should include interventions for a speech therapist evaluation, diet orders, aspiration precautions (strategies to prevent food, liquids, or stomach contents from entering the lungs) such as raising the head of the bed 35-45 degrees, monitoring for coughing and shortness of breath, and monitoring the resident's swallowing. During a concurrent interview and record review on 1/6/2026 at 10 AM with Licensed Vocational Nurse 2 (LVN 2), Resident 2, Resident 3, and Resident 4's Care Plan Reports were reviewed. LVN 2 stated the Care Plan Report listed all the care plans for a resident. LVN 2 stated a care plan was a guide for the resident's treatment of a problem. LVN 1 stated the care plan contained nursing interventions and physician orders that must be followed for a resident's treatment. LVN 2 stated each care plan was individualized and specific to the resident's clinical condition and disease process because each resident had different needs. LVN 2 stated each resident diagnosis should have a care plan. LVN 2 reviewed the Care Plan Report for Resident 2. LVN 2 stated Resident 2 had a diagnosis of dysphagia and a physician order for a pureed texture diet. LVN 2 stated Resident 2's Care Plan Report did not have a specific care plan for dysphagia. LVN 2 reviewed the Care Plan Report for Resident 3. LVN 2 stated Resident 3 had a diagnosis of dysphagia and a physician order for a pureed texture diet. LVN 3 stated Resident 3 did not have a specific care plan for dysphagia. LVN 2 reviewed Resident 4's Care Plan Report. LVN 2 stated Resident 4 had a diagnosis of dysphagia and a physician order for a pureed texture diet. LVN 2 stated Resident 4 did not have a specific care plan for dysphagia. LVN 2 stated Resident 2, Resident 3, and Resident 4 should each have a care plan for dysphagia with interventions that include upright positioning, a swallow evaluation (a medical assessment by a speech-language pathologist (SLP) (SLP) to diagnose difficulties with swallowing (dysphagia) by examining the muscles, coordination, and safety of the swallowing process), diet orders, and monitoring for signs and symptoms of aspiration such as coughing and shortness of breath. LVN 2 stated there was a potential for Resident 2, Resident 3, and Resident 4 to aspirate and develop pneumonia (infection/inflammation in the lungs) without a care plan for dysphagia because the nurses would not know the treatment and interventions the residents needed to treat their dysphagia. During a concurrent interview and record review on 1/6/2026 at 11:01 AM with the Quality Assurance Nurse (QAN), Resident 2, Resident 3, and Resident 4's Care Plan Reports were reviewed. The QAN stated the Care Plan Report described the plan of care for the residents. The QAN stated the care plans listed in the Care Plan Report had interventions the nurses (in general) needed to perform for resident care. The QAN stated the purpose of the care plan was to act as a guideline for the care of each residents' problems. The QAN stated every resident problem and diagnosis needed a care plan. The QAN stated each care plan was specific and individualized to each resident. The QAN stated licensed nurses had access to the care plans. The QAN stated the care plans should be updated by the licensed nurses on admission, quarterly, with a change of condition, and with any update in the resident's physician orders or plan of care. The QAN reviewed the Care Plan Report for Resident 2. The QAN stated Resident 2 had a diagnosis of dysphagia and a physician order for a pureed texture diet. The QAN stated Resident 2's Care Plan Report did not have a specific care plan for dysphagia. The QAN reviewed the Care Plan Report for Resident 3. The QAN stated Resident 3 had a diagnosis of dysphagia and a physician order for a pureed texture diet. The QAN stated Resident 3 did not have a specific care plan for dysphagia. The QAN reviewed Resident 4's Care Plan Report. The QAN stated Resident 4 had a diagnosis of dysphagia and a physician order for a pureed texture diet. The QAN stated Resident 4 did not have a specific care plan for dysphagia. The QAN stated Resident 2, Resident 3, and Resident 4 should each have a care plan that was initiated on admission for dysphagia. The QAN stated the dysphagia care plan should have interventions that include the resident's diet orders, monitoring for signs of aspiration like coughing, educating the resident and family on aspiration precautions, and a swallow evaluation by speech therapy. The QAN stated there was a potential for an increased risk for aspiration if Resident 2, Resident 3, and Resident 4 did not have a care plan for dysphagia. During a concurrent interview and record review on 1/7/2026 at 12:48 PM with the DON, Resident 2, Resident 3, and Resident 4's Care Plan Reports were reviewed. The DON stated Resident 2 had a diagnosis of dysphagia and a physician order for a pureed texture diet. The DON stated Resident 2 did not have a care plan initiated upon admission for dysphagia. The DON stated Resident 3 had a diagnosis of dysphagia and a physician order for a pureed texture diet. The DON stated Resident 3 did not have a specific care plan for dysphagia. The DON stated Resident 4 had a diagnosis of dysphagia and a physician order for a pureed texture diet. The DON stated Resident 4 did not have a care plan initiated upon admission for dysphagia. The DON stated Resident 2, Resident 3, and Resident 4 should have had a dysphagia care plan initiated on admission to address the residents' difficulty swallowing. The DON stated there was a potential for an increased risk for aspiration for Resident 2, Resident 3, and Resident 4 without a dysphagia care plan because nurses would not know the specific plan of care needed for the residents. During a review of the facility's Policy and Procedure (P&P) titled Care Plans, Comprehensive Person-Centered dated 8/28/2025, the P&P indicated A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.The comprehensive, person-centered care plan includes measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; any special services to be provided as a result of PASARR recommendations; and which professional services are responsible for each element of care; includes the residents stated goals upon admission and desired outcomes; building on the resident's strengths; and reflects currently recognized standards of practice for problem areas and conditions.When possible, interventions address the underlying source(s) of the problem area(s), and not just symptoms or triggers. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. The interdisciplinary team reviews and updates the care plan when there has been a significant change in the resident's condition; when the desired outcome is not met; when the resident has been readmitted to the facility from a hospital stay; and at least quarterly, in conjunction with the required quarterly MDS assessment.

Based on observation, interview, and record review, the facility failed to properly store the insulin and albuterol when they stored it in the non-hazardous waste bin. On 9/30/2025 at 11:08 a.m. three used insulin (is a natural hormone [is chemicals that coordinate different functions in the body] that turns food into energy and manages the blood sugar level made with metacresol [m-cresol - a toxic and corrosive preservative]) pens, and; three aerosolized (having tiny particles of matter and gas or liquid that turn into a fine mist to be inhaled) inhalers (a pressurized device/canister that is inhaled to deliver medication(s) into the lungs) was found in the in the pharmaceutical (any medication/drug or dietary supplement for use by humans) waste bin (specialized container for disposing pharmaceutical waste) in one of one inspected Medication Rooms (Medication room [ROOM NUMBER].) This deficient practice violates both state regulations and the facility's own medication disposal policies, which require hazardous pharmaceutical waste to be disposed of in designated hazardous waste containers to prevent environmental contamination and safety risks.Findings: During an observation on 9/30/2025 at 11:08 a.m., in Medication room [ROOM NUMBER], with Registered Nurse (RN) 1, a white pharmaceutical waste bin (a container for disposing of any drug that has medicinal purposes waste) was observed to contain several lose medication tablets and capsules, three (3) disposed insulin pens, and three (3) disposed aerosolized inhalers. A sticker placed on the outside of the white pharmaceutical disposal bin indicated the following: -Non-Hazardous pharmaceutical waste (un-administered or unused medications and containers including intravenous (IV-into a vein) Bags, Vials, Syringes). -No hazardous waste (material must be free of any actual or apparent contamination (infectious, radioactive and/ or hazardous chemical). -No P-listed chemicals or medicines (acutely [sudden onset] toxic means the drug/chemical can cause death or irreversible illness even at low doses). -No U-listed chemicals or medicines. -No DEA (Drug Enforcement Administration) listed controlled substances. -No D-listed chemicals or medicines that exhibit the following characteristics [corrosivity, ignitability, reactivity, toxicity].During a concurrent interview on 9/30/2025 at 11:08 a.m., RN 1 stated the white pharmaceutic bin contained three insulin pens, and three aerosolized inhalers. RN 1 stated insulin pens and inhalers should not be disposed of in the non-hazardous white pharmaceutical bin. During an interview on 9/30/2025 at 2 p.m., the Director of Nursing (DON,) acknowledged and stated that the label/sticker on the outside of the white pharmaceutical bin indicated not to dispose of toxic medications. The DON stated that the white pharmaceutical bin contained several insulin pens, including Lantus (brand name of an insulin) and Aspart (generic name of an insulin), and several inhalers including Albuterol (an aerosolized inhaler- a medication used to relax muscles in the airways and increase air flow to the lungs). The DON stated the white non-hazardous pharmaceutical bin should not contain insulin pens as the insulin pens contain hazardous materials and aerosolized inhalers which can explode. The DON stated a third-party (an outside contracted entity not part of the facility) vendor (an individual or company that sells goods or services to someone else) usually picks up the facility's pharmaceutical waste containers once a month to dispose of the wasted medications. The DON stated the DON needed to contact the pharmaceutical waste container vendor to obtain the appropriate waste bin to waste hazardous medications. The DON stated the facility failed to destroy hazardous medications, like insulin pens and inhalers, in the appropriate waste container, according to state laws and regulations and facility policy and procedures. A review of the facility Policy and Procedures (P&P) titled, Medication Destruction, last reviewed 8/28/2025, indicated:A. All medications are placed in the proper waste container per facility policy. The facility maintains a contract with a waste disposal company specifying pick-up and disposal procedures. A review of a document titled Recovery Act regulations at 40 CFR Part 261 (Subpart C), https://www.ecfr.gov/current/title-40/chapter-I/subchapter-I/part-261/subpart-C, accessed 11/24/2025, the regulation indicated: Characteristic of ignitability:a.3 includes ignitable compressed gas.b. A solid waste that exhibits the characteristic of ignitability has the EPA Hazardous Waste Number of D001. Toxicity characteristic.(a) A solid waste.exhibits the characteristic of toxicity if, ., the extract from a representative sample of the waste contains any of the contaminants listed in table 1 at the concentration equal to or greater than the respective value given in that table. (b) A solid waste that exhibits the characteristic of toxicity has the EPA Hazardous Waste Number specified in Table 1 which corresponds to the toxic contaminant causing it to be hazardous.Hazardous waste number of D024 m-Cresol regulatory level of 200 milligrams ([mg[ unit of measure of mass) per liter ([L] - unit of measure of volume equivalent to 1000 milliliter). A review of manufacturer's guide Highlights of Prescribing Information for Lantus, dated June 2022, the guide indicated: each milliliter of Lantus contains . metacresol 2.7 mg. During a review of manufacturer's guide Highlights of Prescribing Information for Aspart, dated February 2023, the guide indicated: each milliliter of Aspart contains . metacresol 1.72 mg. A review of Recovery Act regulations at 40 CFR Part 266 (Subpart P) at https://www.ecfr.gov/current/title-40/chapter-I/subchapter-I/part-266/subpart-P, accessed 11/44/2025, the regulation indicated: Long-term care facility means a licensed entity that provides assistance with activities of daily living, including managing and administering pharmaceuticals to one or more individuals at the facility. This definition includes, but is not limited to, hospice facilities, nursing facilities, skilled nursing facilities, and the nursing and skilled nursing care portions of continuing care retirement communities. Non-creditable hazardous waste pharmaceutical means a prescription hazardous waste pharmaceutical that does not have a reasonable expectation to be eligible for manufacturer credit . This includes but is not limited to, ., residues of pharmaceuticals remaining in empty containers . A review of the document titled A 10-Step Blueprint for Managing Pharmaceutical Waste in US Healthcare Facilities, 2022 Edition, https://www.epa.gov/system/files/documents/202210/10_step_blueprint_guide_final_9-22.pdf, accessed 11/24/2025, the document indicated: Table 8: Examples of Incompatible Hazardous Waste PharmaceuticalsAlbuterol Inhaler RCRA HW Code D001.

Based on interview and record review, the facility failed to ensure three of seven sampled residents (Resident 6, Resident 44, and Resident 47) were free from significant medication errors (mistakes when giving medications that can cause the resident discomfort or jeopardizes his or her health and safety) according to professional standards of practice. By failing to ensure facility staff rotated the administration site (the practice of moving the injection spot to different places on the body, like the stomach, arms, thighs, or buttocks, to allow previous spots to heal) when administering insulin (a hormone that acts like a key to let sugar (glucose) from the blood enter the body's cells for energy) as per physician's orders and the facility's policy and procedures (P&P) titled Insulin Administration dated 8/25/2025. This failure had the potential for Resident 6, Resident 44, and Resident 77 to develop lipohypertrophy (a condition where lumps of fat and scar tissue form under the skin, often at insulin injection sites, due to repeated injections in the same area that can impair insulin absorption and lead to inconsistent blood sugar levels and difficulty managing diabetes), pain, delayed absorption and effects of insulin therapy. 1. During a review of Resident 6's admission Record, the admission Record indicated the facility admitted Resident 6 on 6/20/2025 with diagnoses that included diabetes mellitus type (a disease in which your body does not produce enough insulin needed to control sugar levels in the blood), DM 2 with foot ulcer (a small open sore or wound), sepsis (a life-threatening medical emergency where the body has an overwhelming and extreme inflammatory response to an infection, which can damage its own tissues and organs), urinary tract infection (UTI- an infection in the bladder/urinary tract), gastrointestinal esophageal reflux disease (GERD - a chronic condition where stomach acid flows back into the esophagus, the tube that carries food from your mouth to your stomach), hypertension (HTN - high blood pressure), major depressive disorder (a serious mental health condition characterized by persistent feelings of sadness, emptiness, and a loss of interest in activities), anemia (when your body has too few healthy red blood cells that carry oxygen throughout your body), and acquired absence of right leg below the knee (the right leg was lost or surgically removed below the knee, not from birth). During a review of Resident 6's history and physical (H&P- physician's examination of a resident, in which the physician obtains a thorough medical history from the resident or resident representative, performs a physical examination, and then documents the findings) dated 6/23/2025, the H&P indicated Resident 6 had the capacity (ability) to understand and make decisions. During a review of Resident 6's Minimum Data Set (MDS - a standardized assessment tool) dated 6/26/2025, the MDS indicated Resident 6 had the ability to make himself understood and had the ability to understand others. During a review of Resident 6's Order Summary Report dated 10/1/2025, the Order Summary Report indicated Resident 6 had an active physician's order dated and started on 6/23/2025 indicating Insulin Glargine (a long-acting, man-made insulin) subcutaneous (fatty layer of tissue just beneath the skin) solution 100 unit/ml (a unit of measure) inject 25 unit subcutaneously at bedtime for DM rotate injection site. The Order Summary Report indicated Resident 6 had a physician order dated and started on 8/13/2025 for Insulin Lispro (a fast-acting, manufactured version of human insulin) subcutaneous solution that indicated rotate site of injection. During a concurrent interview and record review on 10/1/2025 at 9:19 AM with the facility's Quality Assurance Nurse (QAN) and the Director of Nursing (DON), Resident 6's Location of Administration Report for Insulin Glargine Subcutaneous Solution 100 unit/ml dated 9/1/2025 to 9/30/2025 was reviewed. The report indicated the Insulin Glargine Subcutaneous Solution 100 unit/ml was administered (given) consecutively (back-to-back) to Resident 6 on: - 9/4/2025 at 9:39 PM on the abdomen (the body area between the chest and the hips) left lower quadrant (LLQ - the lower-left section of your abdomen, just below and to the left of your belly button).- 9/5/2025 at 9:57 PM on the abdomen LLQ. - 9/6/2025 at 9:51 PM on the abdomen right upper quadrant (RUQ - upper right section of the abdomen just above and to the right of your belly button).- 9/7/2025 at 10:26 PM on the abdomen RUQ. - 9/8/2025 at 9:11 PM on the abdomen RUQ. The QAN and DON stated facility staff should have rotated insulin sites to prevent lipohypertrophy. During a concurrent interview and record review on 10/1/2025 at 9:19 AM with the facility's QAN and DON, Resident 6's Location of Administration Report for Insulin Lispro Injection Solution dated 9/1/2025 to 9/30/2025 was reviewed. The report indicated the Insulin Lispro Injection Solution was administered consecutively to Resident 6 on:- 9/1/2025 at 5:25 PM on the abdomen left upper quadrant (LUQ - left upper side of the abdomen just above and to the left of your belly button). - 9/1/2025 at 9:11 PM on the abdomen LUQ. - 9/6/2025 at 11:55 PM on the abdomen LUQ. - 9/7/2025 at 6:39 PM on the abdomen LUQ. - 9/7/2025 at 4:09 PM on the abdomen LUQ. - 9/11/2025 at 4:51 PM on the abdomen LUQ. - 9/11/2025 at 9:51 PM on the abdomen LUQ. - 9/18/2025 at 4:48 PM on the abdomen LUQ. - 9/18/2025 at 9:10 PM on the abdomen LUQ. - 9/24/2025 at 4:56 PM on the abdomen LUQ.- 9/24/2025 at 9:58 PM on the abdomen LUQ The QAN and DON stated facility staff should have rotated insulin sites to prevent lipohypertrophy. During a concurrent interview and record review on 10/1/2025 at 9:19 AM with the QAN and DON, Resident 6's Care Plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) titled The resident is at risk for hyper (high)/hypoglycemic (low blood sugar) R/T (related to) Diabetes Mellitus, dated 6/24/2025 was reviewed. The Care Plan indicated an intervention (specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition) to rotate site for insulin injections. The QAN and DON stated the facility staff should have followed the doctor's orders and Resident 6's care plan. 2. During a review of Resident 44's admission Record, the admission Record indicated the facility admitted the resident on 2/26/2025 with diagnoses that included type 2 DM and other encephalopathy (any brain disorder or damage that is not from a single, easily defined cause, but instead from a variety of conditions like organ failure, infections, or trauma). During a review of Resident 44's H&P dated 2/28/2025, the H&P indicated Resident 44 was awake, alert and responsive to verbal commands (can understand and act on spoken instructions using simple, everyday language). The H&P indicated Resident 44 did not have the mental capacity (ability to understand and make decisions). During a review of Resident 44's MDS dated [DATE], the MDS indicated Resident 44 rarely had the ability to understand others and rarely had the ability to make himself (Resident 44) understood. During a review of Resident 44's Order Summary Report, dated 11/21/2025, the Order Summary Report indicated Resident 44 had an active physician's order dated and started on 7/29/2025 indicating the staff were to rotate injection sites for Insulin Glargine Subcutaneous Solution 100 unit/ml. The Order Summary Report indicated Resident 44 had an active physician's order dated and started on 6/19/2025 indicating staff were to rotate injection sites for Insulin Regular Injection Solution 100 unit/ml. During a concurrent interview and record review on 9/30/2025 at 3:08 PM with Licensed Vocational Nurse 3 (LVN 3) and QAN, Resident 44's Location of Administration Report for Insulin Regular Human (a man-made, short-acting insulin) injection Solution 100 unit/ml dated 9/1/2025 to 9/30/2025 was reviewed. The report indicated Insulin Regular Injection Solution 100 unit/ml was administered consecutively to Resident 44 on: - 9/11/2025 at 7:06 AM on the abdomen LUQ. - 9/11/2025 at 12:32 AM on the abdomen LUQ. LVN 3 stated insulin sites needed to be rotated to prevent hardening of the injection site. During a concurrent interview and record review on 9/30/2025 at 3:10 PM with the QAN and Registered Nurse 1 (RN 1), Resident 44's Location of Administration Report for Insulin Glargine Subcutaneous Solution 100 unit/ml dated 9/1/2025 to 9/30/2025 was reviewed. The report indicated Insulin Glargine was administered consecutively to Resident 44 on: - 9/8/2025 at 6:42 AM on the abdomen RUQ. - 9/9/2025 at 12:01 AM on the abdomen RUQ. - 9/9/2025 at 6:27 AM on the abdomen LUQ. - 9/9/2025 at 6:27 PM on the abdomen LUQ. - 9/22/2025 at 5:39 AM on the abdomen LUQ. - 9/22/2025 at 7:24 AM on the abdomen LUQ. The QAN stated facility staff had the ability to check Resident 44's electronic medical record (EMR) to see where the previous insulin injection was given. The QAN and RN 1 stated giving insulin at the same injection site could cause hardening of the injection site. During an interview on 9/30/2025 with the DON, the DON stated the facility's staff needed to rotate insulin injection sites to prevent hardening of the injection site. The DON stated staff had previously been educated (unknown date) about rotating insulin sites, 3. During a review of Resident 47's admission Record, the admission Record indicated the facility admitted the resident on 5/2/2025 with diagnoses that included type 2 DM. During a review of Resident 47's MDS dated [DATE], the MDS indicated the resident was cognitively intact (had the ability to think, understand, and reason). The MDS indicated Resident 47 was taking hypoglycemics (medication used to manage blood glucose levels in patients with type 2 diabetes). During a review of Resident 47's Blood Glucose Monitoring Record dated 7/1/2025 - 7/31/2025, the Blood Glucose Monitoring Record indicated the resident received consecutive doses of Lispro Insulin to the same site on: - 7/3/2025 at 4:30 PM and 9 PM on the abdomen LLQ. - 7/6/2025 at 4:30 PM and 9 PM on the abdomen right lower quadrant (RLQ - right lower section of the abdomen just below and to the right of your belly button). - 7/8/2025 at 11:30 AM and 4:30 PM on the left arm. - 7/19/2025 at 11:30 AM and 4:30 PM on the abdomen RLQ. - 7/22/2025 at 4:30 PM and 9 PM on the abdomen LUQ. - 7/23/2025 at 4:30 PM and 9 PM on the abdomen RLQ. - 7/24/2025 at 6:30 AM and 11:30 AM on the abdomen LUQ. - 7/24/2025 at 4:30 PM and 9 PM on the left arm. During a review of Resident 47's Order Summary Report, the Order Summary Report indicated the resident had a physician order dated 8/19/2025 that indicated the resident was to receive Lispro Insulin per sliding scale (a method of determining an insulin dose based solely on a person's current blood sugar level using a pre-established chart) subcutaneously before meals and at bedtime for DM. During a review of Resident 47's Blood Glucose Monitoring Record dated 8/1/2025 - 8/31/2025, the Blood Glucose Monitoring Record indicated the resident received consecutive doses of Lispro insulin in the same site on:- 8/19/2025 at 11:30 AM and 4:30 PM on the left arm. - 8/22/2025 at 4:30 PM and 9 PM on the abdomen RLQ. During a review of Resident 47's Blood Glucose Monitoring Record dated 9/1/2025 - 30/2025, the Blood Glucose Monitoring Record indicated the resident received consecutive doses of Lispro insulin in the same site on:- 9/6/2025 at 4:30 PM and 9 PM on the abdomen RLQ. - 9/13/2025 at 6:30 AM and 11:30 AM on the left arm. - 9/17/2025 at 6:30 Am and 11:30 AM on the left arm. - 9/26/2025 at 11:30 AM and 4:30 PM on the abdomen LLQ. During a review of Resident 47's Care Plan Report revised 9/30/2025, the Care Plan Report indicated the resident was at risk for hypoglycemia (low blood sugar levels)/hyperglycemia (high blood sugar levels) related to DM. The Care Plan Report indicated a goal for Resident 47 to have no signs and symptoms of hypoglycemia/hyperglycemia daily. The Care Plan Report indicated an intervention to rotate Resident 47's site for insulin injections. During a concurrent interview and record review on 10/1/2025 at 10:30 AM with the QAN, Resident 47's Blood Glucose Monitoring Records dated 7/1/2025 - 7/31/2025, 8/1/2025 - 8/31/2025, and 9/1/2025 - 9/30/2025 were reviewed. The QAN stated Resident 47 did not have their insulin injection sites rotated on 7/3/2025, 7/6/2025, 7/8/2025, 7/19/2025, 7/22/2025, 7/23/2025, 7/24/2025, 8/19/2025, 8/22/2025, 9/13/2025, 9/17/2025, and 9/26/2025. The QAN stated insulin sites had to be rotated when administering insulin. The QAN stated there was no documentation that indicated why Resident 47's Lispro insulin was given on the same site. The QAN stated there was a potential for Resident 47 to develop hardened skin or a skin infection if insulin injection sites were not rotated. During a concurrent interview and record review on 10/1/2025 at 11:00 AM with the DON, Resident 47's Blood Glucose Monitoring Records dated 7/1/2025 - 7/31/2025, 8/1/2025 - 8/31/2025, and 9/1/2025 - 9/30/2025 were reviewed. The DON confirmed Resident 47 did not have the insulin injection sites rotated on 7/3/2025, 7/6/2025, 7/8/2025, 7/19/2025, 7/22/2025, 7/23/2025, 7/24/2025, 8/19/2025, 8/22/2025, 9/13/2025, 9/17/2025, and 9/26/2025. The DON stated the nurses should have been rotating insulin injection sites to prevent hardening of the skin. During a review of the facility's Policy and Procedure (P&P) titled Insulin Administration dated 8/25/2025, the P&P indicated Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm).

Based on observation, interview, record review, and the facility policies and procedures (P&P) titled Controlled Medication Storage, last reviewed 8/28/2025, Controlled Medication Disposal, last reviewed 8/28/2025, the facility failed to:1. Reconcile (the process of comparing transactions and activity to supporting documentation) four (4) medication emergency kits (eKITs - kits containing medications needed to be used during emergencies) containing Controlled Substances (CM, Controlled Medications - medications which have a potential for abuse and may also lead to physical or psychological dependence) for September 2025, in one of one inspected medication storage rooms (Medication room [ROOM NUMBER].) 2. Includes the signatures of the Director of Nursing (DON) or a Registered Nurse (RN) with Licensed Vocational Nurse (LVN) on the Antibiotic or Controlled Drug Record accountability logs for seven of seven sampled records awaiting disposal (removal, destroying) in the CS locked cabinet. As a result, control and accountability of CMs, and medications awaiting final disposition (process of returning and/or destroying unused medications) did not follow state and federal regulations and facility policy and procedures. These deficient practices increased the opportunity for CM diversion (the transfer of a controlled medication or other medication from a lawful to an unlawful channel of distribution or use,) and increased the risk that residents in the facility could have accidental exposure to harmful medications possibly leading to physical and psychosocial harm, and hospitalization. Findings: During an observation and concurrent interview on 9/30/2025 at 11:08 a.m., with Registered Nurse (RN) 1, in Medication room [ROOM NUMBER], there were four (4) medication eKITs stored in the refrigerator and labeled 105, 126, 266 and 280, containing CMs without an accountability log for the reconciliation of CM inventory at every shift change for September 2025. RN 1 stated that all CMs, including medication eKITs containing CMs should be reconciled at every shift. RN 1 stated the four (4) eKITs labeled 105, 126, 266 and 280 and containing CMs in Medication room [ROOM NUMBER] were not reconciled at every shift in September 2025, and it was important to account for all CMs, and it was important to account for all CMs to ensure accountability and prevent CM diversion. During an observation, interview, and concurrent record review with the Director of Nursing (DON) in the DON's office, on 9/30/2025 at 1:11 p.m., seven inspected Antibiotic or Controlled Drug Record accountability logs awaiting final disposition in a locked cabinet did not contain verifying signatures of either the DON or an RN along with Licensed Vocational Nurse (LVN). The DON acknowledged and stated that the seven Antibiotic or Controlled Drug Record accountability logs awaiting final disposition in a locked cabinet, did not contain verifying signatures and was unable to locate the verifying signatures of RN /DON. The DON stated the DON and the LVNs failed to sign the accountability logs upon receipt of the CMs from the LVNs. The DON stated the DON counts the CMs with a LVN upon receipt of the accountability log, however, they overlooked to sign & date the seven logs. The DON stated the DON understood the importance of CM accountability to ensure each CM dose was accounted for until disposed throughout the process of CM accountability. The DON stated it was important to verify and sign these logs to prevent medication diversions and accidental exposure of harmful substances to residents. During an interview on 9/30/2025 at 2 p.m., with the DON, the DON stated medication eKITs containing CMs needed to be counted and reconciled at every shift change to ensure accountability and prevent CM diversion. The DON stated four (4) eKITs containing CMs in Medication room [ROOM NUMBER] were not reconciled at every shift in September 2025. A review of the facility policy and procedures (P&P) titled Controlled Medication Storage, last reviewed 8/28/2025, indicated, At each shift change, a physical inventory of all CMs, including the emergency supply is conducted by two licensed nurses and is documented on the CM accountability record. A review of the facility P&P titled Controlled Medications, last reviewed 8/28/2025, indicated, Medications included in the Drug Enforcement Administration classifications as CSs are subject to special handling, storage, disposal, and recordkeeping in the facility, in accordance with federal and state laws and regulations.A. The DON and the consultant pharmacist maintain the facility's compliance with federal and state laws and regulations in the handling of CMs. D. When a dose of a CM is .refused by the resident or not given for any reason.it must be destroyed according to facility policy in the presence of two licensed nurses and the disposal documented on the accountability record. The same process applies to the disposal of unused partial tablets and unused portions of single dose ampules. A review of the facility P&P titled Controlled Medication Disposal, last reviewed 8/28/2025, indicated, Medications included in the Drug Enforcement Administration classifications as CSs are subject to special handling, storage, disposal, and recordkeeping in the facility, in accordance with federal and state laws and regulations.A. The DON and the consultant pharmacist maintain the facility's compliance with federal and state laws and regulations in the handling of CMs. B. When a dose of a CM is .refused by the resident or not given for any reason.it must be destroyed according to facility policy in the presence of two licensed nurses and the disposal documented on the accountability record. The same process applies to the disposal of unused partial tablets .and doses of CS wasted for any reason.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when:a. A pack of hot dogs and three cartons of protein shake were found in the resident refrigerator with no receive dates. b. Dietary Aid 1 (DA1) was observed wearing multiple pieces of jewelry (necklace, rings and bracelets) and watches. These deficient practices have the potential to promote foodborne illness and cross- contamination due to improper food handling, storage and hygiene practices. Findings: a. During an observation on 9/29/2025 at 10:30am in the resident refrigerator located in Nurses Station, one carton of nutritional supplement was observed with no label, name, or date. And a frozen pack of hot dogs in a cellophane bag with no received date was found. During an interview on 9/29/2025 at 10:35 a.m. with the Dietary Supervisor (DS), DS stated that she checked the Resident's refrigerator and that she overlooked and forgot to open the freezer area, DS stated that it is the Nursing staff who receives the food and they are expected to put room number and date received of the food, DS further added that there is no date received in the foods so we don't know when to toss the food. DS stated it is the kitchen staff who checks the Residents refrigerator and food store should not be kept for more than 24 hours. DS stated she doesn't know who put the food in the resident's refrigerator.A review of the facilities Policies & Procedures titled Food Receiving and Storage dated November 2022, under the section Foods and Snacks Kept on nursing Units it indicates All foods belonging to residents are labeled with the resident's name, the item, and the use by date. b. During an observation on 9/29/2025 at 10:45am, one of four kitchen staff members (DA 2) was observed wearing multiple items of jewelry. The Dietary Aide 2 (DA2) was observed to be wearing earrings, bracelet, and a necklace during food preparation in the kitchen. DA two was seen handling juices that will be placed on the lunch tray. During an interview on 9/30/2025 at 2:25 p.m. with the DS, the DS stated that she's been reminding staff that the only jewelry allowed in the kitchen is a wedding ring. DS stated it is high risk for DA to drop the small jewelry and can be dropped at any food they prepare in the kitchen that's why jewelry is not allowed to be worn when working in the kitchen. DS stated that some of the kitchen staff still wear jewelry despite reminding them.A review of the facilities Policies & Procedures titled Dress-Code and Personal Hygiene dated 11/2022 indicates jewelry should be limited to watches and wedding rings. A review of the facilities Policies & Procedures titled Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices dated November 2022 under the section Fingernails/Jewelry it indicates jewelry will be kept to a minimum. Hand jewelry (e.g. rings) and wrist jewelry are kept covered with gloves during food handling.

Based on observation, interview, and record review, the facility failed to ensure two of six sampled residents (Resident 48 and Resident 77), who required assistance from staff with activities of daily living (ADLs - essential and routine activities include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet) were free from neglect (failure of the facility, its employees or service providers to provide services to a resident that were necessary to avoid pain, mental anguish or emotional distress). The facility failed to: -Provide Resident 77, who required substantial / maximal assistance (helper does more than half the effort, helper lifts or holds trunk or limbs) with personal hygiene. Resident 77 was observed lying in bed calling out for help for over 45 minutes, stating, Can somebody change my diaper (incontinence brief)? -Provide Resident 48, who required substantial / maximal assistance, with eye care. Resident 48 was observed with a dry flaky substance around the right eye, which remained from the night prior. These deficient practices resulted in Resident 77 remaining in her soiled incontinence brief with urine and feces for 45 minutes without being helped. Resident 77 stated she felt dirty, unimportant, and frustrated. Resident 48 had the potential to develop an eye infection. Cross Reference F725 Findings: a. A review of Resident 77's Admission Record indicated the facility admitted the resident on 8/13/2024 with diagnoses including chronic osteomyelitis (a bone infection that lasts longer than 30 days, usually with pain) of the left ankle and foot, Type II diabetes (a disease that results in high levels of sugar in the blood), cirrhosis of the liver (a condition that occurs when healthy liver tissue is replaced by scar tissue), abnormalities of gait and mobility, need for assistance with personal care, congestive heart failure (a serious condition that occurs when the heart can't pump enough blood to meet the body's needs). A review of Resident 77's care plan initiated on 8/14/2024, indicated the resident had an Activities of Daily Living (ADLs) self-care performance deficit related to impaired balance, limited mobility, limited range of motion (ROM), and pain. The care plan indicated a goal for Resident 77 was to improve their current level of function in bed mobility, transfers, eating, dressing, toilet use, personal hygiene, and ADL score. The interventions indicated Resident 77 required staff participation to use the toilet, required assistance with washing their hands, adjusting clothing, cleaning themselves, transferring onto the toilet, transferring off the toilet, and using the toilet. The care plan further indicated Resident 77 required total assistance with transfers. A review of Resident 77's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 8/19/2024, indicated the resident had moderately impaired cognition (ability to remember understand and make decisions), required set up or clean up assistance with eating, and required supervision or touching assistance with oral hygiene. The MDS indicated Resident 77 required substantial / maximal assistance with personal hygiene and was always incontinent (unable to control) of urine and bowel. During an observation on 10/28/2024 at 11 AM. Resident 77 was observed lying in bed calling out for help stating, Can somebody change my diaper? During an observation on 10/28/2024 at 11:20 AM, a Certified Nursing Assistant (CNA) was observed passing by Resident 77's room. Resident 77 was observed again calling out for help stating, Can you change my diaper? The CNA was observed stating to resident, Give me one moment. During an observation on 10/28/2024 at 11:25 AM, Licensed Vocational Nurse (LVN) 3 was observed standing across from Resident 77's room. Resident 77 was observed calling out for help stating, Can you change my diaper? LVN 3 did not respond to Resident 77. During a concurrent observation and interview on 10/28/2024 at 11:35 AM, in Resident 77's room, Resident 77 stated she needed to have her incontinence brief changed. Resident 77 stated she had gone both number 1 (urine) and number 2 (feces) and had been sitting in her soiled incontinence brief for 45 minutes. Resident 77 stated she had been asking nurses for help, but no one had come in to help her. Resident 77 stated no one comes to check on her and it made her feel unimportant. Everyone keeps telling me they're coming but don't come. Resident 77 stated she felt frustrated and uncomfortable because she felt dirty. Resident 77 stated, It shouldn't be that hard. During an interview on 10/28/2024 at 11:39 AM, LVN 3 stated the CNA assigned to Resident 77 was at lunch and was not available to help Resident 77. LVN 3 stated they would try to find someone to help Resident 77 clean up. LVN 3 was observed trying to locate staff to assist Resident 77. During an interview on 10/28/2024 at 11:50 AM, CNA 5 stated they were assigned to take care of Resident 77 and that when they were at lunch or on break, there was another CNA that would cover for them and help their residents if needed. CNA 5 stated they did not know who was covering for them during lunch. CNA 5 was then observed assisting Resident 77 clean up. During an interview on 11/1/2024 at 12:05 PM, the Director of Staff Development (DSD) stated when a resident was calling out for help staff should not ignore the resident. The DSD stated when someone was on break, whoever was not scheduled for break should be responsible in answering the resident's needs. The DSD stated if a resident sat in a soiled incontinent brief for a long period of time, 30 minutes or more, there was a potential for skin breakdown. The DSD stated it was uncomfortable for the resident to sit in a soiled incontinent brief. b. A review of Resident 48's Admission Record indicated the facility readmitted the resident on 6/11/2024 with diagnoses including hemiplegia (severe or complete loss / paralysis of one side of the body) and hemiparesis (slight muscle weakness or partial paralysis of one side of the body), glaucoma (a group of eye conditions that cause blindness), need for assistance with personal care, and contracture (permanent or temporary tightening of muscles, tendons, skin, and nearby tissues that limits the normal movement of a joint or body part) of the muscle of the right hand. A review of Resident 48's MDS dated [DATE], indicated the resident was cognitively intact (ability to think, remember, express thoughts and make decisions), required substantial / maximal assistance with eating and was dependent on help for personal hygiene. A review of Resident 48's care plan initiated 10/28/2024, indicated the resident was at risk for injury related to impaired visual function. The care plan indicated Resident 48 followed / tracked moving objects and had a diagnosis of glaucoma. The care plan indicated a goal for Resident 48 was to show no eye redness, scratching, or tearing. The care plan interventions included to clean Resident 48's eyes every day during morning care. During an observation on 10/28/2024 at 9:45 AM, Resident 48 was observed lying in bed with the right eye closed and the left eye open. Resident 48 was observed with dry flaky fluid around the right eye. During a concurrent interview, Resident 48 stated, Can you ask someone to clean my eye. Resident 48 stated there was too much water in his right eye and some of it was dry in the eye. Resident 48 stated his eye had been like that overnight and had not been cleaned since last night. Resident 48 stated it bothered him. During a concurrent observation and interview on 10/28/2024 at 9:56 AM, Resident 48's right eye was observed with the Certified Nursing Assistant (CNA). CNA 7 stated Resident 48 was blind and could not see. CNA 7 stated Resident 48 was total care and needed assistance with cleaning. CNA 7 stated Resident 48's right eye was closed and had dried stuff around it. CNA 7 stated Resident 48's right eye needed to be cleaned so they could open their eyes. During an interview on 11/1/2024 at 1:52 PM, the Director of Nursing (DON) stated Resident 48 was dependent on others for ADLs and was visually impaired. The DON stated it was the expectation of the staff to assist Resident 48 in cleaning their eyes and ensuring their needs were being met. The DON stated there was a potential for Resident 48 to develop an eye infection if the resident was not assisted in having their eyes cleaned. A review of the facility's policy and procedure titled, Activities of Daily Living (ADLs), Supporting, reviewed 8/30/2024, indicated residents would be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who were unable to carry out activities of daily living independently would receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Appropriate care and services would be provided for residents who were unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care); mobility (transfer and ambulation, including walking); elimination (toileting); dining (meals and snacks); and communication (speech, language, and any functional communication systems). A review of the facility's policy and procedure titled, Abuse and Neglect - Clinical Protocol, dated 3/2018, indicated along with staff and management, the physician would help identify situations that might constitute or could be construed as neglect; for example recurrent failure to provide incontinence care. The policy indicated the facility management and staff would institute measures to address the needs of residents and minimize the possibility of neglect. The physician would advise the facility and help review and address neglect issues as part of the quality assurance process.

Based on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident 39), who had a diagnosis of major depressive disorder (a common and serious medical illness, with severe low mood, sadness and despair) was provided necessary behavioral health care. The facility failed to: -Monitor Resident 39 for signs and symptoms of sad feelings and depression, per the Mood Problem with Crying Episodes Care Plan initiated 9/9/22. -Provide Resident 39 with a psychiatrist (a medical practitioner specializing in the diagnosis and treatment of mental illness) or psychologist (a professional who practices and studies mental states, perceptual, emotional, and social processes and behavior, involves the experimentation, observation, and interpretation of how individuals relate to each other and to their environments) to evaluate and assess the resident's mood. -Evaluate the effectiveness of the care plan for Resident 39's depressive symptoms. As a result, on 10/28/24, Resident 39 expressed feelings of frustration since the last comprehensive assessments on 12/1/23 and 2/29/24 and began to cry with tears streaming down his face. Findings: A review of Residents 39's admission record indicated the resident was admitted to the facility on [DATE], with diagnoses including nontraumatic intracerebral hemorrhage (a type of stroke that occurs when a pool of clotted blood forms in the brain tissue), major depressive disorder (a common and serious medical illness, severe low mood, sadness and despair), hemiplegia (loss of the ability to move one side of the body), hemiparesis (weakness on one side of the body), abnormalities in gait and mobility. A review of Resident 39's Mood Problem Care Plan initiated 3/10/21, manifested by feeling down, trouble sleeping, and feeling bad, indicated the interventions were to encourage Resident 39 to verbalize feelings and offer understanding. The Mood Problem Care Plan did not indicate an intervention to monitor the resident for adverse signs and symptoms. In addition, upon request from facility staff, the care plan was not updated, reviewed or revised quarterly, as there were no current dates to reflect the review. A review of Resident 39's Mood Problem with Crying Episodes Care Plan initiated 9/9/22, with psychologist visits every three weeks indicated the interventions were to monitor / record / report to physician as needed acute episodes of sad feelings, sign and symptoms of depression, and monitor for feelings of worthlessness or guilt. A review of Resident 39's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 12/1/2023, indicated the resident presented with feeling down, depressed, or hopeless for 2-6 days. Resident 39's functional abilities and goals indicated the resident used a wheelchair, was dependent on staff assistance for oral hygiene and toileting hygiene. The MDS indicated Resident 39 did not attempt or perform the ability to walk. A review of Resident 39's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 2/29/24, indicated the resident presented with feeling down, depressed, or hopeless for 2-6 days. Resident 39's functional abilities and goals indicated the resident used a wheelchair, was dependent on staff assistance for oral hygiene and toileting hygiene. The MDS indicated Resident 39 did not attempt or perform the ability to walk. According to a review of Resident 39's CSC - PHQ 2 to 9 Evaluation (a self-report patient health questionnaire, social services trauma assessment, tool used to gauge the resident's level of depression) dated 10/21/24, the resident felt down, depressed, or hopeless 12-14 days (nearly every day). During an interview on 10/28/24 at 11:05 AM, the Social Services Director (SSD) stated in her opinion the PHQ questions did not reflect how depressed Resident 39 may be. For example, the SSD stated, she performed an interview with Resident 39 using the CSC -PHQ assessment, the questions asked did not reflect how depressed the resident really appeared. During a concurrent observation and interview on 10/28/24 at 11:15 AM, Resident 39 was in his room, lying in the bed, and the call light was noted within reach. Resident 39 stated he did not like the care he received, and that the facility was not doing enough to provide the assistance he needed to get better. Resident 39 stated he did not know what was needed to get better and started to cry. Resident 39 was observed laying on his right side and began an expressionless cry with tears coming down his face. During an interview on 10/30/24 at 12:49 PM, Certified Nurse Assistant (CNA) 3 stated Resident 39 expressed feeling down and sad to the nursing staff in the past. CNA 3 stated she had observed Resident 39 cry about feeling down in the past and that the nurses were aware. CNA 3 stated when the resident expressed those feelings, CNA 3 tried to get Resident 39 to smile and focus on something happy. A review of Resident 39's clinical record indicated there was no monitoring / recording / reporting to the physician as needed of acute episodes of sad feelings, sign and symptoms of depression, or monitor for feelings of worthlessness or guilt, per Resident 39's care plan. A review of Resident 39's October Medication Administration Record (MAR) with Licensed Vocational Nurse (LVN) 1 indicated the resident was not being monitored for mood problem behavior or episodes sadness, hopelessness, or depression. During an observation on 10/30/24 at 1:02 PM, LVN 1 entered the nurse's computer system to review Resident 39's monitoring which remained blank. During a concurrent interview, LVN 1 stated Resident 39 was not being monitored for a mood problem. LVN 1 stated, The resident did not appear down or depressed and did not have diagnoses of psychosis (a mental disorder, collection of symptoms that affect the mind, where there has been some loss of contact with reality), aggressive behavior, or did not verbalize wanting to harm himself or others. During concurrent interview and record review on 10/30/24 at 1:22 PM, with the Social Services Director (SSD), Resident 39's PHQ / trauma assessment by Social Services dated 10/21/24, was reviewed. The SSD stated the evaluation was performed 72 hours after admission, but if the resident had been at the facility for a while, then trauma assessments were done quarterly (Resident 39's last PHQ trauma assessment was dated 5/2024). The SSD confirmed that Resident 39 was not being monitored for signs and symptoms of depression, nor had a visit from a psychiatrist or psychologist. During a concurrent interview and record review on 11/1/24 at 1:31 PM with the Director of Nursing (DON), Resident 39's CSC - PHQ Evaluation dated 10/21/24 was reviewed. The DON stated the process to monitor a resident with behavioral issues begins with a psychologist or psychiatrist on staff who would place an order to monitor the resident. The DON stated a change of condition would be done to monitor the resident per the doctor's orders and psych evaluation. The DON stated the impact to the residents who were not monitored resulted in the resident's behavioral situation as unmanaged. The DON stated the CSC - PHQ Evaluation occurred during the time when the new social services director was hired and the old director was leaving. The DON stated Resident 39 was not receiving medication for his depression diagnosis therefore he would not be monitored. The DON stated the facility is obligated to provide the needed care. A review of the facility's policy and procedure titled, Behavioral Assessment, Intervention and Monitoring, dated 8/30/24, indicated the facility would provide behavioral health services to maintain the highest practicable physical, mental, and psychosocial well-being. The policy indicated nursing staff would identify, document, and inform the physician about specific changes in the resident's mental status, behavior, and cognition. The policy indicated new onset or changes in behavior would be documented.

Based on observation, interview, and record review, the facility failed to ensure staff turned and repositioned one of four sampled residents (Resident 1), every 2 hours (Q 2hrs) and as needed (PRN) to prevent pressure sores (also known as pressure ulcer, pressure injury, or bed sore - is an injury to the skin that develops over bony areas of the body from prolonged pressure to the area) according to physician's order and facility's policy and procedures. Resident 1 was identified as at high risk for regression of pressure sores/injuries and was at high risk to develop new pressure sores. These failures resulted in Resident 1 developed five (5) new facility acquired (not present on arrival to the facility) pressure sores to the left ear, right ear, right 5th metatarsal head, right 1st metatarsal head (joint where the long bone of the foot connects to the great toe bone), right great medial toe (surface area of the toe on the inside of the body) and left lateral malleolus (the bony protuberance on either side of the ankle). Findings: A review of Resident 1's Admission Record, dated 4/12/24, indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including traumatic subarachnoid hemorrhage (brain bleed caused by trauma) with loss of consciousness, metabolic encephalopathy, seizures, hypertension (HTN - high blood pressure), muscle weakness, abnormalities of mobility, and pressure-induced deep tissue damage (bed sore) of sacral (portion of spine between lower back and tail bone) region. A review of Resident 1's Admission Summary dated 8/31/23 at 9:21 pm, indicated the facility admitted Resident on 8/31/23with diagnoses including, traumatic brain injury and HTN. Resident 1, needs assist with all ADLs (activities of daily living - bed mobility, transfer dressing, eating, toilet use and personal hygiene). Admission summary indicated Resident 1's skin was dry and warm to touch but did not indicate Resident 1 had any skin integrity concerns/pressure sores. A review of Resident 1's Braden scale (tool for predicting pressure sore risk), dated 9/1/23, indicated Resident 1 was at high risk for pressure sores. A review of Resident 1's Skin/Wound Note dated 9/1/23 at 1 pm, indicated Resident 1 had Sacrococcyx injury measuring 6 x 6.4 x UTD (Unable to determine), 100% deep maroon. MD (medical doctor) made aware with order noted and carried out (order not specified). A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/7/23, indicated, Resident 1 had severe cognitive (function of the mind, related to thinking memory, problem-solving, decision making, judgement) impairment and was totally dependent on staff for all ADLs. The MDS indicated Resident 1 to apply pressure reducing device on bed and receive pressure ulcer/injury care for Resident 1. However, the MDS did not have a check mark to turn and reposition Resident 1 A review of Resident 1's care plan on Sacrococcyx (pertaining to both the sacrum and coccyx [the tailbone]), area initiated 9/1/23, indicated Resident 1 was admitted to the facility with Deep Tissue Injury (DTI - purple or maroon localized area of discolored intact skin or blood?filled blister due to damage of underlying soft tissue from pressure and/or shear) pressure injury at risk for unavoidable pressure ulcer or potential for pressure ulcer development related to (r/t) disease process, immobility. The Care plan interventions included: ., 1. Educate the resident/family/caregivers as to the causes of skin breakdown; including: transfer/ positioning requirements; importance of taking care during mobility, good nutrition, and frequent repositioning 2. Follow facility policies / protocols for the prevention/treatment of skin breakdown . 3. Obtain and monitor laboratory/diagnostic work as ordered. Report results to MD and follow up as indicated . 4. Low Air Loss Therapy Mattress to bed for wound management . 5. To turn/reposition Resident 1, at least every 2 hours, more often as needed or requested . A review of Resident 1's Health Status Note, did not indicate if Resident 1 was turned and repositioned Q2Hrs (every two hours) on the following dates: 9/4/23 and 9/5/23, 9/7/23, 9/11/23 and 9/12/23, 9/15/23 and 9/16/23, 9/17/23 and 9/18/23 - No nursing notes, 9/24/23, and, 9/25/23 to 9/30/23 - No nursing notes. A review of Resident 1's Multidisciplinary Care Conference (MCC - a term used to describe a treatment planning approach or team that includes a number of doctors and other health care professionals who are experts in different specialties) note, dated 9/5/23 at 3:59 pm, indicated Resident 1 was new to the facility. MCC note indicated, alteration in skin integrity, high risk factors for developing pressure sores/interventions and prevention/education to responsible party and resident. MCC note indicated Resident 1 to use pressure relieving mattress and, turn and reposition Q2hrs. A review of Resident 1's Health Status Note, did not indicate if Resident 1 was turned and repositioned Q2Hrs on 10/15/23 by 3:57 pm. A review of Resident 1's Skin/Wound Note, dated 10/22/23 at 4:39 pm, indicated Resident 1 was turned and repositioned Q2Hrs and PRN. A review of Resident 1's Health Status Note, did not indicate if Resident 1 was turned and repositioned Q2Hrs on 11/29/24 from 11 pm to 7 am. A review of Resident 1's Skin/Wound Note dated 12/1/23 at 1:53 pm, indicated Resident 1 had a follow up visit by a wound doctor. Resident 1 had Sacral Stage 4 pressure sore measuring 2.3 x 2.1 x 1.2 cm (centimeter- unit of measurement) with undermining (occurs when significant erosion occurs underneath the outwardly visible wound margins resulting in more extensive damage beneath the skin surface) of 12 o'clock=2.5 cm with moderate serous (a clear to yellow fluid that leaks out of a wound) drainage. The sacral stage 4 sore had 20% eschar (a hardened, dry, black, or brown dead tissue) tissue, 30% slough (refers to the yellow/white material in the wound bed), and 50% granulation (new tissue). Sharp debridement (a method for the removal of loosely adherent necrotic tissue using sterile instruments such as scalpel and scissors) done by the wound doctor. Tx (Treatment) with Santyl (Collagenase - is a topical medication used for removing damaged or burned skin to allow for wound healing and growth of healthy skin) and foam dressing (wound care material used to provide a moist wound environment, most commonly in wounds with moderate-to-heavy exudate [drainage]) . The Skin/Wound Note, indicated, Resident 1 remained high risk for further wound regression/breakdown due to comorbidities (the simultaneous presence of two or more diseases or medical conditions in a patient), and impaired mobility. CNA (unidentified) was reminded the importance of turning and repositioning Resident 1 Q2Hrs and PRN (as needed) and offload Resident 1's heels. The Skin/Wound Note did not indicate Resident 1 had other pressure sores. A review of Resident 1's Health Status Note, did not indicate if Resident 1 was turned and repositioned Q2Hrs on for the following dates: 12/1/23, 12/5/23, and, 12/12/23 to 12/23/23. A review of Resident 1's Order Summary Report dated 12/1/23 to 1/31/24, indicated, Low Air loss Mattress in Bed for skin integrity, was discontinued on 1/2/24 and on 1/17/24. A review of Resident 1's ADL Documentation Survey Report' for 12/23 indicated Resident 1 was not rolled from left to right on the following dates and time: 12/1/23 - 7 am to 3 pm, and 11 pm to 7 am, 12/3/24 - 7 am to 3 pm, and 11 pm to 7 am, 12/4/24 - 7 am to 3 pm, 12/5/24 - 7 am to 3 pm, 12/7/24 - 7 am to 3 pm, and 3 pm to 11 pm, 12/9/24 - 11 pm to 7 am, 12/13/24 - 7 am to 3 pm, 12/17/24 - 11 pm to 7 am, 12/18/24 - 3 pm to 11 pm, and 3 pm to 11 pm, 12/19/24 - 3 pm to 11 pm, 12/21/24 - 11 pm to 7 am, 12/24/24 - 3 pm to 11 pm, and 12/25/24 - 3 pm to 11 pm. A review of Resident 1's MCC, dated 12/5/23, indicated any alteration in skin integrity, high risk factors for developing pressure sores/interventions and prevention/education to responsible party and resident. MCC indicated, Resident 1 with sacrococcyx stage 4, sharp debridement done at bedside by wound MD . Resident 1 will continue with plan of care. A review of Resident 1's IDT Note, dated 12/7/23, indicated the IDT discussed on the phone about Sacral Stage 4 and wound debridement for Resident 1, with Resident 1's family member and Resident 1's Responsible Party. A review of Resident 1's Skin/Wound Note dated 12/10/23, indicated, one pressure injury of: sacral stage four (pressure injury classification [four stages], full thickness tissue [involving all layers of the skin into the subcutaneous [fat] tissue or beyond into muscle, bone, tendons, etc] loss with exposed bone, tendon, or muscle), and Wound progress: improved evidenced by decrease surface area . Resident will remain high risk for further wound regression/breakdown due to comorbidities, and impaired mobility. Reminded the Certified Nursing Assistant (CNA) importance of repositioning Q (every) two hours and as needed. A review of Resident 1's Skin/Wound Note, dated 12/12/23 at 10:32 am, indicated Resident 1 observed with left earlobe wound. MD notified, and new order received and carried out (order not specified). A review of Resident 1's Skin/Wound Note, dated 12/15/23 at 6:11 pm, indicated follow up visit by wound MD. Resident 1 noted with right ear/right lateral face area measuring 1.5 x 0.4 x UTD and Tx with bacitracin (medication to treat infection). Skin/Wound Note indicated Resident 1 remains high risk for further wound regression/breakdown due to comorbidities and impaired mobility. CNA (unidentified) reminded the importance of turning and repositioning Q2Hrs and PRN, and off load heels. A review of Resident 1's Skin/Wound Note, dated 12/15/23 at 6:11 pm, indicated Resident 1 had a follow up visit by a wound doctor. Resident 1 had sacral stage 4 pressure sore measuring 4.2 x 4.0 x 1.0 cm (centimeter- unit of measurement) with undermining of 12 o'clock=3.5 cm with moderate serous drainage. The sacral stage 4 sore had 15% necrotic tissue, 20% slough and 65% granulation. Sharp debridement done by the wound doctor. Tx with Santyl and foam dressing . The Skin/Wound Note, indicated, Resident 1 remained high risk for further wound regression/breakdown due to comorbidities and impaired mobility. CNA (unidentified) was reminded the importance of turning and repositioning Resident 1 Q2Hrs and PRN (as needed) and offload Resident 1's heels. A review of Resident 1's Skin/Wound Note dated 1/1/24 at 10 am, indicated, body assessment was initiated on Resident 1. Skin/Wound Note indicated Resident 1 with three new facility acquired wounds namely, right 5th metatarsal (long bone of the foot that connects to the small toe) head (area where the metatarsal connects to the toe bone) pressure injury stage 1 (pressure injury classification, area of redness that is non-blanchable [the area stays red when pressed indicating tissue damage]), right lateral (side that is away for the middle of the body) leg pressure injury stage 1, and right lateral malleolus (knobby bones on the outside and inside of ankle area) pressure injury stage 1. A review of Resident 1's Skin/Wound Note dated 1/2/24 at 12:30 pm, indicated Resident 1 with stage 4 pressure injury and MD notified with an order to discontinue (d/c -stop) pressure reduction mattress and change to LALM for wound management, and that MD's order noted and carried. A review of Resident 1's Health Status Note, did not indicate if Resident 1 was turned and repositioned Q2Hrs on the following dates: 1/1/24, 1/7/24 - 11 pm to 7 am, 1/9/24 and 1/10/24, 1/11/24 on 7 am to 3 pm, 1/12/24 - No nursing notes, 1/13/24 at 8:27 am, Resident 1 had shortness of breath, 1/17/24 at 2:50 pm, Resident 1 was readmitted from GACH, and, 1/18/24 to 1/23/24. A review of Resident 1's ADL Documentation Survey Report' for 1/24 indicated Resident 1 was not rolled from left to right on the following dates and time: 1/2/24 -11 pm to 7 am 1/2/24 - 3 pm to 11 pm 1/7/24 - 7 am to 3 pm 1/10/24 - 7 am to 3 pm, and 11 pm to 7 am. 1/17/24 - 7 am to 3 pm 1/20/24 - 11 pm to 7 am 1/23/24 - 11 pm to 7 am 1/24/24 - 7 am to 3 pm, and 11 pm to 7 am 1/25/24 - 11 pm to 7 am A review of Resident 1's Skin/Wound Note, dated 1/5/24 at 4:44 pm, indicated Resident 1 was seen and assessed by a wound MD for weekly wound assessment follow up on 1/5/24. Skin/Wound Note indicated the following for Resident 1: 1. Sacro Coccyx Stage 4 Pressure Injury measured 3 x 2.4 x 0.9 cm 2. Right, lateral face full thickness measuring wound 3 x 1.5 x 0.1 with light drainage. Tissue type 90% granulation and 10% cartilage (a tough, flexible tissue that lines joints and gives structure to the nose, ears, and other parts of the body). Tx with bacitracin. 3. Left face full thickness wound measuring 0.9 x 0.7 x 0.1. Tissue type 50% granulation and 50% dermis (skin). 4. Right heel unstageable due to necrosis of the right, lateral, fifth foot full thickness measuring 2.2 x 2 x UTD. No drainage. Tissue type 100% black eschar. Wound progress (first observation) and Tx with betadine (medication used on the skin to treat or prevent skin infection in minor cuts, scrapes, or burns) and rolled gauze (wound care material). The same Resident 1's Skin/Wound Note, indicated Resident 1 remains high risk for further wound regression breakdown due to comorbidities, and impaired mobility. CNA (unidentified) was reminded the importance of turning and repositioning Resident 1 Q2 hrs and PRN, and offload heels. A review of Resident 1's Health Status Note, did not indicate if Resident 1 was turned and repositioned Q2Hrs on the following dates: 2/9/24 and 2/10/24, 2/11/24 - No nursing notes, 2/12/24, 2/13/24 to 2/22/24 - No nursing notes, 2/23/24, and, 2/24/24 to 2/29/24 - No nursing notes. A review of Resident 1's Health Status Note, did not indicate if Resident 1 was turned and repositioned Q2Hrs on the following: 3/1/24 to 3/11/24 - No nursing notes, 3/12/24, 3/13/24 and 3/14/24 - No nursing notes, 3/21/24 Resident 1 transferred to GACH, 3/28/23 at 8 pm, Resident 1 was readmitted from GACH, and, 3/29/24 to 3/31/24. A review of Resident 1's MCC dated 3/4/24, indicated alteration in skin integrity, high risk factors for developing pressure sores/interventions and prevention/education to responsible party and resident. MCC indicated, Resident 1 with left ear stage 4, right ear stage 4, left elbow UTS (unable to stage), sacrococcyx stage 4, right lateral malleolus UTS, right 5th metatarsal had UTS, right lateral midfoot UTS, right 1st metatarsal head UTS, right 1st toe UTS. Tx included med honey, and Santyl. Resident 1 will continue with plan of care. A review of Resident 1's Health Status Note, did not indicate if Resident 1 was turned and repositioned Q2Hrs on the following dates: 4/1/24 to 4/3/24, and, 4/5/24 at 10:16 am, Resident 1 was readmitted from GACH. During a telephone interview on 4/9/24 at 1:39 pm with Resident 1's Responsible Party (RP), the RP stated when Resident 1 was admitted to the facility, Resident 1 had one pressure sore now has many more pressure sores. The RP further stated, They (CNAs) are not turning [Resident 1] as they should every two hours. They just leave [Resident 1] and don't change [Resident 1] unless they are asked to do it. There should be more oversite on the CNAs. During a concurrent interview with Treatment Nurse 1 (TXN 1) and Resident 1's wound treatment observation in Resident 1's room by TXN 1, on 4/10/2024 from 9:52 am to 10:54 am, the following were observed: 1. Right ear pink colored wound measuring 0.5 x 0.5 with epithelial tissue. 2. Left ear dime size red beefy colored wound with granulation tissue. 3. Left elbow quarter size wound with less than dime size pink colored epithelial tissue. The same elbow wound bed with yellow tissue. 4. Sacral red beefy colored wound bed surrounded by pink colored epithelial tissue. TNX 1 stated the sacral wound used to have yellow slough. 5. Left trochanter with dark discoloration of old scar tissue. 6. Left foot lateral wounds healed with dark discoloration on lateral (side) aspect. 7. Left lateral malleolus with nickel/dime size eschar tissue surrounded by ink epithelial tissue. 8. Right lateral 5th metatarsal head healed. During a concurrent interview and records review on 4/12/24 at 10:25 am with Medical Doctor 1 (MD 1), Resident 1's Surgical Consult, dated 4/5/24 was reviewed. The Surgical Consult record indicated, pressure injury left ear, pressure injury left trochanter (joint that connected the thigh phone to the hip bone), pressure injury left elbow, pressure injury sacrococcyx pressure injury right ear, pressure injury right 5th metatarsal head, pressure injury right 1st metatarsal head (joint where the long bone of the foot connects to the great toe bone), right great medial toe (surface area of the toe on the inside of the body), pressure injury left lateral malleolus. MD 1 stated Resident 1 has a total of nine wounds. MD 1 further stated the facility has a variety of CNAs that may not be as diligent with their work or training. MD 1 stated some CNAs have an attitude and some CNAs are nowhere to be found, when MD 1 was asked the reason why Resident 1 pressure sores developed in 12/2023. During a concurrent interview and record review with Director of Nursing (DON) on 4/16/24 at 3:45 pm, Resident 1's MDS, dated [DATE], was reviewed. The MDS indicated on admission to the facility, Resident 1 had one pressure sore. The DON verified and stated Resident 1 was admitted to the facility with one pressure sore. The DON further stated, DON and was unaware that Resident 1's pressure sores/injuries; specifically, to Resident 1's bilateral (both) ears documented on 12/12/23 and 12/24/23, respectively, and to the right 5th metatarsal head, right lateral malleolus and right leg documented on 1/1/24. DON stated the pressures sores to Resident 1's bilateral ears, right 5th metatarsal head, right lateral malleolus, and right leg, were acquired in the facility. During a concurrent interview and record review with DON on 4/16/24 at 3:45 pm, the facility's policy, and procedures (P&P) titled, Repositioning, revised 5/2013, was reviewed. The P&P indicated, The purpose of this procedure is to provide guidelines of the evaluation of the resident repositioning needs . and to prevent skin breakdown, and promote circulation and provide pressure relief for residents . The following information should be recorded in the resident's medical record: 1. The position in which the resident was placed. This may be on a flow sheet. 2. The name and title of the individual who gave the care . 7. The signature and title of the person recording the data. During the same interview, DON stated, with the Point Click Care (PCC, application used by facility to document in the resident's medical record). There is no way to chart that (resident's turning and repositioning). They (staff) only chart once at the end of the shift. A review of the facility's policy and procedures (P&P), titled, Repositioning, revised 5/2013, the P&P indicated, Interventions included: . 1. A turning/repositioning program includes a continuous consistent program for changing the resident's position and realigning the body. A program is defined as a specific approach that is organized, planned, documented, monitored, and evaluated. 2. Frequency of repositioning a bed- or chair-bound resident should be determined by: a. The type of support surface used. b. The condition of the skin; c. The overall condition of the resident. d. The response to the current repositioning schedule; and e. Overall treatment objectives. 3. Resident who are in bed should be on at least an every two hour (q2Hr) repositioning schedule. 4. For resident with a Stage 1 or above pressure ulcer, an every two hour repositioning schedule is inadequate. A review of the facility's P&P, titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, revised 2/2024, the P&P indicated, Cause Identification 1. The physician will help identify factors contributing or predisposing residents to skin breakdown. 2. The physician will clarify the status of relevant medical issues. Treatment/Management 1. The physician will order pertinent wound treatments. a. The physician will help identify medical interventions related to wound management. The physician may help staff characterize the likelihood of wound healing. Healing or prevision Likely: The residents underlying physical condition, prognosis, personal goals, and wishes, care instructions, and ability to cooperate with the treatment plan make wound healing and subsequent wound prevention realistic.

Based on observation, interview and record review, the facility failed to ensure a resident, who was at risk to leave the facility and had expressed to multiple staff that he wanted to leave, did not elope (Resident leaves the premises or a safe area without the facility's knowledge and supervision) from the facility for one of four sampled residents (Resident 1). The facility failed to: 1. Assess Resident 1's risk for elopement upon admission. 2. Implement their care plan interventions to check resident's whereabouts. 3. Communicate with the facility staff the planned intervention of every 30 minutes monitoring for Resident 1 who is at risk to leave the facility. 4. Identify Resident 1's risk for elopement behavior of repeatedly asking to leave the facility. 5. Follow their policy and procedure (P&P) titled, Wandering and Elopements, which indicated, if identified as at risk for elopement, or other safety issues, the resident's care plan would include strategies and intervention to maintain the resident's safety. As a result of these deficient practices, around 12 AM on 3/3/2024, Resident 1 was found to have eloped from the facility. The facility is unaware of how and when the resident eloped and has not found Resident 1. Resident 1 had an increased risk of serious harm or death due to not receiving the physician ordered care which includes dialysis (a treatment to filter wastes and water from your blood, as your kidneys did when they were healthy) and medications. On 3/11/2024 at 3:14 PM, 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) due to the facility's failure to assess Resident 1's risk for elopement upon admission, properly perform the elopement risk assessment for Resident 1, and to implement their care planned interventions to check resident's whereabouts every thirty-minute visual check log to prevent his elopement from the facility on 3/3/2024. This put Resident 1 at an increased risk of serious harm or death due to not receiving dialysis, medications and care. On 3/13/2024, 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 3/13/2024 at 4:12 PM, in the presence of the facility's ADM and the Director of Nursing (DON). The facility's IJRP included the following immediate actions: - On 3/4/24 thru 3/12/2024 conducted in-services for all staff regarding the elopement policy and procedure and elopement risks. - Conducted an elopement drill for 11 - 7 shift and will continue/ongoing to all shifts. - Reassessed all residents for their elopement risk. - Any resident identified as at risk for elopement on admission or as a change of condition will be placed on close monitoring every 30 minutes by visual checks for 72 hours. This will be accomplished by staff using a hard copy location monitoring sheet for each shift. - On 3/11/2024, all residents who are at risk for elopement were reassessed. Two residents were initially assessed at risk for the years 2018 and 2017 but have not had an incident of elopement since elopement. - All newly admitted and readmitted residents will be assessed for elopement risk by the admission nurse within 24 hours. All patients who are assessed to be at risk for elopement will be placed on every 30-minute visual check as a best practice for the building. - A comprehensive risk assessment will be conducted by a designated staff upon identification based on initial elopement risk review. - Elopement assessment will be completed at least quarterly, or if change of condition occurs by a licensed staff designee. - Elopement care plan will be initiated upon completion of elopement assessment. - All resident identified to be at risk for elopement will be reviewed by Interdisciplinary Team (IDT) the following business day (Monday - Friday), quarterly and as needed as indicated. - Medical records will audit all elopement risks assessments for all residents identified as at risk for elopement weekly for eight weeks or until compliance is achieved to ensure elopement assessments are conducted quarterly or as needed and care plan is in place for elopement. - All findings will be discussed during the morning IDT meeting to ensure follow up is completed. Findings: A review of the general acute care hospital (GACH 1) Medicine Discharge Summary Note, dated 2/29/2024, indicated on 2/5/2024 after being found on a bus incontinent of bowel, Resident 1 was brought to the Emergency Department (ED) in shock (the body's response to a sudden drop in blood pressure) and in renal failure (a condition in which one or both of the kidneys no longer work on their own). Resident 1 was admitted to the hospital and a hemodialysis catheter (a tubular medical device for insertion into canals, vessels, passageways, or body cavities for diagnostic or therapeutic purposes) was placed. Resident 1 was started on continuous renal replacement therapy (a slower dialysis that is 24 hours or longer). The Discharge Summary further indicated on 2/13/2024 Resident 1 had an open reduction and internal fixation (ORIF - a surgical procedure for repairing fractured bone using either plates, screws or a rod to stabilize the bone) of his left femur (thigh bone). It also indicated Resident 1 required continued hemodialysis and the resident's discharge diagnoses (active problems) included acute renal failure, septic shock (When blood pressure drops to a dangerously low level after an infection), chronic osteomyelitis (a bone infection), altered mental status, severe opioid (A class of drug used to reduce moderate to severe pain ) use disorder and severe methamphetamine (A powerful, highly addictive stimulant that affects the central nervous system) use disorder. A review of Resident 1's admission record indicated the facility admitted the resident on 2/29/2024 with only one diagnosis of high blood pressure. It also indicated Family Member 1 (FM 1) and Family Member 2 (FM 2) were Resident 1's emergency contacts (first person medical personnel will get in touch within an emergency). A review of Resident 1's History and Physical (H&P) Note, dated 2/29/2024, Resident 1's diagnoses included acute kidney failure, severe sepsis (A life-threatening complication of an infection) , altered mental status, hepatitis C, opioid disorder and methamphetamine use disorder. It further indicated on admission the resident was irritable and uncooperative during examination. It also indicated the resident had fluctuating capacity to understand and make decisions. A review of the physician orders, dated 2/29/2024, indicated Resident 1 was to receive the following medications/care: Valproic acid (Used to treat bipolar disorder) 250 milligrams (mg) - Give two capsules (=500 mg) twice a day for mood disorder. Valproic acid 250mg - Give five capsules (=1250 mg) with dinner for mood disorder. Olanzapine (Zyprexa - an antipsychotic) oral tablet (tab) five mg give one tablet by mouth as needed for anxiety/agitation. Diazepam two mg (An anti-anxiety medication) Give one tab twice a day for anxiety manifested by agitation. Eliquis (Used to prevent serious blood clots from forming due to a certain irregular heartbeat) five mg -Give one tablet twice a day for deep vein thrombosis (DVT - a blood clot in a deep vein of the leg, pelvis and sometimes arm) prophylaxis for 68 days. Sodium Zirconium Cyclosilicate (To treat high potassium [salt] in the blood) - Give one packet one time a day for high blood potassium level. Cefazolin (an antibiotic) one gm intravenously (IV - into or within a vein) one time a day every Tuesday, Thursday, Saturday, Sunday for sepsis for 36 days. Cefazolin two gm IV one time in the evening every Monday, Wednesday for sepsis for 37 days. Give after dialysis at the dialysis center. Cefazolin three gm IV one time in the evening every Fri for sepsis for 40 days. Give after dialysis at the dialysis center on Friday. May reinforce dialysis catheter or shunt as needed and every day shift. Monitor dialysis site for tenderness, redness or bleeding every shift. A review of Resident 1's Interdisciplinary Team (IDT) Review, dated 3/1/2024, indicated Resident 1's psychosocial (involving both psychological and social aspects) needs and behaviors were agitation. It also indicated the facility explained out on pass (OOP) protocol and the risk of safety. A review of Resident 1's Care Plan for Risk for Against Medical Advice (AMA) Identified, initiated 3/1/2024, indicated Resident 1 was identified to be at risk to leave the facility AMA and the facility explained the risk of injury versus the benefits of complying with his stay. The interventions included to check the resident's whereabouts and redirect as needed. A review of the Progress Notes, dated 3/1/2024 at 9 AM, indicated Resident 1was admitted to the facility and had a Perma catheter (a flexible tube inserted into a blood vessel in the neck or upper chest used for dialysis treatment) on the right upper chest and a Heplock (an IV catheter placed in a vein to administer medication or fluid into the bloodstream) on the right hand. A review of the March 2024 Certified Nursing Assistant (CNA) Documentation Survey Report on 3/2/2024 for the 3 PM to 11 PM shift, Certified Nursing Assistant 1 (CNA 1) indicated the resident was not available on the 3 PM to 11 PM shift for personal hygiene, toilet transfer, toileting hygiene and amount [of meal] eaten. A review of Resident 1's 30 Minute Visual Check forms, dated 3/1/2024 and 3/2/2024 indicated assigned staff would document duty performed (whereabouts) and initial of the assigned staff every thirty minutes. The 30- Minute Visual Check were pre-printed on the form and start from 6:30 AM to 6 AM the next day. A further review of the 30 Minute Visual Check form dated 3/2/2024 indicated Resident 1's whereabouts was the last identified at 9:30 PM on 3/2/2024 (2.5 hours prior to determining the resident had eloped) that resident was in his room. A review of the SBAR (an acronym for Situation-Background-Assessment-Recommendation is a technique used to provide a framework for communication between members of the health care team) form, dated 3/3/2024, indicated at 12 AM upon arrival to the facility, Licensed Vocational Nurse 1 (LVN 1) made rounds and noted Resident 1 was not in bed and the resident's dinner tray was at bedside and was untouched. The form further indicated LVN 1 called the previous shifts charge nurse, Licensed Vocational Nurse 2 (LVN 2) and LVN 2 reported he last saw Resident 1 at 5 PM. A review of Resident 1's Elopement Risk Assessment, dated 3/4/2024 (after the resident eloped), indicated Resident 1 was not considered an elopement risk. The Elopement Risk Assessment indicated the resident was not independently mobile and did not perceive that he needed to be doing something other than what he was doing. A further review of the elopement risk assessment indicated it did not assess the resident's cognition (the states and processes involved in knowing, which in their completeness include perception and judgment), medications or history of drug use. During an interview on 3/5/2024 at 9:05 AM, the Director of Nursing (DON) stated Resident 1 was determined to be at risk to leave the facility against medical advice (AMA) so, she initiated a monitoring log for the resident in which staff were to monitor the resident's location every 30 minutes. During a phone interview on 3/5/2024 at 9:23 AM, Registered Nurse 1 (RN 1) stated she worked the 3 PM to 11 PM shift on 3/2/2024. RN 1 stated she last saw Resident 1 sometime between 9 and 10 PM. RN 1 stated Resident 1 inquired about being able to go to a money transfer business that night in order to get money and buy clothes. RN 1 stated she told Resident 1 he would have to wait until Monday to speak with social services. RN 1 further stated Resident 1 replied, Man, that's too late. RN 1 further stated she did not consider Resident 1 an elopement risk and did not check the resident's whereabouts every 30 minutes. RN 1 also stated she was not aware that Resident 1's location was to be monitored every 30 minutes. During a concurrent interview and observation on 3/5/2024 at 10:39 AM, with the Maintenance Director (MTD) a general observation of the facility premises was performed. MTD stated the facility did not have any working cameras inside or outside the building. During an observation of the smoking area, MTD stated there was no staff to continuously monitor the electronic parking gate that opened onto the area and the door to the parking area was not alarmed at this time (daytime), but staff were to alarm it at night. During an interview on 3/5/2024 at 10:56 AM, LVN 1 stated he worked the 11 PM to 7 AM shift on 3/2/2024. LVN 1 stated he arrived at the facility at 11:59 PM on 3/2/2024. LVN 1 stated he went to check all of the residents assigned to him and discovered Resident 1 was not in bed, his dinner tray was still at bedside and untouched. LVN 1 stated Resident 1 was known to complete 100% of meals and usually wanted a snack around midnight. LVN 1 stated he assumed the resident returned to the GACH and he completed checking the rest of the residents assigned to him. LVN 1 stated he then started looking on the computer to find out what happened to Resident 1. LVN 1 stated he did not find any notes regarding Resident 1's whereabouts and so contacted LVN 2, who was assigned to Resident 1 on the previous shift. LVN 1 stated LVN 2 told him he last saw Resident 1 around 5 PM. LVN 1 further stated he asked the current certified nursing assistant assigned to Resident 1 and she said she had not seen the resident at all. LVN 1 stated he then thought Resident 1 had eloped, he initiated a thorough search for the resident of the facility's premises and after Resident 1 was not found, extended the search to the surrounding area. LVN 1 also stated, he called law enforcement. LVN 1 stated he was very concerned because Resident 1 had intravenous (IV - inside the vein) access and that the resident could give himself IV drugs and overdose. LVN 1 further stated Resident 1 was not considered an elopement risk and the resident was not on any monitoring for his location. LVN 1 stated Resident 1 was never found. During a phone interview on 3/5/2024 at 12:13 PM, FM 1 stated she was informed by a transportation company that Resident 1 was missing. FM 1 stated the facility never informed her Resident 1 was missing. FM 1 further stated the facility never told her that Resident 1 was at risk for AMA nor did the facility contact her to be part of an IDT meeting. During an interview on 3/5/2024 at 1:58 PM, LVN 2 stated he worked on 3/2/2024 on the 3 PM to 11 PM shift. LVN 2 stated he last saw Resident 1 at 9 PM on 3/2/2024 when he administered Resident 1's medications. LVN 2 stated Resident 1 mentioned he did not want to be in the facility and LVN 2 told Resident 1 he would have to wait until the morning to speak with social services. LVN 2 further stated he was not aware that Resident 1's location was being monitored and he did not monitor or document Resident 1's whereabouts. During a concurrent interview with RN 1 and record review on 3/5/2024 at 3:45 PM, Resident 1's 30 Minute Visual Check forms, dated 3/1/2024 and 3/2/2024 were reviewed. RN 1 stated she had never seen this form. RN 1 stated after Resident 1 stated he wanted to leave the facility; she did not start monitoring his (Resident 1) location or have communicated to the other staff on duty. During a phone interview on 3/6/2024 at 8:04 AM, Certified Nursing Assistant 1 (CNA 1) stated she worked as a registry (staff personnel provided by a placement service on a temporary or on a day-to day basis) CNA at the facility on 3/2/2024 for the 3 PM to 11 PM shift and was assigned to care for Resident 1. CNA 1 stated Resident 1 told her he was going to dialysis, and he needed help adjusting his resident's clothes. CNA 1 stated the last time she saw Resident 1 was around 3:30 PM or 4 PM, when she adjusted Resident 1's clothes in the activities room. CNA 1 stated she placed Resident 1's dinner tray on his bedside table around 5:15 PM and the resident was not present. CNA 1 stated she left his dinner tray at bedside because she thought the resident went to dialysis, she knew dialysis took a while and the resident would probably be hungry when he returned to the facility. CNA 1 stated she never spoke to the Resident 1's charge nurse during that shift. CNA 1 stated she was not aware Resident 1 was at risk to leave the facility and she was not instructed to monitor the resident's location. CNA 1 stated if she had known Resident 1 was at risk to leave the facility, when the resident stated he had an appointment and would leave the facility, she would have reported this to the charge nurse and monitored his location more. CNA 1 further stated when I did my charting, I put the resident wasn't available. During a phone interview on 3/6/2024 at 9:15 AM, Registered Nurse 2 (RN 2) stated she worked on 3/2/2024 during the 11 PM to 7 AM shift. RN 2 stated she did not observe Resident 1 when she did her rounds at the start of her shift. RN 2 stated LVN 1 arrived around midnight. RN 2 stated LVN 1 informed her Resident 1 was missing and the staff searched the facility and the surrounding neighborhood. Resident 1 was not found. RN 2 stated, she did not know how and when Resident 1 left. Stated she was not informed Resident 1 was at risk to leave the facility and was not informed to monitor Resident 1's location every 30 minutes. RN 2 stated Resident 2's IV access catheter (if he pulled out) was not found in the room, and it was not safe for him to have IV access as he could overdose if he does drugs. During an interview on 3/6/2024 at 9:57 AM, Director of Staff Development (DSD) stated CNA 1 did not have training on elopement. DSD stated Resident 1's AMA care plan is not specific enough. DSD stated every 30 Minute Visual Check form should have been specified in his care plan. DSD stated Resident 1's whereabouts should have been monitored at all times and not as needed. DSD further stated if Resident 1's risk for elopement should have been discussed in huddle and all staff should have known not just the staff assigned to him. DSD also stated residents expressing a wish to leave the facility or go to the store is an indication of being an elopement risk and CNA 1 should have followed up with the charge nurse or RN Supervisor when Resident 1 stated he had an appointment. DSD stated CNA informing the charge nurse or RN Supervisor may have prevented Resident 1 from eloping. During a concurrent interview and record review on 3/6/2024 at 11:09 AM, Resident 1's medical chart was reviewed. Licensed Vocational Nurse 3 (LVN 3) stated she was assigned to Resident 1 on the 7 AM to 3 PM shift on 3/1/2024 and 3/2/2024. LVN 3 stated Resident 1 would repeatedly say he wanted to leave the facility to go somewhere else. LVN 3 stated at that time I did not think of him as an elopement risk but now thinking about that he always wanted to go out of the facility, I think he was. LVN 3 stated she was never told he was at risk for leaving AMA. LVN 3 at first stated she was not aware of any monitoring of Resident 1's location and she did not document Resident 1's location on a log. After showing LVN 3 the 30 Minute Visual Check forms, dated 3/1/2024 and 3/2/2024 , LVN 3 stated she did remember completing the forms. During a concurrent record review, every 30 Minute Visual Check forms dated 3/1/2024 and 3/2/2024 were reviewed. LVN 3 stated she completed the 30 Minute Visual Check form dated, 3/2/2024, from 6:30 AM to 9:30 PM. LVN 3 stated she documented what LVN 2 told her, and she did not independently witness observations from 3:30 PM to 9:30 PM and then LVN 2 signed her documentation. During an interview on 3/6/2024 at 2:59 PM, the DON stated Resident 1 was assessed to be at risk for exiting behavior to his history of drug abuse. DON stated Resident 1 has not been found. DON stated she signed Resident 1's elopement risk assessment as part of the admission assessment on 3/4/2024 after she assessed the resident (did not stated when did she assessed Resident 1). DON stated it is her expectation that the staff who admit Resident 1 signed the elopement risk assessment on 3/1/2024. DON stated the charge nurses were to monitor Resident 1's location every thirty minutes and should have followed the protocol as part of the elopement binder. DON stated the last entry by the charge nurse on the 30-minute visual check sheet was at 9:30 PM. DON stated the RN 1 flushed Resident 1's IV around 11 PM. However, DON unable to show order for IV flush on medication administration record (MAR) and when asked does an IV flush require a physician order and if performed without an order does that constitute a medication error, the DON did not answer. A review of Resident 1's Medication Admin Audit Report, dated 3/6/2024, indicated RN 1 performed Monitor IV site every shift for signs of inflammation/infiltration, on 3/2/2024 at 6:33 PM. It also indicated LVN 2 administered Tylenol Extra Strength 500mg, Lasix (water pill) 40 mg, on 3/2/2024 at 8:11 PM and Melatonin (aid to sleep) 3 mg on 3/2/2024 at 8:23 PM. A record review on 3/12/2024 at 3:30 PM of the Resident 1's physician orders from 2/29/2024 through 3/4/2024, indicated there was no order for IV flush. A review of the facility P&P titled, Wandering and Elopements, revised 3/2019, indicated the facility would identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan would include strategies and intervention to maintain the resident's safety. A review of the facility policy titled, Safety and Supervision of Residents, revised on 7/2017, indicated 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 including adequate supervision and assistive device. Implementing interventions to reduce accident risks and hazards shall include ensuring that interventions were implemented correctly and consistently. A review of the facility P&P titled, Emergency Procedure - Missing Resident, updated 1/2023, indicated resident elopement resulting in a missing resident was considered a facility emergency. It also indicated residents at risk for wandering and or elopement would be monitored, and staff would take necessary precautions to ensure resident safety.

Based on interview and record review the facility failed to implement measures to prevent fall and injury for one of three sampled residents (Resident 1). For Resident 1, who was confused, with unsteady gait and history of falls, the facility failed to: 1. Supervise and monitor the whereabouts of Resident 1. 2. Identify interventions related to the resident's specific risks and causes to try to prevent resident from falling and try to minimize complications from falling As a result, Resident 1 suffered five unwitnessed falls on 8/20/23, 9/5/23, 9/27/23, 11/19/23, and 11/23/23. On 11/23/23 at 2 p.m., Resident 1 was found with his face down in his room and was bleeding from the right side of the head and required transfer to general acute hospital 1 (GACH 1) by paramedics (Medical professionals who specializes in emergency treatment). At GACH 1, Resident 1 was found with three centimeters (cm., unit of measurement) laceration (tear in the skin caused by blunt trauma [A tissue injury that occurs more or less suddenly due to violence or accident]) in the right forehead, traumatic brain injury (TBI, caused by a forceful bump, blow or jolt to the head) with subarachnoid (The middle of three membranes that cover the central nervous system [system that sends messages back and forth between the brain and the body] and subdural (The area between the brain and the skull) hemorrhage (bleeding in the space surrounding the brain that is life threatening and can cause brain damage) because of the fall. Resident 1 was admitted in the trauma intensive care unit (ICU, unit in the hospital that provide highly specialized care to patients who suffer from a serious injury or illness) for further treatment. Findings: During a review of the Admission Record indicated the facility admitted Resident 1 on 6/30/22 with diagnoses including Parkinson's disease (disorder of the nervous system [controls internal functions of the body that receives, interprets and responds to stimuli] that affects movement), cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) with right side hemiplegia (weakness or paralysis on one side of the body) and hemiparesis (one sided muscle weakness) During a review of the Resident Fall Risk Evaluation dated 3/15/23 at 3:07 p.m., indicated Resident 1 was at risk for falls. During a review of untitled Care Plan revised on 3/30/23 indicated Resident 1 was at risk for fall and injury due to confusion, gait, and balance problems. The care plan goal indicated Resident 1 will minimize fall and injury through the next review date. Interventions included to provide Resident 1 with safe environment that included the bed in low position at night. During a review of untitled Care Plan revised on 6/20/23, indicated Resident 1 was at risk for fall and injury due to unsteady gait and attempts to get up from wheelchair and bed unassisted. The care plan goal indicated Resident 1 will minimize fall and injury through the next review date. Intervention included to observe Resident 1 for unsafe behavior such as attempting to get out of bed or wheelchair unassisted. During a review of untitled Care Plan initiated on 8/20/23 and revised on 9/5/23 indicated Resident 1 was found on the floor on 8/20/23 and 9/5/23. The care plan goal indicated Resident 1 will have no further injury related to the fall through the next review date. Intervention included frequent visual checks by staff for Resident 1 and refer to Interdisciplinary Team (IDT, A group of health care professionals with various areas of expertise who work together toward the goals of their clients) for further review of plan of care. During a review of the Post Fall Review dated 8/20/23 at 3:27 p.m., indicated Resident 1 had an unwitnessed fall on 8/20/23 at 2:55 p.m. The Post Fall Review indicated Resident 1 was found lying on the floor in the hallway. Resident 1 was observed wandering per self on wheelchair prior to the fall. The IDT recommendation indicated will .escalate the plan of care for when he (Resident 1) is up in the chair to facilitate increased safety for the resident. During a review of the Post Fall Review dated 9/5/23 at 4:36 p.m. indicated Resident 1 had an unwitnessed fall on 9/5/23 at 3:10 p.m. Resident 1 was found sitting upright on the floor next to the sofa in the front lobby. The section on IDT review and summary of the root cause [fall] was left blank. During a review of the Minimum Data Set (MDS, a standardized care and health screening tool) dated 9/13/23, indicated Resident 1 had severely impaired cognitive skills (mental process that take place in the brain including thinking, attention, language, learning, memory, and perception). Resident 1 needed one-person physical assistance with bed mobility, transfer, dressing, eating, toilet use, personal hygiene, and bathing. Resident 1 was unsteady and only able to stabilize with assistance when moving from seated to standing position and transfer between bed and chair or wheelchair. Resident 1 had limited range of motion (ROM, measurement of movement around the joint or body part) in the lower extremity (hip, knee, ankle, and foot). During a review of the Situation, Background, Appearance, Review and Notify (SBAR, communication tool that share information among healthcare team about resident condition) and Progress Notes dated 11/23/23 at 2 p.m., indicated Resident 1 was found on the floor in his room face down beside his bed. The SBAR indicated Resident 1 was bleeding a lot from the right side of his head. The paramedics were called and transported Resident 1 to the GACH 1. During a review of the Paramedic Patient Care Report dated 11/23/23 at 2:17 p.m., indicated the paramedics were informed that Resident 1 fell out of bed and the fall was unwitnessed (had unwitnessed fall out of bed on 11/23/23). Resident 1 had laceration in the eyebrow area and bleeding was controlled. The paramedics placed a cervical collar (c-collar, brace or support used to support and protect the neck) to Resident 1 for spinal (backbone) precautions and transported Resident 1 to the GACH 1. During a review of GACH 1 Emergency Documentation dated 11/23/23 at 2:56 p.m., indicated Resident 1 was found with blunt head trauma and had changes in mentation (mental activity). Resident 1 was admitted to GACH 1 trauma ICU. During a review of the GACH 1 computerized tomography scan (CT, procedure that use combination of x-rays and computer to produce images) of the head dated 11/23/23 at 3:23 p.m. indicated Resident 1 had an acute subarachnoid and subdural hemorrhage within the left parietal region (near the back of the head). During a review of GACH 1 Consultation record dated 11/24/23 at 2 p.m., indicated Resident 1 was started on Keppra 500 milligrams (mg., unit of measurement) by intravenous (IV, given into a vein [blood vessel] every 12 hours. During a review of the GACH 1 Physician Notes dated 11/24/23 at 8:57 a.m., indicated Resident 1 was noted to have three centimeters (cm., unit of measurement) of laceration on the right forehead. During a review of the Physician Note dated 11/24/23 at 9:48 a.m., indicated Resident 1's subdural hematoma (A serious condition where blood collects between the skull and the surface of the brain) was non operable (cannot be treated by surgery). During a review of the Physician Note dated 11/27/23 at 10:06 a.m., indicated Resident 1, Keeps his eyes closed and had no movement to stimuli, was not improving and appears will be his current mental status in the future. Resident 1 needed nasogastric tube (NGT, a thin, soft tube that goes through the nose, down the throat and into the stomach) for feeding, hydration, or medication. During a review of the GACH 1 Discharge Summary dated 12/2/23 indicated Resident 1 was discharged to GACH 2 for traumatic brain injury with subarachnoid and subdural hemorrhage, continued therapies . During an interview on 1/12/24 at 7:46 a.m., Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 was confused, restless, tries to get out of bed and wheelchair unassisted. LVN 1 stated Resident 1 had history of falls and Resident 1 needed a one to one (1:1, continuous observation/monitoring) sitter (staff that are immediately at hand to prevent fall or redirect unsafe behavior) to make sure Resident 1 does not fall or prevent the resident from falling. LVN 1 stated Resident 1 had an unwitnessed fall on 11/23/23 and was found face down on the floor in his room beside his bed. During an interview and record review with LVN 2 on 1/12/24 at 9:41 a.m., Resident 1's fall incidents were reviewed. During concurrent interview, LVN 2 stated Resident 1 had five fall incidents while at the facility. LVN 2 stated Resident 1 fell on the following dates and time: 1. On 8/20/23 at 2:55 p.m. Resident 1 had unwitnessed fall and was found lying on his right side near Room A. Resident 1 had an x-ray and he had no injury. 2. On 9/5/23 at 3:10 p.m., Resident 1 had unwitnessed fall and was found sitting in the floor next to the sofa in the front lobby. Resident 1 had no injury. 3. On 9/27/23 at 3:15 p.m., Resident 1 was found on the floor in the lobby lying on his left side and had no injury. 4. On 11/19/23 at 3 p.m., Resident 1 was found lying in the floor in the hallway and had no injury. Resident 1 was trying to transfer from wheelchair to the sofa. 5. On 11/23/23 at 2 p.m., LVN 2 stated Resident 1 had another fall and was found face down in his room when Resident 1 was last seen trying to reach for something (unknown object). LVN 2 stated the paramedics were called and Resident 1 was transferred to the GACH 1. During an interview on 1/12/24 at 10:52 a.m., the Director of Rehabilitation (DOR) stated Resident 1 was confused, impulsive, had poor safety awareness and a fall risk. DOR stated Resident 1 was able to stand but balance is poor. Resident 1 needed constant supervision and have someone keep an eye on him to prevent Resident 1 from falling. During an interview on 1/12/24 at 11:53 a.m., the Director of Nursing (DON) stated she was not employed at the facility when Resident 1 had the fall incidents. DON stated she started working for the facility after Resident 1 had been discharged . DON stated Resident 1 should not fall five times. DON stated Resident 1 needed constant supervision, need his bed in lowest position and bilateral floor mats by his bed. DON stated she would ask the family member if they were willing to provide 1:1 sitter for Resident 1. DON further stated CNAs can alternate as 30-minute room sitters to monitor Resident 1 and prevent the resident from falling. During a follow-up interview and record review with LVN 2 on 1/24/23 at 1:38 p.m., Resident 1's care plan for falls were reviewed. During concurrent interview, LVN 2 stated she was unable to find floor mat and that the bed was always not in lowest position as part of the fall intervention for Resident 1. LVN 2 stated the floor mat and bed placed in the lowest position will prevent injury in case Resident 1 falls. During a review of the facility's policy and procedures (P&P) titled Falls and Fall Risk, Managing, reviewed on 8/30/23, indicated, based on previous evaluations and current data, the facility will identify interventions related to the resident's specific risks and causes to try to prevent resident from falling and try to minimize complications from falling. Environmental factors that contribute to the risk of falls include incorrect bed height. If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant. In conjunction with the attending physician, staff will identify and implement relevant interventions to try to minimize serious consequences of falling. During a review of the facility's P&P titled Safety and Supervision of Residents reviewed on 8/30/23, indicated, the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility wide priorities. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices.

Based on interview and record review the facility failed to implement measures to prevent fall and injury for one of three sampled residents (Resident 1). For Resident 1, who was confused, with unsteady gait and history of falls, the facility failed to: 1. Supervise and monitor the whereabouts of Resident 1. 2. Identify interventions related to the resident's specific risks and causes to try to prevent resident from falling and try to minimize complications from falling As a result, Resident 1 suffered five unwitnessed falls on 8/20/23, 9/5/23, 9/27/23, 11/19/23, and 11/23/23. On 11/23/23 at 2 p.m., Resident 1 was found with his face down in his room and was bleeding from the right side of the head and required transfer to general acute hospital 1 (GACH 1) by paramedics (Medical professionals who specializes in emergency treatment). At GACH 1, Resident 1 was found with three centimeters (cm., unit of measurement) laceration (tear in the skin caused by blunt trauma [A tissue injury that occurs more or less suddenly due to violence or accident]) in the right forehead, traumatic brain injury (TBI, caused by a forceful bump, blow or jolt to the head) with subarachnoid (The middle of three membranes that cover the central nervous system [system that sends messages back and forth between the brain and the body] and subdural (The area between the brain and the skull) hemorrhage (bleeding in the space surrounding the brain that is life threatening and can cause brain damage) because of the fall. Resident 1 was admitted in the trauma intensive care unit (ICU, unit in the hospital that provide highly specialized care to patients who suffer from a serious injury or illness) for further treatment. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 6/30/22 with diagnoses including Parkinson's disease (disorder of the nervous system [controls internal functions of the body that receives, interprets and responds to stimuli] that affects movement), cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) with right side hemiplegia (weakness or paralysis on one side of the body) and hemiparesis (one sided muscle weakness) During a review of the Resident Fall Risk Evaluation dated 3/15/23 at 3:07 p.m., indicated Resident 1 was at risk for falls. During a review of untitled Care Plan revised on 3/30/23 indicated Resident 1 was at risk for fall and injury due to confusion, gait, and balance problems. The care plan goal indicated Resident 1 will minimize fall and injury through the next review date. Interventions included to provide Resident 1 with safe environment that included the bed in low position at night. During a review of untitled Care Plan revised on 6/20/23, indicated Resident 1 was at risk for fall and injury due to unsteady gait and attempts to get up from wheelchair and bed unassisted. The care plan goal indicated Resident 1 will minimize fall and injury through the next review date. Intervention included to observe Resident 1 for unsafe behavior such as attempting to get out of bed or wheelchair unassisted. During a review of untitled Care Plan initiated on 8/20/23 and revised on 9/5/23 indicated Resident 1 was found on the floor on 8/20/23 and 9/5/23. The care plan goal indicated Resident 1 will have no further injury related to the fall through the next review date. Intervention included frequent visual checks by staff for Resident 1 and refer to Interdisciplinary Team (IDT, A group of health care professionals with various areas of expertise who work together toward the goals of their clients) for further review of plan of care. During a review of the Post Fall Review dated 8/20/23 at 3:27 p.m., indicated Resident 1 had an unwitnessed fall on 8/20/23 at 2:55 p.m. The Post Fall Review indicated Resident 1 was found lying on the floor in the hallway. Resident 1 was observed wandering per self on wheelchair prior to the fall. The IDT recommendation indicated will .escalate the plan of care for when he (Resident 1) is up in the chair to facilitate increased safety for the resident. During a review of the Post Fall Review dated 9/5/23 at 4:36 p.m. indicated Resident 1 had an unwitnessed fall on 9/5/23 at 3:10 p.m. Resident 1 was found sitting upright on the floor next to the sofa in the front lobby. The section on IDT review and summary of the root cause [fall] was left blank. During a review of the Minimum Data Set (MDS, a standardized care and health screening tool) dated 9/13/23, indicated Resident 1 had severely impaired cognitive skills (mental process that take place in the brain including thinking, attention, language, learning, memory, and perception). Resident 1 needed one-person physical assistance with bed mobility, transfer, dressing, eating, toilet use, personal hygiene, and bathing. Resident 1 was unsteady and only able to stabilize with assistance when moving from seated to standing position and transfer between bed and chair or wheelchair. Resident 1 had limited range of motion (ROM, measurement of movement around the joint or body part) in the lower extremity (hip, knee, ankle, and foot). During a review of the Situation, Background, Appearance, Review and Notify (SBAR, communication tool that share information among healthcare team about resident condition) and Progress Notes dated 11/23/23 at 2 p.m., indicated Resident 1 was found on the floor in his room face down beside his bed. The SBAR indicated Resident 1 was bleeding a lot from the right side of his head. The paramedics were called and transported Resident 1 to the GACH 1. During a review of the Paramedic Patient Care Report dated 11/23/23 at 2:17 p.m., indicated the paramedics were informed that Resident 1 fell out of bed and the fall was unwitnessed (had unwitnessed fall out of bed on 11/23/23). Resident 1 had laceration in the eyebrow area and bleeding was controlled. The paramedics placed a cervical collar (c-collar, brace or support used to support and protect the neck) to Resident 1 for spinal (backbone) precautions and transported Resident 1 to the GACH 1. During a review of GACH 1 Emergency Documentation dated 11/23/23 at 2:56 p.m., indicated Resident 1 was found with blunt head trauma and had changes in mentation (mental activity). Resident 1 was admitted to GACH 1 trauma ICU. During a review of the GACH 1 computerized tomography scan (CT, procedure that use combination of x-rays and computer to produce images) of the head dated 11/23/23 at 3:23 p.m. indicated Resident 1 had an acute subarachnoid and subdural hemorrhage within the left parietal region (near the back of the head). During a review of GACH 1 Consultation record dated 11/24/23 at 2 p.m., indicated Resident 1 was started on Keppra 500 milligrams (mg., unit of measurement) by intravenous (IV, given into a vein [blood vessel] every 12 hours. During a review of the GACH 1 Physician Notes dated 11/24/23 at 8:57 a.m., indicated Resident 1 was noted to have three centimeters (cm., unit of measurement) of laceration on the right forehead. During a review of the Physician Note dated 11/24/23 at 9:48 a.m., indicated Resident 1's subdural hematoma (A serious condition where blood collects between the skull and the surface of the brain) was non operable (cannot be treated by surgery). During a review of the Physician Note dated 11/27/23 at 10:06 a.m., indicated Resident 1, Keeps his eyes closed and had no movement to stimuli, was not improving and appears will be his current mental status in the future. Resident 1 needed nasogastric tube (NGT, a thin, soft tube that goes through the nose, down the throat and into the stomach) for feeding, hydration, or medication. During a review of the GACH 1 Discharge summary dated [DATE] indicated Resident 1 was discharged to GACH 2 for traumatic brain injury with subarachnoid and subdural hemorrhage, continued therapies . During an interview on 1/12/24 at 7:46 a.m., Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 was confused, restless, tries to get out of bed and wheelchair unassisted. LVN 1 stated Resident 1 had history of falls and Resident 1 needed a one to one (1:1, continuous observation/monitoring) sitter (staff that are immediately at hand to prevent fall or redirect unsafe behavior) to make sure Resident 1 does not fall or prevent the resident from falling. LVN 1 stated Resident 1 had an unwitnessed fall on 11/23/23 and was found face down on the floor in his room beside his bed. During an interview and record review with LVN 2 on 1/12/24 at 9:41 a.m., Resident 1's fall incidents were reviewed. During concurrent interview, LVN 2 stated Resident 1 had five fall incidents while at the facility. LVN 2 stated Resident 1 fell on the following dates and time: 1. On 8/20/23 at 2:55 p.m. Resident 1 had unwitnessed fall and was found lying on his right side near Room A. Resident 1 had an x-ray and he had no injury. 2. On 9/5/23 at 3:10 p.m., Resident 1 had unwitnessed fall and was found sitting in the floor next to the sofa in the front lobby. Resident 1 had no injury. 3. On 9/27/23 at 3:15 p.m., Resident 1 was found on the floor in the lobby lying on his left side and had no injury. 4. On 11/19/23 at 3 p.m., Resident 1 was found lying in the floor in the hallway and had no injury. Resident 1 was trying to transfer from wheelchair to the sofa. 5. On 11/23/23 at 2 p.m., LVN 2 stated Resident 1 had another fall and was found face down in his room when Resident 1 was last seen trying to reach for something (unknown object). LVN 2 stated the paramedics were called and Resident 1 was transferred to the GACH 1. During an interview on 1/12/24 at 10:52 a.m., the Director of Rehabilitation (DOR) stated Resident 1 was confused, impulsive, had poor safety awareness and a fall risk. DOR stated Resident 1 was able to stand but balance is poor. Resident 1 needed constant supervision and have someone keep an eye on him to prevent Resident 1 from falling. During an interview on 1/12/24 at 11:53 a.m., the Director of Nursing (DON) stated she was not employed at the facility when Resident 1 had the fall incidents. DON stated she started working for the facility after Resident 1 had been discharged . DON stated Resident 1 should not fall five times. DON stated Resident 1 needed constant supervision, need his bed in lowest position and bilateral floor mats by his bed. DON stated she would ask the family member if they were willing to provide 1:1 sitter for Resident 1. DON further stated CNAs can alternate as 30-minute room sitters to monitor Resident 1 and prevent the resident from falling. During a follow-up interview and record review with LVN 2 on 1/24/23 at 1:38 p.m., Resident 1's care plan for falls were reviewed. During concurrent interview, LVN 2 stated she was unable to find floor mat and that the bed was always not in lowest position as part of the fall intervention for Resident 1. LVN 2 stated the floor mat and bed placed in the lowest position will prevent injury in case Resident 1 falls. During a review of the facility's policy and procedures (P&P) titled Falls and Fall Risk, Managing, reviewed on 8/30/23, indicated, based on previous evaluations and current data, the facility will identify interventions related to the resident's specific risks and causes to try to prevent resident from falling and try to minimize complications from falling. Environmental factors that contribute to the risk of falls include incorrect bed height. If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant. In conjunction with the attending physician, staff will identify and implement relevant interventions to try to minimize serious consequences of falling. During a review of the facility's P&P titled Safety and Supervision of Residents reviewed on 8/30/23, indicated, the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility wide priorities. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices.

Based on interview, and record review, the facility failed to identify and ensure one of three sampled residents (Resident 77), who had a diagnosis of Human Immunodeficiency Virus (HIV - a virus that attacks the body's immune system), received care, treatment, and services in accordance with professional standards of practice by failing to: - Conduct a comprehensive reassessment of Resident 77, including risk for immunocompromised (immune system's defenses are low, affecting its ability to fight off infections and diseases) status. - Conduct an Interdisciplinary Team (IDT - a group of health care professionals from different fields who coordinate resident care) meeting to address Resident 77's HIV positive status. -Develop and implement a care plan with specific interventions for Resident 77's HIV positive status. As a result of the deficient practices of failing to provide HIV-related medical care including HIV medications, Resident 77's CD4+ cells (immune system cells attacked by the HIV virus) decreased to a level below normal at 29% (reference range 30-61%) on 11/30/2023, and the HIV RNA level increased to 148339 copies (ideally this number is undetectable or so low the test cannot measure the number) per milliliter (ml, unit of measurement), which increased the likelihood that Resident 77 could have contracted life-threatening opportunistic infections (occur mostly in individuals with an impaired immune system) possibly leading to hospitalization or death. On 11/30/2023 at 4:22 PM, 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 identified in the presence of the Administrator (ADM) and Interim Director of Nursing (DON), regarding the facility's failure to identify and ensure Resident 77, who had a diagnosis of HIV, received HIV-related medical care including HIV medications, treatment, and services in accordance with professional standards of practice. If HIV was not treated, it can lead to acquired immunodeficiency syndrome [AIDS - the most advanced stage of HIV infection]). On 12/2/2023 at 4:05 PM, while onsite at the facility, the IJ was removed in the presence of the ADM and Interim DON, after the ADM submitted an acceptable Removal Plan (interventions and implementation to correct the deficient practices) which was verified and confirmed through observation, interview, and record review. The acceptable removal plan was as follows: On 11/29/2023, the attending physician for Resident 77 evaluated the resident and ordered blood workup that was drawn for Resident 77. Resident 77's mother was made aware of the order on 11/29/2023. The following blood tests were ordered for this blood draw: -CD4 -Hepatitis panel (a blood test that's used to find out if you have been infected with a hepatitis A, hepatitis B, or hepatitis C virus). On 11/30/2023, a care conference was held with the IDT and Resident 77's responsible party regarding her awareness of his possible immunocompromised condition and any medical treatment that he was receiving that was not currently being provided by the facility, and to help develop a plan of care. On 11/30/2023, the responsible party stated she would sign consent for records from GACH 1 clinic. On 11/30/2023, a person-centered care plan was initiated for Resident 77 to reflect monitoring of possible signs and symptoms of complications related to a probable immunocompromised condition (HIV) which includes coordination with GACH 1 clinic regarding potential medical treatment plan coordinated with Primary Care Physician such as medication, diagnostic testing, and other related treatments as needed. On 12/1/2023 - A Physician Progress note was completed by Physician 1 (PHYS) to reflect review of resident's status and action plan. All residents were at risk of being affected by this potential issue. On 11/30/2023, the Regional Nurse Resources conducted an audit of 84 residents who were identified with an actual change in condition within the last 30 days. Based on this audit, there were about 10 out of 84 residents that were found to have new diagnoses. The Physicians were notified at the time the change of condition occurred. The care plans of the 84 residents were reviewed and validated for timely completion of corresponding plan of care. All of which reflected timely completion of care plan. On 11/30/2023, the Medical Records Director audited all residents with potential diagnosis of HIV disease and no other resident was identified with a diagnosis of HIV disease. On 11/30/2023, there were 15 residents who were admitted or readmitted within the last 30 days. The Licensed Nurse conducted an audit of all 15 residents which revealed at least six residents with new diagnosis but noted with missing or incomplete care plans. Two residents were identified to be discharged at the time of review. On 12/1/2023, the licensed nurse designee initiated appropriate care plans based on new diagnosis. On 11/30/2023, the Director of Staff Development/Infection Prevention/DSD Resource conducted an interview with licensed nurses to determine if there were any diagnoses for residents that the MD/facility staff were not aware, and if such diagnosis was not captured on the resident's medical record. It was determined that no other residents have been affected. On 12/1/2023 and 12/2/2023, the Regional Nurse Resource (RNR) conducted in-services with the Licensed Nurses on Identification and Escalation of Resident Change of Condition which included corresponding validation of skills competency. As of 12 PM on 12/2/2023, 56% of the licensed nurses had been in-serviced. It was expected that 100% of the licensed nurses will have been in-serviced by end of day on 12/5/2023. This in-service included but not limited to the following areas of focus: -Review of process of identification of new diagnosis or medical condition -Review of process to address a new diagnosis or medical condition -MD/Responsible Party notification -Detailed documentation in resident's medical record (progress note) -Development of resident centered care plan -Initiation of MD orders (meds, treatment, labs, etc.) -Interdisciplinary Team Review (IDT) -Review of process of escalation of issues i.e., chain of command -Review of process when to escalate problem/issue to Medical Director -Review process on acceptable timeframes to address unresolved issues -Review possible adverse risk or outcome if information or issues are not addressed in a timely manner. -It was expected that 100% of the Licensed Nurses skills competency on Identification and Escalation of Resident Condition would be conducted and completed via in person review and/or via face time/zoom call method and completed by 12/5/2023. As of 12 PM on 12/2/2023, 56% had been completed. Any newly hired Licensed Nurse will be educated during orientation particularly on how to identify and escalate changes in condition. -The RN Supervisor/Designee will review and validate if a new diagnosis or medical condition was identified and addressed timely by Licensed staff during shift huddles. Issues identified during shift huddles would be forwarded to the RN Supervisor for action review and follow as needed. There was no current stop date to these shift huddles. -By 12/4/2023, during the daily Clinical meeting that was typically held Monday through Friday, the DON or designee would include a review of the following areas: PCC communication New Admissions Change of condition review Progress Notes Review of new orders 24 hr Report Any other pertinent items needing to be reviewed On any day that the regular daily clinical meeting was not held (i.e., a weekend or a holiday), a licensed nurse designee would review the above items to ensure compliance. Any areas of concern identified will be corrected or followed up within 24 hours. Any repeated or unresolved issues must be reported to the Administrator/DON, and maybe escalated to the Medical Director within 24 hours as deemed necessary by the facility key leaders. There was no current stop date to these clinical meetings or licensed designee reviewing the items to ensure compliance on holiday and weekends. For newly admitted residents, medical records will continue to perform an audit to determine if there were any diagnoses that were not captured on admission and COCs. Resident centered care plans would be developed for any missed diagnoses within 24 hours of identification by medical records staff. This plan of correction will be presented at the next scheduled Quality Assurance (QA&A) committee meeting on 12/20/2023. Ongoing findings/results from the daily clinical meeting, daily shift huddles, and medical records audits will be reported to the QA monthly meeting by the DON or licensed designee for at least three (3) months, and quarterly thereafter until substantial compliance was achieved. Findings: A review of Resident 77's Laboratory Report from GACH 1 clinic, with a collection date of 5/8/2023, indicated a HIV RNA (viral load, a laboratory test used to quantify how much HIV is replicating in a patient's body which can be useful to determine if current treatments are effective) level of 1130 copies / ml, CD4+ cells (white blood cells used to fight disease that are attacked by the HIV virus. Measuring these can be used to determine the level of a patient's immune impairment) of 570 cells per microliter (cell/uL unit of measurement [reference range [PHONE NUMBER]]), and CD4+ cells were 38% (reference range 30-61). The Laboratory Report indicated Resident 77 received Symtuza (antiviral medicine, combines different drugs in one pill used to treat HIV) one tablet every day with meals. A review of Resident 77's admission record indicated the facility admitted the resident on 7/3/2023 with diagnoses including a person injured in unspecified motor vehicle accident, unspecified intracranial injury (brain dysfunction caused by an outside force, usually a violent blow to the head) with loss of consciousness, pressure ulcer Stage IV (wound penetrates all three layers of skin, exposing muscles, tendons and bones) and encounter for attention to gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food). The admission record did not indicate Resident 77 had a diagnosis of HIV-1 (the most common type of HIV, the virus attacks your body's immune system by destroying CD4+ cells, which help your body fight infections. This can lead to Acquired Immune Deficiency Syndrome [AIDS]). A review of the Physician's Orders dated 7/3/2023 through 11/20/2023, indicated Resident 77 was to receive Lovenox (an anticoagulant [blood thinner] medication injection, used to treat and prevent harmful blood clots) injection 40 mg one time a day for deep vein thrombosis (DVT - a blood clot in a deep vein, usually in the legs) prophylaxis (action taken to prevent disease). Further review of Resident 77's Physician's Orders indicated no orders for Symtuza or any other antiretroviral (class of drugs that inhibit the activity of such viruses) therapy, and no orders for laboratory tests i.e., HIV RNA or CD4+ cells. A review of Resident 77's Care Plan dated 7/3/2023, indicated the resident was on anticoagulant therapy related to DVT prophylaxis. The care plan interventions included give medications at the same time of day, and review medication list for adverse interactions. Further review of Resident 77's care plans indicated there were no care plans with interventions developed for the HIV status or risk of developing opportunistic infections and immunocompromised (the immune system's defenses are low, affecting its ability to fight off infections and diseases) status. According to a review of the Progress Note dated 8/9/2023, RN 1 attempted to make an Ear Nose and Throat (ENT - specialists treat hearing, swallowing and speech) appointment for Resident 77 at the GACH 1 HIV / AIDS clinic. On 8/23/2023 the Progress Note indicated RN 1 spoke with GACH 1 HIV / AIDS clinic staff who indicated Resident 77 was HIV positive and required medications. A review of Resident 77's full medical record indicated the facility did not request or obtain medical records from GACH 1 clinic on 8/23/2023 to confirm Resident 77's HIV positive status. A review of the Minimum Data Set (MDS- a comprehensive assessment and care screening tool), dated 9/12/2023, indicated Resident 77 was cognitively moderately impaired (decisions poor; cues/supervision required), and required extensive assistance with one person assist for bed mobility. Under the Active Diagnoses section of the MDS, Resident 77 did not have a medically complex condition and did not have any infections. A review of the Progress Note dated 10/13/2023 indicated Licensed Vocational Nurse (LVN) 7 documented she received a call from GACH 1 clinic Case Manager (CM) 1 regarding Resident 77 receiving his HIV medication. The CM 1 informed LVN 7 that Resident 77 was in fact HIV positive and advised LVN 7 confirm this information. A review of Resident 77's Laboratory Report from the facility, collection date 11/30/2023, indicated a decrease of CD4+ cells at 461 cells/uL (reference range 355-1,213), and CD4+ cells at 29% (reference range 30-61). A review of Resident 77's Laboratory Report from the facility, collection date 12/5/2023, indicated an increase in HIV RNA at 148339 (a detectable level indicates the virus is actively replicating and may represent a treatment failure). According to a review of the Centers for Disease Control (CDC), if HIV is not treated, it can lead to acquired immunodeficiency syndrome (AIDS - the most advanced stage of HIV infection) and reduced CD4+ cell counts. There is currently no effective cure. https://www.cdc.gov/hiv/basics/whatishiv.html A review of Resident 77's medical record indicated there was no IDT meeting conducted for the HIV positive status. During an interview on 11/28/2023 at 3:49 PM, with Licensed Vocational Nurse 7 (LVN 7), she confirmed she documented the nursing note dated 10/13/2023 and that she received a call from CM 1. LVN 7 stated she was not aware Resident 77 was HIV positive and requested documentation to verify. LVN 7 stated she placed the communication regarding Resident 77's HIV status and medications on the 24 hours communication board and nursing notes dated 10/13/2023. LVN 7 stated she did not conduct additional follow ups regarding the potential HIV status of Resident 77 or his medications. LVN 7 stated she did not inform the physician. During an interview on 11/29/2023 at 8:31 AM, Registered Nurse 1 (RN 1) stated she was informed Resident 77 was HIV positive and would require HIV medication by the staff at GACH 1 clinic on 8/23/2023 as noted in her nursing note. RN 1 stated she failed to document she informed PHY 1 in the nursing notes and that was why PHY 1 stated he did not have any records to indicate the resident was HIV positive. RN 1 stated PHY 1 did not order any labs to confirm HIV status, or request to obtain records from GACH 1. RN 1 stated the normal protocol when a hospital or clinic informs the facility a resident had a disease, the facility would request confirmation by requesting medical records from the hospital or clinic. RN 1 stated she did not ask Medical Records Director (MRD) to obtain medical records from GACH 1. RN 1 stated the facility did not conduct an IDT care conference for Resident 77's HIV status and did not create a care plan for HIV status. RN 1 stated Resident 77 was not provided HIV medications since his admission on 7/3/2023, because the facility did not confirm the resident was HIV positive and required medication. During an interview on 11/29/2023 at 8:50 AM, with Medical Records Director (MRD), he stated he was not requested to obtain medical records for Resident 77 from GACH 1. He stated he did not request or obtain medical records from GACH 1 for Resident 77. On 11/29/2023 at 1:55 PM, during an interview, Physician 1 (PHY 1) stated he was the primary physician for Resident 77 and the facility received confirmation the resident was in fact HIV positive from Registered Nurse 2 (RN 2) on 11/28/2023 (over four months since the resident's admission to the facility). PHY 1 stated he spoke with RN 2 regarding Resident 77's HIV status on 11/28/2023 and he placed orders on 11/29/2023 for the viral load (HIV RNA) and T-cell count (CD4+ cells) for Resident 77. PHY 1 stated the facility documents indicated the facility staff had discussions with GACH 1 clinic staff regarding Resident 77 beginning from 8/9/2023 when RN 1 attempted to schedule an appointment for the resident. PHY 1 stated there was a follow up nursing note on 8/23/2023 indicating GACH 1 clinic was an HIV/AIDS clinic and to follow up with the clinic regarding Resident 77's medications. PHY 1 stated he did not order the test at that time in 8/2023 or in 10/2023. PHY 1 stated if he had known Resident 77 was HIV positive, he would have provided treatment for the diagnoses including medications. During an interview on 11/30/2023 at 9:23 AM, with Case Manager 2 (CM 2), he stated Resident 77 was a patient at GACH 1 and the resident's medical records indicated the resident was HIV positive and was receiving HIV medication. During an interview on 11/30/2023 at 3:22 PM, the interim Director of Nursing (IDON) stated the facility protocol when hospital or clinic called the facility to inform facility staff of potential new diagnoses not present or available upon admission, the staff would notify the physician and relay the information obtained from the hospital or clinic. The IDON stated the staff would wait for physician response, carry out an order or response, and document in the resident records. The IDON stated when the physician did not respond, the staff would follow up and attempt to contact the physician again. The IDON stated the facility would endorse the information to the incoming staff to follow up and when the primary physician did not respond, then staff can notify the Medical Director. She stated facility staff should notify physician urgent matters within 24 hours and non-emergent within 72 hours. IDON stated the facility staff should have requested medical records from GACH 1 to validate Resident 77's diagnosis when they were made aware as documented on the nursing progress notes dated 8/23/2023 and 10/13/2023. She stated PHY 1 was made aware of Resident 77's potential HIV status but cannot confirm when he was made aware. The IDON stated the facility staff should have followed up with PHY 1 and/or Medical Director to recommend a laboratory test for HIV status for Resident 77. She stated there was no laboratory test prior to 11/29/2023 for HIV status such as HIV RNA or CD4+ cells. She stated the facility failed to conduct IDT care conference or care planning for Resident 77 potential HIV positive status to provide continuation of care for the HIV diagnosis. She stated the potential outcome of an HIV resident not receiving treatment was the resident could develop AIDS and have an increased risk for infection, and suffer serious harm, and death. During an interview on 12/1/2023 at 2:17 PM, the Administrator (Admin) stated according to the facility nursing documentation dated 8/23/2023 and 10/13/2023, the facility staff RN 1 and LVN 7 had communication with GACH 1 regarding the potential HIV diagnosis and medication for Resident 77. The Admin stated the facility staff failed to obtain medical records and/or laboratory tests to confirm the HIV diagnosis for Resident 77. Admin stated the potential outcome of Resident 77 not receiving treatment for HIV is the resident is at risk to become sick, suffer harm from illness, and potentially death. A review of the facility policy and procedure titled, Admission Assessment and Follow up: Role of the Nurse, revised 9/2012, indicated to conduct an admission assessment including a summary of the individual's recent medical history, including hospitalization s, acute illness, and overall status prior to admission; relevant medical, social, and family history. It further indicated, to contact the attending physician to communicate and review the findings. In addition, contact outside services, such as laboratory or diagnostic services, as necessary. A review of the facility's policy and procedure titled, Care plans, comprehensive person centered, revised March 2022, indicated assessments of residents were ongoing and care plans were revised as information about the residents and the residents conditions change. A review of the facility policy and procedure titled, Change in a Resident's Condition or Status, revised 2021, indicated our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. The nurse would notify the resident's attending physician or physician on call when there was a need to alter the resident's medical treatment significantly. Prior to notifying the physician or healthcare provider, the nurse would make detailed observations and gather relevant and pertinent information for the provider, including information prompted by the Interact SBAR Communication form.

Based on interview and record review the facility failed to protect one of three sampled residents (Resident 1) identified as a high risk for fall from repeated falls in accordance with the facility's policy and procedures titled, Falls and Fall Risk, Managing, dated 3/2018, by failing to: 1. Identify and implement additional or different interventions related to the resident's specific risk and causes to prevent further falls and injuries. 2. Implement interdisciplinary team (IDT, a group of professional and direct care staff that have primary responsibility for the development of a plan for the care) recommendations to prevent further falls and injuries. 3. Ensure Resident 1 was placed on one to one (1:1- to provide continuous observation for an individual patient for a period of time during acute physical or mental illness) supervision and monitoring for safety and to prevent falls. 4. Ensure Resident 1 safety helmet (head protection gear), knee, and elbow pads were implemented as per the Nurse Practitioner (NP - advanced practice registered nurse and a type of mid-level practitioner trained to assess patient needs, order and interpret diagnostic and laboratory tests, diagnose disease, formulate and prescribe medications and treatment plan) orders. These deficient practices resulted in Resident 1 falling multiple times and sustaining injuries in the facility on the following dates: a. On 4/4/2023, Resident 1 was found next to his bed after a fall and was transported to a general acute care hospital (GACH) for further treatment of facial abrasions (is wearing away of the upper layer of the skin as a result of applied friction force), hematoma (a pool/collection of blood that forms in an organ, tissue, or body space) on the right side of the head and nosebleed. b. On 4/6/2023, Resident 1 fell out of a wheelchair in the activities room and sustained scratches (a mark or wound) on the eyebrow. c. On 4/12/2023, Resident 1 fell on the floor face down, bled from the nose, and sustained discoloration (any change in your natural skin tone) and swelling to the left eyes. The facility transferred Resident 1 to a GACH for further evaluation and treatment. Resident 1 was admitted at GACH's Intensive Care Unit (ICU - Specialist hospital wards that provide treatment and monitoring for people who are very ill) for higher level of care. Resident1 was diagnosed with Subgaleal (accumulation of blood under the scalp) with left pre-septal orbital (surrounding the eye) hematoma (occurs when a blood vessel in the space between the skull and the brain), right subdural (something beneath the outer layer of membranes around the brain) hematoma, left temporal skull (head) fracture (break in a bone that forms part of the side and base of the skull), subarachnoid hemorrhage (bleeding in the space below one of the thin layers that cover and protect your brain), [NAME] II facial fracture (broken bones within the face), Cervical spine (C-spine - the neck region) fractures; and left frontal epidural bleeding (bleeding between the inside of the skull and the outer covering of the brain). Findings: A review of Resident 1's Admission Record (Face sheet) indicated, the facility initially admitted Resident 1 on 2/16/2023 and readmitted the resident on 4/4/2023 with diagnoses that included Parkinson Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), progressive supranuclear ophthalmoplegia (a rare neurological disorder [disorders that affect the brain, the nerves, and the spinal cord] that affects your body movements, walking and balance, and eye movement), muscle weakness (decreased muscle function), abnormalities of gait and mobility (the body systems that control the way a person walks do not function in the usual way), type 2 diabetes (condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), and hypertension (high blood pressure). A review of Resident 1's History and Physical dated 2/17/2023, indicated Resident 1 had the capacity to understand and make his own decisions. A review of Resident 1's Minimum Date Set (MDS-a standardized assessment care screening tool) for an initial assessment, dated 2/23/2022, indicated Resident 1 required extensive two person assist with transfers and one person assist with bed mobility, dressing, toilet use and personal hygiene. A review of Resident 1's Care Plan for fall risk prevention and management, was initiated on 2/16/2023, was related to musculoskeletal (Having to do with muscles, bones, tendons, ligaments, joints, and cartilage) pain, shuffled gait (manner of walking), stiffness, unsteadiness, dizziness, tender joints, swollen joints, poor weight bearing (decreased ability to place force or weight on a specific limb), poor fitting shoes. The Goals included Resident 1, will be free of serious injury if a fall would occur. The Interventions included, to ensure the call light in reach and answer promptly, encourage to use safety devices as ordered, explain all procedures, monitor resident safety, provide privacy when giving care and remind the resident and reinforce safety awareness. A review of Resident 1's Care Plan for Altered thought process related to at risk for ., falls and injuries, initiated 2/16/2023, did not indicate any goals or interventions to address at risk for falls and injuries. A review of Resident 1's Care Plan for at risk for falls and injury initiated 2/22/2023, indicated the interventions included to monitor Resident 1 for risk for falls. A review of Resident 1's Care Plan for poor safety awareness, initiated 3/1/2023, indicated the interventions included to observe Resident 1 for unsafe behavior or mobility and redirect as needed. A review of Resident 1's Nursing progress notes dated 4/4/2023 timed at 10:05 AM, indicated the paramedics (a team of healthcare professionals who responds to emergency calls for medical help outside of a hospital. Paramedics mainly work as part of the emergency medical services, most often in ambulances) transferred Resident 1 out of the facility via 911 (a telephone number in the US [United States] that links the public to the police and mobile rescue units to provide emergency care) to a GACH for status post fall incident per medical doctors' orders. Resident 1 was noted with a hematoma (a collection (or pooling) of blood outside the blood vessel) on the right side of his head and a nosebleed. A review of Resident 1's Nursing Progress notes dated 4/4/2023 timed at 8 PM, indicated, the facility readmitted Resident 1 from a GACH emergency department (ED) post (after) fall . No new order (physician orders) noted from the ED. Resident 1 was in stable condition. Resident 1 was placed on a low bed (bed in low position, close to the floor) with floor mats (soft mats to assist with prevention of injury due to a fall) on the floor for injury prevention. All needs for Resident 1 were anticipated and met and the call light left within reach. A review of Resident 1's Care Plan dated 4/4/2023, indicated Resident 1 was found on the floor. The goals indicated that Resident 1, will have no further delayed injury related to fall. The interventions indicated to monitor Resident 1's vital signs (measurements of the body's basic functions such as the body temperature, heart rate [the rate of the heartbeat]), respiratory rate (rate of breathing) blood pressure, oxygen saturation (the amount of oxygen circulating in your blood), neuro checks (neurological examination is an assessment tool to determine a patient's brain function) for at least 72 hours. The interventions further indicated to notify a medical doctor of noticeable changes, refer to IDT for review of plan of care, and to transfer to hospital for further evaluation for Resident 1. On 4/19/2023, the surveyor requested the facility for Resident 1's Fall risk assessment documentation after the fall on 4/4/2023. However, the facility was not able provide the requested fall risk assessment documentation. A review of Resident 1's Care Plan for Actual Fall initiated on 4/6/2023, indicated Resident 1 had actual falls on 4/4/2023, 4/6/2023, and 4/12/2023. The goals included that Resident 1, will not have life threatening injury related to fall. The interventions included Resident 1 for, frequent visual supervision, prompt as needed to redirect behavior such as to stay in the wheelchair and to avoid getting up. A review of Resident 1's Nursing Progress notes dated 4/6/2023 timed at 5:42 PM, indicated Resident 1, is on monitoring for status post found on the floor times (x) 2 (two). The nursing progress notes indicated Resident 1 had an actual fall on 4/6/2023 (second fall) and the NP was notified. The NP ordered Ativan (a medication that sedates and can be used for anxiety, difficulty sleeping and seizure), blood work, safety helmet (head protection gear), knee, and elbow pads on 4/6/2023. A review of Resident 1's Care Plan dated 4/6/2023, indicated Resident 1 was found on the floor and had an actual fall. The goals for the care plan indicated Resident 1, will have no further delayed injury related to fall initiated on 4/6/2023. The interventions included, to monitor vital signs and neuro checks for at least 72 hours, notify a medical doctor of any noticeable changes, and refer to IDT team for further review of plan of care for Resident 1. A review of Resident 1's Post Fall Review notes dated 4/6/2023, timed at 6:18 PM, indicated, IDT met and had a post fall discussion about the resident [Resident 1]. IDT agreed that resident [Resident 1] should be supervised during activities and when out of his room to ensure he is assisted and when attempting to get up will have staff to prompt him to sit back, . Instruct the rest of staff to be observant when he is showing signs of being restless . Inform MD (medical doctor) of any change of condition. A review of Resident 1's Post Fall Review notes dated 4/12/2023, timed at 10:30 PM, indicated Resident 1, was found on the floor face down, ., with a left eye swollen and discoloration and also bleeding from the nose and hematoma. Vital signs (measures the basic functions of the body - temperature, blood pressure, pulse and respiratory [breathing]) were within normal range. A Medical Doctor was notified and ordered to transfer Resident 1 to GACH via 911. Resident 1 was transferred to a GACH via 911 paramedics on 4/12/2023 at 11 PM. A review of Resident 1's Post Fall Review notes dated 4/13/2023, timed at 11 AM, indicated, IDT met to discuss measures to prevent further falls, impulsive, able to follow instructions only for brief periods. Forgets directions such as avoid getting up and wait for assistance . Dependent for ADLs (activities of daily living), history of dementia. He [Resident 1] will be placed on 1:1 staffing for close monitoring and redirect as needed to prevent further episode of fall. A review of Resident 1's GACH history and physical, dated 4/13/2023, indicated, Resident 1, who lives in a nursing home, was brought in by paramedics after sustaining a fall when he fell getting out of bed. The patient [Resident 1] normally has depressed Glaucoma Coma Scale (GCS - used to objectively describe the extent of a person's impaired consciousness [is a state where consciousness has been affected by damage to the brain] in all types of acute medical and trauma [injury] patients). However, according to staff at the facility, his [Resident 1] GCS was significantly depressed from normal. He [Resident 1] was therefore brought in as a level 1 trauma (the highest level of trauma care to critically ill or injured patients). Upon arrival, the patient was arousable (able to respond to stimulation) but unable to answer questions effectively and unable to give answers. This is . old gentleman, status post sustaining a blunt head trauma (physical injury caused by a non-penetrating impact via a blunt object or surface and suffering numerous intracranial hemorrhages [refers to acute bleeding inside your skull or brain]) consisting of left frontal epidural bleeding (bleeding between the inside of the skull and the outer covering of the brain) and subdural hematoma is damaged as well as right subdural hematoma and associated left temporal skull fracture (break in the bone in the brain), pneumocephalus (presence of air or gas within the brain cavity), subarachnoid hemorrhage (bleeding in the space below one of the thin layers that cover and protect your brain) as well as [NAME] II facial fracture (broken bones within the face) and numerous maxillary (the bones that form the upper part of the jaw, the roof of the mouth, and parts of the eye socket and nose) ) sinus fractures.The patient will be admitted to ICU. A review of Resident 1's GACH Consultation document dated 4/13/2023, indicated reason for the consultation was facial fractures. The consultation document indicated Resident 1 was in the ICU and was noted with ecchymosis (a discoloration of the skin resulting from bleeding underneath) to both periorbital regions. Resident 1 had a hard collar (a device designed to support and limit movement of the commonly used to manage spinal fractures) to the neck. The consultation had the following impressions were noted for Resident 1: 1. Subgaleal with left pre-septal orbital (surrounding the eye) hematoma, and the left temporal bone fracture is mildly depresses measuring 2 (two) millimeters (mm- unit of measurement). 2. Left Le Fort II fracture complex fractures of the left maxillozygomatic (The bones that form the upper part of the jaw and cheekbones) complex as described in detail above with associated left tripod (a bone that that is part of the eye socket) fracture. 3. Acute comminuted (crushed into numerous pieces) left squamosal (a bone within the human skull) bone fracture with 2 mm depression. 4. Left greater wing of the sphenoid (a bone within the human skull) fracture with bilateral (both) lesser wing of the sphenoid fracture and extension through bilateral walls of the sphenoid sinus and the anterior (the front) and posterior (the back) walls extending through the basisphenoid (a bone at the base of the human skull). 5. Left comminuted frontal zygomatic (facial bone) suture fractures of the left orbit (bones that make up the human eye socket) to include the lateral (relating to the side of the human body), medial (relating to the middle of the human body) and inferior (relating to the inside portion of the human body) walls as well as the left inferior rim. 6. Acute left nasal bone fracture with patent nasopharynx (The upper part of the throat behind the nose). 7. Hemosinus (Hemo [blood] and sinus [a pouch or a cavity within the tissues]) of the left maxillary, sphenoid and bilateral ethmoid sinuses (a hollow space in the bones around the nose). A review of Resident 1's GACH discharge summary report dated 4/17/2023, indicated, Resident 1 was admitted to the ICU, neurosurgery (medical doctor who specializes in brain surgery) consult was requested, Neurosurgeon (A doctor who specializes in surgery on the brain, spine, and other parts of the nervous system) recommended Magnetic Resonance Imaging (MRI - is a non-invasive imaging technology that produces three dimensional detailed anatomical images) of the C-spine. The C-spine MRI was negative for acute injury, neurosurgeon recommended nonoperative management of head injury. The Ear, Nose and Throat (ENT) Medical Doctor consult recommended nonoperative management of facial fractures. Patient [Resident 1] was cleared for discharge back to skilled nursing facility on 4/17/2023. A review of Resident 1's Nursing Progress notes dated 4/17/2023 timed at 9 PM, indicated the facility readmitted Resident 1 from GACH on 4/17/2023. Resident 1 was complaining of five out of 10 pain level (5/10 - Numerical pain assessment tool where zero is no pain and 10 is severe pain). Resident 1 was administered Tylenol (medication that can be used for pain) 325 milligram (mg), 2 tablets when needed for facial headache pain and medication was effective. Resident 1 was placed on 1:1 monitoring for fall prevention and safety. On 4/19/2023, the surveyor requested for Resident 1's Fall risk assessment documentation during the initial admission on 2/16/2023 and for the actual fall that occurred on 4/6/2023. However, the medical records director was not able to provide the requested fall risk assessment documentation. On 4/19/2023 at 11:44 PM during an interview, the Registered Nurse Supervisor (RNS) stated that a few weeks ago (unsure of exact date) Resident 1 was found next to his bed on the floor. Resident 1 was noted with bleeding from the nose and Resident 1 was transferred to a GACH. On 4/19/2023 at 1:40 PM during an interview, Licensed Vocational Nurse 1 (LVN 1) stated that on 4/4/2023, a Certified Nursing Assistant (CNA) informed her that Resident 1 was on the floor by the bed. LVN 1 stated Resident 1 had a history of trying to get up out of bed. LVN 1 stated she went to Resident 1's bed and found Resident 1 on the floor, on top of the floor mat which was next to the resident's bed. LVN 1 stated Resident 1 was bleeding from the nose and had a bump on the right side of the head. LVN 1 stated, I informed the registered nurse in charge and 911 was called. The resident was sent to the hospital. LVN 1 stated Resident 1 returned to the facility the same night on 4/4/2023. LVN 1 stated that on 4/6/2023 Resident 1 was in the dining room seated in a wheelchair and later the activity's assistant informed her that Resident 1 was found on the ground, on his left side, and sustained a minor scratch on the side of his eyebrow. LVN 1 further stated the treatment nurse placed a bandage on Resident 1's eyebrow and Resident 1 was placed back into the wheelchair. LVN 1 stated she was not in the facility when Resident 1 fell on [DATE]. On 4/19/2023 at 1:57 PM during an interview, CNA 1 stated the facility assigned her to Resident 1 as a 1:1 sitter since 4/6/2023 and to monitor Resident 1 for safety and prevent Resident 1 from falling. CNA 1 stated she was on light duty and worked from 7 AM to 3 PM five days a week. CNA 1 stated from 4/6/2023 to 4/12/2023, Resident 1 was awake and was to communicate with her and was able to state his needs. CNA 1 stated Resident 1 regularly tried to get out of bed. CNA 1 stated Resident 1 required to be redirected to remain in bed. CNA 1 stated she was unsure if the facility continued to provide 1:1 monitoring for Resident 1 after her 7 AM to 3 PM ended. On 5/11/2023 at 3:38 PM, during an interview, the Director of Nursing (DON) stated Resident 1 was a high risk for falls. The DON stated following Resident 1's second fall on 4/6/2023, Resident 1 should have been placed on 1:1 monitoring to prevent further falls. The DON stated that on 4/12/2023, Resident 1 was in his wheelchair and was sitting in the DON's office until the DON left the facility at 8 PM. The DON further stated she placed Resident 1 at the nursing station and informed unnamed staff, to monitor Resident 1 until the 11 PM-7 AM shift staff arrived. The DON stated she was unsure why the nursing staff placed Resident 1 back into his [Resident 1] room unsupervised before the 11 PM. The DON stated that Resident 1 should not have been placed back into his room unsupervised and should have been on 1:1 monitoring for safety and to prevent falls. The DON stated Resident 1's fall(s) could have been prevented if Resident 1 was placed on 1:1 monitoring and supervision. On the same interview, the DON stated the facility never implemented the helmet, knee pads and elbow pads ordered by NP on 4/6/2023 for Resident 1. The DON stated, if this were [the helmet, knee pads and elbow pads] implemented this will lessen the impact of the fall. A review of the facility's policy and procedures titled, Falls and Fall Risk, Managing, dated 3/2018, indicated, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risk and causes to try to prevent the resident from falling and try to minimize complications from falling .Resident-Centered approaches to managing falls and fall risk, the staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls .If a systematic evaluation of resident's fall risk identifies several possible interventions, the staff my choose to prioritize interventions .If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant .If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified.

Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from neglect by failing to provide the appropriate services and treatment to maintain or improve range of motion (ROM, full movement potential of a joint) to one of three sampled residents (Resident 1) with identified ROM limitations by failing to: 1) Provide passive ROM (PROM, movement of a joint through the ROM with no effort from the resident) exercises to both of Resident 1's arms in accordance with physician ' s orders to start Restorative Nurse Aide (RNA, nursing aide program that helps residents to maintain their function and joint mobility) program and the Occupational Therapist (OT - profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) recommendations to apply splints to both of Resident 1 arms, including resting hand splint (RHS, splint secured from the hand to the forearm to position the hand in a functional position), Posey pillow (soft splint secured to the hand to bring the fingers away from the palm), and elbow splints (splint secured from the forearm to the upper arm to extend the elbow or prevent the elbow from bending) from 6/1/2020, 6/8/2020 to 6/10/2020, 6/14/2020, 6/15/2020, 6/21/2020, 6/22/2020, 6/27/2020, 7/2/2020, 7/4/2020, 7/5/2020, 7/9/2020, 7/15/2020, 7/17/2020, 7/17/2020, 7/21/2020, 7/28/2020, 8/2/2020, 8/6/2020 to 8/8/2020, 8/11/2020, 8/12/2020, 8/14/2020, 8/15/2020, 8/18/2020, 8/24/2020 to 8/31/2020, 10/1/2020 to 10/7/2020, 10/12/2020, 10/13/2020, 10/19/2020, 10/24/2020, 10/26/2020, 10/29/2020, 10/30/2020, 11/7/2020, 11/19/2020, 11/25/2020, 11/27/2020, 11/29/2020, 11/30/2020, 12/1/2020 to 12/8/2020, 12/12/2020 to 12/20/2020, 12/22/2020, 12/23/2020, 12/25/2020 to 12/31/2020, 1/1/2021 to 1/18/2021, 1/20/2021 to 1/24/2021, 1/26/2021 to 1/30/2021, 2/1/2021 to 2/7/2021, 2/9/2021 to 2/14/2021, 2/16/2021 to 2/21/2021, 2/23/2021 to 2/28/2021, 3/1/2021 to 3/3/2021, 3/9/2021, 3/21/2021, 3/26/2021, 3/28/2021, 4/1/2021, 4/3/2021, 4/15/2021, 4/16/2021, 4/20/2021, 4/22/2021, 4/27/2021, 4/28/2021 to 4/30/2021, 6/1/2021 to 6/8/2021, 6/17/2021, 6/18/2021, 6/21/2021 to 6/25/2021, 6/28/2021 to 6/30/2021, 7/1/2021, 7/2/2021, 7/5/2021 to 7/9/2021, 7/12/2021 to 7/16/2021, 7/19/2021 to 7/23/2021, 7/26/2021 to 7/30/2021, 8/6/2021, 8/13/2021, 8/16/2021 to 8/20/2021, 8/23/2021 to 8/27/2021, 8/30/2021, and 8/31/2021 (total of 13 months); and 2) Apply both hand splints (a rigid or flexible device that maintains in position a displaced or movable part) and both elbow splints to Resident 1 ' s arms in accordance with the OT recommendation since discharge from OT on 5/19/2021, a total of over one year and seven months. These failures resulted in Resident 1 experiencing further decline in ROM to both arms, including the development of contractures (irreversible deformity and joint stiffness) which interfered with Resident 1 ' s activities of daily living (ADLs, tasks related to personal care including bed mobility, hygiene, grooming, dressing, toileting, and bathing). Cross Reference F688 Findings: A record review of Resident 1's Admission Record indicated the facility originally admitted Resident 1 on 10/28/2019 with diagnoses including chronic respiratory failure (inability to effectively exchange carbon dioxide from the blood), ventilator dependence (mechanical ventilation to sustain daily respiration), and quadriplegia (paralysis [loss of ability to move all or part of the body] that affects all a person's limbs and body from the neck down). A review of Resident 1's History and Physical, dated 10/30/2019, did not indicate Resident 1 had preexisting contractures. A review of Resident 1's Minimum Data Set (MDS - standardized assessment and screening tool), dated 11/4/2019, indicated Resident 1 did not have an active diagnosis of impairment/contractures to both sides of upper extremity (BUE, both arms) and lower extremities (BLE, both legs). The MDS indicated Resident 1 had functional limitation (restriction or lack of ability to perform an action or activity in the manner or within the range considered normal that results from impairment) in range of motion in both arms and both legs. The MDS indicated Resident 1 was totally dependent for ADLs, including bed mobility, transfers, dressing, eating, toilet use, hygiene, and bathing. A review of Resident 1's Occupational Therapy (OT) Evaluation and Plan of Treatment report, dated 10/29/2019, indicated Resident 1's did not have any functional limitations due to contractures in both arms. The OT Evaluation indicated the following ROM for both of Resident 1's arms: - Right shoulder: within functional limits (WFL, sufficient ROM without significant limitation) - Right elbow/forearm: WFL - Right wrist: WFL with limited extension (wrist bend upward) - Right thumb: Impaired - Right index finger: Impaired - Right middle finger: Impaired - Right ring finger: WFL - Right little finger: WFL - Left shoulder flexion (raising the arm in front of the body and then overhead): 0-45 degrees - Left shoulder abduction (raising the arm to the side of the body and then overhead): 0-45 degrees - Left elbow/forearm: WFL - Left wrist: WFL with limited extension - Left thumb: Impaired - Left middle finger: Impaired - Left ring finger: WFL - Right little finger: WFL The OT Evaluation for Resident 1 indicated the reason for skilled therapy services included but was not limited to establish the RNA program to enhance patient's quality of life. A review of the facility's policy and procedures titled, Specialized Rehabilitative Services dated 7/2017, indicated once a resident has met his/her care plan goals, a licensed professional can either discontinue treatment or initiate a maintenance program which either nursing or restorative aides will implement to assure that the resident maintains his/her functional status. A review of Resident 1's physician's order indicated to discontinue PT (Physical Therapy), OT, and ST (Speech Therapy) effective 11/13/2019 and to start the RNA program. A review of Resident 1's physician ' s order, dated 11/14/2019 at 2:26 PM, indicated RNA program for PROM (passive ROM, movement of a joint through the ROM with no effort from patient)/gentle sustained stretch to all joints of BUE and BLE to end of range one time a day. A review of Resident 1's RNA flow sheet for the month of 11/2019, indicated Resident 1 to start RNA program from 11/14/2019 and Resident 1 receive RNA therapy from 11/15/2019 to 11/30/2019. A review of Resident 1's RNA flow sheet for the month 6/2020, indicated blank records for the following nine dates: 6/1/2020, 6/8/2020, 6/9/2020, 6/10/2020, 6/14/2020, 6/15/2020, 6/21/2020, 6/22/2020, and 6/27/2020. A review of Resident 1's RNA flow sheet for the month 7/2020, indicated blank records for the following eight dates: 7/2/2020, 7/4/2020, 7/5/2020, 7/9/2020, 7/15/2020, 7/17/2020, 7/21/2020, and 7/28/2020. A review of Resident 1's RNA flow sheet for the month 8/2020, indicated blank records for the following 17 dates: 8/2/2020, 8/6/2020, 8/7/2020, 8/8/2020, 8/11/2020, 8/12/2020, 8/14/2020, 8/15/2020, 8/18/2020, 8/24/2020, 8/25/2020, 8/26/2020, 8/27/2020, 8/28/2020, 8/29/2020, 8/30/2020, and 8/31/2020. A review of Resident 1's Care Profile (admission and discharge records) report, indicated Resident 1 was discharged from the facility on 8/22/2020 and readmitted to the facility on [DATE]. A review of Resident 1's physician ' s order, dated 9/30/2020 at 3:38 PM, indicated to provide Resident 1 with an RNA program for PROM/gentle sustained stretch to all joints of BUE to end of range as tolerated, every day shift. A review of Resident 1's Restorative Nursing Flow Sheet (record of RNA treatment sessions) for the month of 10/2020 indicated blank records for the following 14 dates: 10/1/2020, 10/2/2020, 10/3/2020, 10/4/2020, 10/5/2020, 10/6/2020, 10/7/2020, 10/12/2020, 10/13/2020, 10/19/2020, 10/24/2020, 10/26/2020, 10/29/2020, and 10/30/2020. A review of Resident 1's Restorative Nursing Flow Sheet for the month of 11/2020 indicated blank records for the following six dates: 11/7/2020, 11/19/2020, 11/25/2020, 11/27/2020, 11/29/2020, and 11/30/2020. A review of Resident 1's Restorative Nursing Flow Sheet for the month of 12/2020 indicated blank records for 26 dates: 12/1/2020, 12/2/2020, 12/3/2020, 12/4/2020, 12/5/2020, 12/6/2020, 12/7/2020, 12/8/2020, 12/12/2020, 12/13/2020, 12/14/2020, 12/15/2020, 12/16/2020, 12/17/2020, 12/18/2020, 12/19/2020, 12/20/2020, 12/22/2020, 12/23/2020, 12/25/2020, 12/26/2020, 12/27/2020, 12/28/2020, 12/29/2020, 12/30/2020, and 12/31/2020. A review of Resident 1's Restorative Nursing Flow Sheet for the month of 1/2021 indicated blank records for the following 28 dates: 1/1/2021, 1/2/2021, 1/3/2021, 1/4/2021, 1/5/2021, 1/6/2021, 1/7/2021, 1/8/2021, 1/9/2021, 1/10/2021, 1/11/2021, 1/12/2021, 1/13/2021, 1/14/2021, 1/15/2021, 1/16/2021, 1/17/2021, 1/18/2021, 1/20/2021, 1/21/2021, 1/22/2021, 1/23/2021, 1/24/2021, 1/26/2021, 1/27/2021, 1/28/2021, 1/29/2021, and 1/30/2021. A review of Resident 1's Restorative Nursing Flow Sheet for the month of 2/2021 indicated blank records for the following 25 dates: 2/1/2021, 2/2/2021, 2/3/2021, 2/4/2021, 2/5/2021, 2/6/2021, 2/7/2021, 2/9/2021, 2/10/2021, 2/11/2021, 2/12/2021, 2/13/2021, 2/14/2021, 2/16/2021, 2/17/2021, 2/18/2021, 2/19/2021, 2/20/2021, 2/21/2021, 2/23/2021, 2/24/2021, 2/25/2021, 2/26/2021, 2/27/2021, and 2/28/2021. A review of Resident 1's Restorative Nursing Flow Sheet for the month of 3/2021 indicated blank records for the following seven dates: 3/1/2021, 3/2/2021, 3/3/2021, 3/9/2021, 3/21/2021, 3/26/2021, and 3/28/2021. A review of Resident 1's OT Evaluation and Plan of Treatment report, dated 4/14/2021, indicated Resident 1 had functional limitations due to contractures which increased difficulty for caregivers to provide care due to the limited ROM in both arms. The OT Evaluation indicated the caregiver goals for Resident 1 included for ROM to improve to allow for efficient self-care. The OT Evaluation indicated the following ROM for both arms: - Right shoulder flexion: 0-70 degrees - Right shoulder abduction: 0-45 degrees - Right elbow/forearm: flexion contracture (elbow fixed in a bent position) to 60 degrees of extension (unable to fully straighten elbow) - Right wrist: flexion contracture (wrist fixed in a bent position) - Right hand: MP (metacarpophalangeal joint, knuckle joint) contractures at 90 degrees of flexion (knuckles fixed in a bent position) - Left shoulder flexion: 0-20 degrees - Left shoulder abduction: 0-30 degrees - Left elbow/forearm: flexion contracture to 90 degrees of extension - Left wrist: WFL - Left hand: MP contractures at 90 degrees of flexion The OT Evaluation indicated the reason for skilled therapy services included but was not limited to providing skilled ROM, establishing a splinting protocol (procedure to apply and remove a splint) and redesign and implement Restorative Nursing Programs in order to enhance patient ' s quality of life by improving ROM and positioning in both arms. A review of Resident 1's RNA Flow Sheet for the month of 4/2021, indicated blank RNA program records for PROM gentle sustained stretch to all joints of BUE and BLE to end range as tolerated for the following 10 days dates: 4/1/2021, 4/3/2021, 4/15/2021, 4/16/2021, 4/20/2021, 4/22/2021, 4/27/2021, 4/28/2021, 4/29/2021, and 4/30/2021. A review of Resident 1's Occupational Therapy (OT) Discharge Summary, dated 5/19/2021, indicated an RNA program was established and trained in providing Resident 1 with PROM/gentle-sustained stretch to all joint of both arms. The OT Discharge Summary also indicated the RNA program was established and trained in applying splints to both of Resident 1 arms, including a right resting hand splint left Posey pillow and elbow splints to both of Resident 1 ' s arms. A review of Resident 1's Restorative Therapy Referral document, dated 5/19/2021, signed by the RNA and Occupational Therapist (OT), indicated Resident 1 was at risk for decline in range of motion of both arm and both legs. The note indicated the goal was to maintain current ROM of arms and legs and prevent joint stiffness. The approaches included for the RNA to perform PROM exercises to both arms and both legs and to apply the right resting hand splint, left pillow splint, and both elbow splints for six to eight hours, five days a week. A review of Resident 1's physician ' s order, dated 5/19/2021 at 1:20 PM, indicated RNA program for PROM/gentle sustained stretch to all joints of both arms and both legs, every day, five times per week. Resident 1's physician ' s order did not include to apply a right resting hand splint, left pillow splint, and both elbow splints to Resident 1's arms. A review of Resident 1's Restorative Nursing Flow Sheet for the month of 6/2021 indicated blank records for the following 18 dates: 6/1/2021, 6/2/2021, 6/3/2021,6/4/2021, 6/5/2021, 6/6/2021, 6/7/2021, 6/8/2021, 6/17/2021, 6/18/2021, 6/21/2021, 6/22/2021, 6/23/2021, 6/24/2021, 6/25/2021, 6/28/2021, 6/29/2021, and 6/30/2021. A review of Resident 1's Care Profile (admission and discharge records) report, indicated Resident 1 was discharged from the facility on 6/7/2021 and readmitted to the facility on [DATE]. A review of Resident 1's physician ' s order, dated 6/17/2021 at 3:00 PM, indicated RNA program for PROM/gentle sustained stretch to all joints of both arms to end of range as tolerated, five times a week, every day shift, every Monday, Tuesday, Wednesday, Thursday, and Friday. Resident 1 ' s physician ' s order did not include to apply a right resting hand splint, left pillow splint, and both elbow splints to Resident 1 ' s arms. A review of Resident 1's Restorative Nursing Flow Sheet for the month of 7/2021 indicated blank records for the following 22 dates: 7/1/2021, 7/2/2021, 7/5/2021, 7/6/2021, 7/7/2021, 7/8/2021, 7/9/2021, 7/12/2021, 7/13/2021, 7/14/2021, 7/15/2021, 7/16/2021, 7/19/2021, 7/20/2021, 7/21/2021, 7/22/2021, 7/23/2021, 7/26/2021, 7/27/2021, 7/28/2021, 7/29/2021, and 7/30/2021. A review of Resident 1 ' s RNA flow sheet for the month 8/2021, indicated blank records for the following 14 dates: 8/6/2021, 8/13/2021, 8/16/2021, 8/17/2021, 8/18/2021, 8/19/2021, 8/20/2021, 8/23/2021, 8/24/2021, 8/25/2021, 8/26/2021, 8/27/2021, 8/30/2021 and 8/31/2021. A review of Resident 1's Care Profile (admission and discharge records) report, indicated Resident 1 was discharged from the facility on 8/12/2021 and readmitted to the facility on [DATE]. The Care Profile report indicated Resident 1 had multiple discharges and readmissions to the facility, including a readmission on 1/5/2023. A review of Resident 1's physician's orders indicated the following RNA orders between 8/27/2021 to 1/5/2023 which did not include application of splints to both of Resident 1's arms: - 10/5/2021 at 8:21 AM: RNA program for PROM/gentle sustained stretch to all joints of BUE and BLE to end of range as tolerated daily, every day shift. - 10/12/2022 at 6:38 PM: RNA program for PROM/gentle sustained stretch to all joints of BUE to end of range as tolerated daily, every day shift. - 11/2/2021 at 12:22 PM and 12:23 PM: RNA program for PROM/gentle sustained stretch to all joints of BUE and BLE to end of range as tolerated daily, every day shift. - 11/4/2021 at 6:43 PM: RNA program for PROM/gentle sustained stretch to all joints of BUE and BLE to end of range as tolerated daily, every day shift. - 8/9/2022 at 3:44 PM: RNA program for PROM/gentle sustained stretch to all joint of BUE to end range as tolerated daily, every day shift. - 11/30/2022 at 3:54 PM: RNA program for PROM/gentle sustained stretch to all joints of BUE to end of range as tolerated daily, every day shift. - 12/26/2022 at 3:54 PM: RNA program for PROM/gentle sustained stretch to all joint of BUE to end range as tolerated daily, every day shift. On 1/12/2023 at 1:00 PM, during an interview and record review, the Occupational Therapist (OT) stated OT evaluated Resident 1 on 10/29/2019 and on 4/14/2021. OT stated Resident 1 was to continue with the RNA Program for ROM to both arms and recommended for the RNA to apply a right hand splint, a left hand splint and both elbow splints after Resident 1's discharge on 5/19/2021. The OT further stated the splints would maintain joint mobility and prevent Resident 1 from abnormal positions to both elbows. The OT reviewed Resident 1's physician ' s orders and was unable to locate orders for the application of both hand splints and both elbow splints to Resident 1's arms. The OT stated the facility did not implement the aforementioned recommendations for Resident 1. OT further stated the facility did not a joint mobility assessment for initial admission and readmission. On 1/12/2023 at 1:30 PM, during an observation and interview with the Registered Nurse (RN), Resident 1 was awake in bed. Resident 1's arms were bent at the elbows, causing both hands to touch Resident 1's body. Resident 1 did not have any splints to both hands and both elbows. The Registered Nurse (RN) stated Resident 1 was not wearing any splints and that the RNAs were responsible for applying splints on Resident 1. The RN did not know if Resident 1 had a physician's order for the application of splints. On 1/12/2023 at 1:35 PM, during an interview and record review, the Licensed Vocational Nurse (LVN) stated Resident 1 has not had any splints to her elbows. The LVN reviewed Resident 1's physician's orders for RNA and did not locate any orders to apply splints on Resident 1's arms. The LVN stated it was the RNAs responsibility to apply splints if Resident 1 needed it. The LVN stated it was important to have splints to prevent further contractures to extremities. On 1/13/2023 at 2:00 PM., during an interview and record review with Restorative Nurse Assistant (RNA), Resident 1 ' s medical chart was reviewed. The RNA stated splints were not applied to Resident 1's arms because there was no order to apply splints in the RNA flow sheet, that she did not apply any splints or hand rolls on Resident 1, and the facility did not have enough nurses to provide RNA treatment. The RNA stated ROM exercises were important so they (the residents) don ' t become contracted (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff). The RNA further stated it was important to apply the splints on a resident to prevent further contractures of the joints. On 1/13/2023 at 2:30 PM, during an interview, the Director of Nurses (DON) stated, the facility currently had staffing shortage and was in the process hiring more nurses. The DON stated the facility was responsible to carry out orders and that the facility was supposed to obtain an order from the Medical Doctor to apply the splints to Resident 1 and did not know why this was not done as per OT recommendation on 5/19/2021. The DON stated splints were important because it prevents developing further contractures. On 1/23/2023 at 10:30AM, during an interview and record review with the OT, Resident 1's evaluation and plan of treatment dated 10/29/2019 was reviewed. The OT stated Resident 1's functional limitations were present due to contracture and that the resident's functional limitation was a result of contracture which increased difficulty for caregiver to provide care due to Resident 1's limited ROM of joints. The OT further stated Resident 1's upper extremity muscle tone was rigid, hypertonic (abnormal increase in muscle tone) in a fixed position and had recommended orthotic (an external medical device such as a brace or splint to support, immobilize, or treat muscles and or joints) hand roll splint to right hand, carrot (a device that positions the finger away from the palm to protect the skin from moisture, pressure and nail puncture) to left hand, potential use of elbow extension. Resident 1's evaluation and plan treatment under clinical impressions, indicated Resident 1 continues to be TD (total dependent) with ADLs, bed mobility, and functional mobility but presents with decreased joint ROM and increased contractures. Resident (Resident 1) requires skilled OT services to maximize rehab potential by providing skilled range of motion, establishing splinting protocol and redesign and implement restorative nursing programs in order to enhance patient's quality of life by improving ROM and positioning in upper extremities to allow for improves ADL participation. The OT stated there was a recommendation to apply a splint to the right hand, a carrot splint to the left hand, and both elbow splints for Resident 1. A review of the facility's policy and procedures titled, Resident Mobility and Range of Motion dated 7/2017, indicated residents will not experience an avoidable reduction in range of motion. Residents with limited range of motion will receive treatment and services to increase and or prevent further decrease in range of motion. Residents with limited mobility will receive appropriate services, equipment, and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. A review of the facility's document titled Abuse and Neglect-Clinical protocol revised 3/2018, indicated neglect means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. A review of the facility's policy and procedures titled Abuse Prevention Program revised 8/2021, indicated Our residents have the right to be free from . neglect . A review of the facility's policy and procedures titled Staffing, Sufficient and Competent Nursing, revised 8/2022, indicated Our facility provides sufficient numbers of nursing staff with appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with residents care plans and the facility assessment . Licensed nurses and certified nursing assistants are available 24 hours a day, seven (7) days a week to provide competent resident care services including . (b) Attaining or maintaining the highest practicable physical, mental and psychological well-being of each resident . (7) Factors considered in determining appropriate staffing ratios and skills include an evaluation of the diseases, conditions, physical or cognitive limitations of the of the resident population, and acuity (the level of severity of an illness).

Based on observation, interview, and record review, the facility failed to provide the appropriate services and treatment to maintain or improve range of motion (ROM, full movement potential of a joint) to one of three sampled residents (Resident 1) with identified ROM limitations by failing to: 1) Provide passive ROM (PROM, movement of a joint through the ROM with no effort from the resident) exercises to both of Resident 1's arms in accordance with physician's orders to start Restorative Nurse Aide (RNA, nursing aide program that helps residents to maintain their function and joint mobility) program and the Occupational Therapist (OT - profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) recommendations to apply splints to both of Resident 1 arms, including a right resting hand splint (RHS, splint secured from the hand to the forearm to position the hand in a functional position), left Posey pillow (soft splint secured to the hand to bring the fingers away from the palm), and elbow splints (splint secured from the forearm to the upper arm to extend the elbow or prevent the elbow from bending) from 6/1/2020, 6/8/2020 to 6/10/2020, 6/14/2020, 6/15/2020, 6/21/2020, 6/22/2020, 6/27/2020, 7/2/2020, 7/4/2020, 7/5/2020, 7/9/2020, 7/15/2020, 7/17/2020, 7/17/2020, 7/21/2020, 7/28/2020, 8/2/2020, 8/6/2020 to 8/8/2020, 8/11/2020, 8/12/2020, 8/14/2020, 8/15/2020, 8/18/2020, 8/24/2020 to 8/31/2020, 10/1/2020 to 10/7/2020, 10/12/2020, 10/13/2020, 10/19/2020, 10/24/2020, 10/26/2020, 10/29/2020, 10/30/2020, 11/7/2020, 11/19/2020, 11/25/2020, 11/27/2020, 11/29/2020, 11/30/2020, 12/1/2020 to 12/8/2020, 12/12/2020 to 12/20/2020, 12/22/2020, 12/23/2020, 12/25/2020 to 12/31/2020, 1/1/2021 to 1/18/2021, 1/20/2021 to 1/24/2021, 1/26/2021 to 1/30/2021, 2/1/2021 to 2/7/2021, 2/9/2021 to 2/14/2021, 2/16/2021 to 2/21/2021, 2/23/2021 to 2/28/2021, 3/1/2021 to 3/3/2021, 3/9/2021, 3/21/2021, 3/26/2021, 3/28/2021, 4/1/2021, 4/3/2021, 4/15/2021, 4/16/2021, 4/20/2021, 4/22/2021, 4/27/2021, 4/28/2021 to 4/30/2021, 6/1/2021 to 6/8/2021, 6/17/2021, 6/18/2021, 6/21/2021 to 6/25/2021, 6/28/2021 to 6/30/2021, 7/1/2021, 7/2/2021, 7/5/2021 to 7/9/2021, 7/12/2021 to 7/16/2021, 7/19/2021 to 7/23/2021, 7/26/2021 to 7/30/2021, 8/6/2021, 8/13/2021, 8/16/2021 to 8/20/2021, 8/23/2021 to 8/27/2021, 8/30/2021, and 8/31/2021 (total of 13 months); and 2) Apply both hand splints (a rigid or flexible device that maintains in position a displaced or movable part) and both elbow splints to Resident 1's arms in accordance with the OT recommendation since discharge from OT on 5/19/2021, a total of over one year and seven months. These failures resulted in Resident 1 experiencing further decline in ROM to both arms, including the development of contractures (irreversible deformity and joint stiffness) which interfered with Resident 1's activities of daily living (ADLs, tasks related to personal care including bed mobility, hygiene, grooming, dressing, toileting, and bathing). Cross Reference F600 Findings: A record review of Resident 1's Admission Record indicated the facility originally admitted Resident 1 on 10/28/2019 with diagnoses including chronic respiratory failure (inability to effectively exchange carbon dioxide from the blood), ventilator dependence (mechanical ventilation to sustain daily respiration), and quadriplegia (paralysis [loss of ability to move all or part of the body] that affects all a person's limbs and body from the neck down). A review of Resident 1's History and Physical, dated 10/30/2019, did not indicate Resident 1 had preexisting contractures. A review of Resident 1's Minimum Data Set (MDS - standardized assessment and screening tool), dated 11/4/2019, indicated Resident 1 did not have an active diagnosis of impairment/contractures to both sides of upper extremity (BUE, both arms) and lower extremities (BLE, both legs). The MDS indicated Resident 1 had functional limitation (restriction or lack of ability to perform an action or activity in the manner or within the range considered normal that results from impairment) in range of motion in both arms and both legs. The MDS indicated Resident 1 was totally dependent for ADLs, including bed mobility, transfers, dressing, eating, toilet use, hygiene, and bathing. A review of Resident 1's Occupational Therapy (OT) Evaluation and Plan of Treatment report, dated 10/29/2019, indicated Resident 1's did not have any functional limitations due to contractures in both arms. The OT Evaluation indicated the following ROM for both of Resident 1's arms: - Right shoulder: within functional limits (WFL, sufficient ROM without significant limitation) - Right elbow/forearm: WFL - Right wrist: WFL with limited extension (wrist bend upward) - Right thumb: Impaired - Right index finger: Impaired - Right middle finger: Impaired - Right ring finger: WFL - Right little finger: WFL - Left shoulder flexion (raising the arm in front of the body and then overhead): 0-45 degrees - Left shoulder abduction (raising the arm to the side of the body and then overhead): 0-45 degrees - Left elbow/forearm: WFL - Left wrist: WFL with limited extension - Left thumb: Impaired - Left middle finger: Impaired - Left ring finger: WFL - Right little finger: WFL The OT Evaluation for Resident 1 indicated the reason for skilled therapy services included but was not limited to establish the RNA program to enhance patient's quality of life. A review of the facility's policy and procedures titled, Specialized Rehabilitative Services dated 7/2017, indicated once a resident has met his/her care plan goals, a licensed professional can either discontinue treatment or initiate a maintenance program which either nursing or restorative aides will implement to assure that the resident maintains his/her functional status. A review of Resident 1's physician's order indicated to discontinue PT (Physical Therapy), OT, and ST (Speech Therapy) effective 11/13/2019 and to start the RNA program. A review of Resident 1's physician's order, dated 11/14/2019 at 2:26 PM, indicated RNA program for PROM (passive ROM, movement of a joint through the ROM with no effort from patient)/gentle sustained stretch to all joints of BUE and BLE to end of range one time a day. A review of Resident 1's RNA flow sheet for the month of 11/2019, indicated Resident 1 to start RNA program from 11/14/2019 and Resident 1 receive RNA therapy from 11/15/2019 to 11/30/2019. A review of Resident 1's RNA flow sheet for the month 6/2020, indicated blank records for the following nine dates: 6/1/2020, 6/8/2020, 6/9/2020, 6/10/2020, 6/14/2020, 6/15/2020, 6/21/2020, 6/22/2020, and 6/27/2020. A review of Resident 1's RNA flow sheet for the month 7/2020, indicated blank records for the following eight dates: 7/2/2020, 7/4/2020, 7/5/2020, 7/9/2020, 7/15/2020, 7/17/2020, 7/21/2020, and 7/28/2020. A review of Resident 1's RNA flow sheet for the month 8/2020, indicated blank records for the following 17 dates: 8/2/2020, 8/6/2020, 8/7/2020, 8/8/2020, 8/11/2020, 8/12/2020, 8/14/2020, 8/15/2020, 8/18/2020, 8/24/2020, 8/25/2020, 8/26/2020, 8/27/2020, 8/28/2020, 8/29/2020, 8/30/2020, and 8/31/2020. A review of Resident 1's Care Profile (admission and discharge records) report, indicated Resident 1 was discharged from the facility on 8/22/2020 and readmitted to the facility on [DATE]. A review of Resident 1's physician's order, dated 9/30/2020 at 3:38 PM, indicated to provide Resident 1 with an RNA program for PROM/gentle sustained stretch to all joints of BUE to end of range as tolerated, every day shift. A review of Resident 1's Restorative Nursing Flow Sheet (record of RNA treatment sessions) for the month of 10/2020 indicated blank records for the following 14 dates: 10/1/2020, 10/2/2020, 10/3/2020, 10/4/2020, 10/5/2020, 10/6/2020, 10/7/2020, 10/12/2020, 10/13/2020, 10/19/2020, 10/24/2020, 10/26/2020, 10/29/2020, and 10/30/2020. A review of Resident 1's Restorative Nursing Flow Sheet for the month of 11/2020 indicated blank records for the following six dates: 11/7/2020, 11/19/2020, 11/25/2020, 11/27/2020, 11/29/2020, and 11/30/2020. A review of Resident 1's Restorative Nursing Flow Sheet for the month of 12/2020 indicated blank records for 26 dates: 12/1/2020, 12/2/2020, 12/3/2020, 12/4/2020, 12/5/2020, 12/6/2020, 12/7/2020, 12/8/2020, 12/12/2020, 12/13/2020, 12/14/2020, 12/15/2020, 12/16/2020, 12/17/2020, 12/18/2020, 12/19/2020, 12/20/2020, 12/22/2020, 12/23/2020, 12/25/2020, 12/26/2020, 12/27/2020, 12/28/2020, 12/29/2020, 12/30/2020, and 12/31/2020. A review of Resident 1's Restorative Nursing Flow Sheet for the month of 1/2021 indicated blank records for the following 28 dates: 1/1/2021, 1/2/2021, 1/3/2021, 1/4/2021, 1/5/2021, 1/6/2021, 1/7/2021, 1/8/2021, 1/9/2021, 1/10/2021, 1/11/2021, 1/12/2021, 1/13/2021, 1/14/2021, 1/15/2021, 1/16/2021, 1/17/2021, 1/18/2021, 1/20/2021, 1/21/2021, 1/22/2021, 1/23/2021, 1/24/2021, 1/26/2021, 1/27/2021, 1/28/2021, 1/29/2021, and 1/30/2021. A review of Resident 1's Restorative Nursing Flow Sheet for the month of 2/2021 indicated blank records for the following 25 dates: 2/1/2021, 2/2/2021, 2/3/2021, 2/4/2021, 2/5/2021, 2/6/2021, 2/7/2021, 2/9/2021, 2/10/2021, 2/11/2021, 2/12/2021, 2/13/2021, 2/14/2021, 2/16/2021, 2/17/2021, 2/18/2021, 2/19/2021, 2/20/2021, 2/21/2021, 2/23/2021, 2/24/2021, 2/25/2021, 2/26/2021, 2/27/2021, and 2/28/2021. A review of Resident 1's Restorative Nursing Flow Sheet for the month of 3/2021 indicated blank records for the following seven dates: 3/1/2021, 3/2/2021, 3/3/2021, 3/9/2021, 3/21/2021, 3/26/2021, and 3/28/2021. A review of Resident 1's OT Evaluation and Plan of Treatment report, dated 4/14/2021, indicated Resident 1 had functional limitations due to contractures which increased difficulty for caregivers to provide care due to the limited ROM in both arms. The OT Evaluation indicated the caregiver goals for Resident 1 included for ROM to improve to allow for efficient self-care. The OT Evaluation indicated the following ROM for both arms: - Right shoulder flexion: 0-70 degrees - Right shoulder abduction: 0-45 degrees - Right elbow/forearm: flexion contracture (elbow fixed in a bent position) to 60 degrees of extension (unable to fully straighten elbow) - Right wrist: flexion contracture (wrist fixed in a bent position) - Right hand: MP (metacarpophalangeal joint, knuckle joint) contractures at 90 degrees of flexion (knuckles fixed in a bent position) - Left shoulder flexion: 0-20 degrees - Left shoulder abduction: 0-30 degrees - Left elbow/forearm: flexion contracture to 90 degrees of extension - Left wrist: WFL - Left hand: MP contractures at 90 degrees of flexion The OT Evaluation indicated the reason for skilled therapy services included but was not limited to providing skilled ROM, establishing a splinting protocol (procedure to apply and remove a splint) and redesign and implement Restorative Nursing Programs in order to enhance patient's quality of life by improving ROM and positioning in both arms. A review of Resident 1's RNA Flow Sheet for the month of 4/2021, indicated blank RNA program records for PROM gentle sustained stretch to all joints of BUE and BLE to end range as tolerated for the following 10 days dates: 4/1/2021, 4/3/2021, 4/15/2021, 4/16/2021, 4/20/2021, 4/22/2021, 4/27/2021, 4/28/2021, 4/29/2021, and 4/30/2021. A review of Resident 1's Occupational Therapy (OT) Discharge Summary, dated 5/19/2021, indicated an RNA program was established and trained in providing Resident 1 with PROM/gentle-sustained stretch to all joint of both arms. The OT Discharge Summary also indicated the RNA program was established and trained in applying splints to both of Resident 1 arms, including a right resting hand splint left Posey pillow and elbow splints to both of Resident 1's arms. A review of Resident 1's Restorative Therapy Referral document, dated 5/19/2021, signed by the RNA and Occupational Therapist (OT), indicated Resident 1 was at risk for decline in range of motion of both arm and both legs. The note indicated the goal was to maintain current ROM of arms and legs and prevent joint stiffness. The approaches included for the RNA to perform PROM exercises to both arms and both legs and to apply the right resting hand splint, left pillow splint, and both elbow splints for six to eight hours, five days a week. A review of Resident 1's physician's order, dated 5/19/2021 at 1:20 PM, indicated RNA program for PROM/gentle sustained stretch to all joints of both arms and both legs, every day, five times per week. Resident 1's physician's order did not include to apply a right resting hand splint, left pillow splint, and both elbow splints to Resident 1's arms. A review of Resident 1's Restorative Nursing Flow Sheet for the month of 6/2021 indicated blank records for the following 18 dates: 6/1/2021, 6/2/2021, 6/3/2021,6/4/2021, 6/5/2021, 6/6/2021, 6/7/2021, 6/8/2021, 6/17/2021, 6/18/2021, 6/21/2021, 6/22/2021, 6/23/2021, 6/24/2021, 6/25/2021, 6/28/2021, 6/29/2021, and 6/30/2021. A review of Resident 1's Care Profile (admission and discharge records) report, indicated Resident 1 was discharged from the facility on 6/7/2021 and readmitted to the facility on [DATE]. A review of Resident 1's physician's order, dated 6/17/2021 at 3:00 PM, indicated RNA program for PROM/gentle sustained stretch to all joints of both arms to end of range as tolerated, five times a week, every day shift, every Monday, Tuesday, Wednesday, Thursday, and Friday. Resident 1's physician's order did not include to apply a right resting hand splint, left pillow splint, and both elbow splints to Resident 1's arms. A review of Resident 1's Restorative Nursing Flow Sheet for the month of 7/2021 indicated blank records for the following 22 dates: 7/1/2021, 7/2/2021, 7/5/2021, 7/6/2021, 7/7/2021, 7/8/2021, 7/9/2021, 7/12/2021, 7/13/2021, 7/14/2021, 7/15/2021, 7/16/2021, 7/19/2021, 7/20/2021, 7/21/2021, 7/22/2021, 7/23/2021, 7/26/2021, 7/27/2021, 7/28/2021, 7/29/2021, and 7/30/2021. A review of Resident 1's RNA flow sheet for the month 8/2021, indicated blank records for the following 14 dates: 8/6/2021, 8/13/2021, 8/16/2021, 8/17/2021, 8/18/2021, 8/19/2021, 8/20/2021, 8/23/2021, 8/24/2021, 8/25/2021, 8/26/2021, 8/27/2021, 8/30/2021 and 8/31/2021. A review of Resident 1's Care Profile (admission and discharge records) report, indicated Resident 1 was discharged from the facility on 8/12/2021 and readmitted to the facility on [DATE]. The Care Profile report indicated Resident 1 had multiple discharges and readmissions to the facility, including a readmission on 1/5/2023. A review of Resident 1's physician's orders indicated the following RNA orders between 8/27/2021 to 1/5/2023 which did not include application of splints to both of Resident 1's arms: - 10/5/2021 at 8:21 AM: RNA program for PROM/gentle sustained stretch to all joints of BUE and BLE to end of range as tolerated daily, every day shift. - 10/12/2022 at 6:38 PM: RNA program for PROM/gentle sustained stretch to all joints of BUE to end of range as tolerated daily, every day shift. - 11/2/2021 at 12:22 PM and 12:23 PM: RNA program for PROM/gentle sustained stretch to all joints of BUE and BLE to end of range as tolerated daily, every day shift. - 11/4/2021 at 6:43 PM: RNA program for PROM/gentle sustained stretch to all joints of BUE and BLE to end of range as tolerated daily, every day shift. - 8/9/2022 at 3:44 PM: RNA program for PROM/gentle sustained stretch to all joint of BUE to end range as tolerated daily, every day shift. - 11/30/2022 at 3:54 PM: RNA program for PROM/gentle sustained stretch to all joints of BUE to end of range as tolerated daily, every day shift. - 12/26/2022 at 3:54 PM: RNA program for PROM/gentle sustained stretch to all joint of BUE to end range as tolerated daily, every day shift. On 1/12/2023 at 1:00 PM, during an interview and record review, the Occupational Therapist (OT) stated OT evaluated Resident 1 on 10/29/2019 and on 4/14/2021. OT stated Resident 1 was to continue with the RNA Program for ROM to both arms and recommended for the RNA to apply a right hand splint, a left hand splint and both elbow splints after Resident 1's discharge on 5/19/2021. The OT further stated the splints would maintain joint mobility and prevent Resident 1 from abnormal positions to both elbows. The OT reviewed Resident 1's physician's orders and was unable to locate orders for the application of both hand splints and both elbow splints to Resident 1's arms. The OT stated the facility did not implement the aforementioned recommendations for Resident 1. OT further stated the facility did not a joint mobility assessment for initial admission and readmission. On 1/12/2023 at 1:30 PM, during an observation and interview with the Registered Nurse (RN), Resident 1 was awake in bed. Resident 1's arms were bent at the elbows, causing both hands to touch Resident 1's body. Resident 1 did not have any splints to both hands and both elbows. The Registered Nurse (RN) stated Resident 1 was not wearing any splints and that the RNAs were responsible for applying splints on Resident 1. The RN did not know if Resident 1 had a physician's order for the application of splints. On 1/12/2023 at 1:35 PM, during an interview and record review, the Licensed Vocational Nurse (LVN) stated Resident 1 has not had any splints to her elbows. The LVN reviewed Resident 1's physician's orders for RNA and did not locate any orders to apply splints on Resident 1's arms. The LVN stated it was the RNAs responsibility to apply splints if Resident 1 needed it. The LVN stated it was important to have splints to prevent further contractures to extremities. On 1/13/2023 at 2:00 PM., during an interview and record review with Restorative Nurse Assistant (RNA), Resident 1's medical chart was reviewed. The RNA stated splints were not applied to Resident 1's arms because there was no order to apply splints in the RNA flow sheet. The RNA stated Resident 1's RNA Flow Sheets had missing initials. The RNA stated missing initials indicated Resident 1 did not receive RNA treatment. The RNA stated the facility did not have enough nurses to provide RNA treatment. The RNA stated ROM exercises were important so they (the residents) don't become contracted (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff). The RNA further stated it was important to apply the splints on a resident to prevent further contractures of the joints. On 1/13/2023 at 2:30 PM, during an interview, the Director of Nurses (DON) stated, the facility currently had staffing shortage and was in the process hiring more nurses. The DON stated the facility was responsible to carry out orders and that the facility was supposed to obtain an order from the Medical Doctor to apply the splints to Resident 1 and did not know why this was not done as per OT recommendation on 5/19/2021. The DON stated splints were important because it prevents developing further contractures. On 1/23/2023 at 10:30AM, during an interview and record review with the OT, Resident 1's evaluation and plan of treatment dated 10/29/2019 was reviewed. The OT stated Resident 1's functional limitations were present due to contracture and that the resident's functional limitation was a result of contracture which increased difficulty for caregiver to provide care due to Resident 1's limited ROM of joints. The OT further stated Resident 1's upper extremity muscle tone was rigid, hypertonic (abnormal increase in muscle tone) in a fixed position and had recommended orthotic (an external medical device such as a brace or splint to support, immobilize, or treat muscles and or joints) hand roll splint to right hand, carrot (a device that positions the finger away from the palm to protect the skin from moisture, pressure and nail puncture) to left hand, potential use of elbow extension. Resident 1's evaluation and plan treatment under clinical impressions, indicated Resident 1 continues to be TD (total dependent) with ADLs, bed mobility, and functional mobility but presents with decreased joint ROM and increased contractures. Resident (Resident 1) requires skilled OT services to maximize rehab potential by providing skilled range of motion, establishing splinting protocol and redesign and implement restorative nursing programs in order to enhance patient's quality of life by improving ROM and positioning in upper extremities to allow for improves ADL participation. The OT stated there was a recommendation to apply a splint to the right hand, a carrot splint to the left hand, and both elbow splints for Resident 1. A review of the facility's policy and procedures titled, Resident Mobility and Range of Motion dated 7/2017, indicated residents will not experience an avoidable reduction in range of motion. Residents with limited range of motion will receive treatment and services to increase and or prevent further decrease in range of motion. Residents with limited mobility will receive appropriate services, equipment, and assistance to maintain or improve mobility unless reduction in mobility is unavoidable.

Based on interview and record review the facility failed to ensure one of three sampled residents (Resident 1), who was receiving continuous oxygen therapy and was a smoker, was provided a safe environment and supervision as indicated in the plan of care and the facility's policies by allowing Resident 1 to have cigarettes and a lighter at bedside and smoke in his room. As a result, on 1/29/2022, around 5 pm, Resident 1 suffered [CONDITION(S)] to his face after lighting a cigarette in his room, while receiving oxygen. Resident 3 (Resident 1's roommate) was fearful for Resident 3's life. Findings: A review of Resident 1's Admission Record indicated the facility admitted Resident 1 on 1/10/2022, with diagnosis that included [CONDITION(S)] ([CONDITION(S)], a chronic lung disease that causes obstructed airflow and makes it difficult to breaths) with acute exacerbation (an increase in the severity of a disease or its signs and symptoms), dependence on supplemental oxygen (treatment in which a storage tank of oxygen or a machine called a compressor is used to give oxygen to people with breathing problems), [CONDITION(S)] (is a serious mental disorder in which people interpret reality abnormally), nicotine dependency (an addiction to tobacco products caused by nicotine), and muscle weakness (decrease in the strength in one or more muscles). A review of Resident 1's Care Plan for [CONDITION(S)] related to smoking initiated on 1/10/2022, included in the interventions identifying and eliminating sources of respiratory irritation such as cigarette smoke. A review of the Physician's Order for Resident 1, dated 1/10/2022, indicated to have Nicotine Patch (medication can help quit smoking) 24-hour, 21 milligram (mg) every 24 hours, apply one patch transdermal (a route of administration wherein active ingredients are delivered across through the skin) once a day for smoking cessation and remove the patch per schedule. A review of the History and Physical (H&P) for Resident 1, dated 1/11/2022, indicated Resident 1's skin was warm and dry. A review of the Skin/Wound Note for Resident 1, dated 1/11/2022, indicated the facility admitted Resident 1 from a general acute care hospital (GACH), body assessment initiated, resident with nasal canula, . right upper extremity with multiple skin discoloration . A review of the Physician's Order for Resident 1, dated 1/12/2022, indicated to give oxygen at 2 (two) liters per minute (L/min) via nasal cannula (consists of a lightweight tube which on one end splits into two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows) PRN (as necessary) DX (diagnosis) [CONDITION(S)]. A review of the Minimum Data Set (MDS - a standardized assessment and care-screening tool) for Resident 1, dated 1/17/2022, indicated the resident had moderate cognitive impairment (a condition in which people have more memory or thinking problems than other people their age). A review of the Medication Administration Record (MAR) for Resident 1 dated 1/2022, indicated the resident was administered the Nicotine Patch from 1/11/2022 through 1/29/2022. A review of the Health Status Note for Resident 1 dated 1/29/2022, indicated activity staff took Resident 1 to smoke on 1/29/2022 at 4:00 PM. The health status note indicated at on 1/29/2022 at 5:00 PM, Resident 3 called for help and LVN 1 noted Resident 1 was smoking in the room with oxygen cannula on. The health status note indicated Resident 1 face got burned . A review of Resident 1's EMS report dated 1/29/2022, indicated paramedics arrived at the facility on 1/29/2022 at 5:08 pm and found a male patient sitting in a nursing room with [CONDITION(S)] to his face near the nose, inside nose and top of nose. Patient denies shortness of breath but feels pain to his lower lip and feeling swelling in his nose. Patient was lighting cigarette while on oxygen via nasal cannula. A review of GACH 1 Emergency Department (ED) Progress Notes, dated 1/29/2022, indicated Resident 1 presents after a flash burn injury due to lighting a cigarette while he was on oxygen. The ED progress notes indicated Resident 1 had Partial-thickness (involving the two layers of the skin) burn to the lower lip, bilateral (both) malar areas (beneath the eye that forms the prominence of the cheek), and the tip of the nose. There is no evidence on exam of imminent airway compromise .Case discussed with burn center. Burn center advised for emergency department transfer of Resident 1 to GACH 2 .Patient beginning to feel anxious, was given a nicotine patch and oral [MEDICATION(S)] (medication used to treat anxiety). A review of Resident 1's Interdisciplinary Team (IDT - group of health care staff from different fields who are involved in the care of the resident) Notes, dated 2/1/2022, indicated on 1/29/2022, at about 5:00 pm Resident 1's roommate called for help. When the charge nurse arrived, the smell of cigarette pervaded the room. Resident 1 was observed with [CONDITION(S)] on the face with the oxygen nasal cannula still in Resident 1's nostrils. Resident 1 was alert and oriented with no signs or symptoms of respiratory distress. Emergency Medical Services (EMS, paramedics) was called, and Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1). On 2/1/2022 at 11:30 am, during an interview, the Activities Assistant (AA) stated the facility had five or six residents that smoked cigarettes. The AA stated the facility had smoking times and designated smoking location and staff escorted the residents to the smoking area. The AA stated she took Residents 1 and 2 out to smoke at around 3:30 pm on 1/29/2022. Resident 1 required assistance because he was on oxygen and was in a wheelchair and Resident 1 smoked two cigarettes during the smoke break. Resident 1 was back to his room at around 4:00 pm. The AA stated Resident 1's lighter and cigarettes were kept at the resident's bedside table. On 2/2/2022 at 12:49 pm, during an interview, the Activities Director (AD) stated the licensed nurses complete the smoking assessment once a resident is identified as a smoker. If the resident required assistance with smoking, the activities staff would assist the resident while smoking. Residents were not supposed to have lighters at bedside. The AD stated Resident 1 did not have a smoking assessment completed and was listed as a No for smoking on the initial assessment. The AD did not know how Resident 1 came to possess a lighter at the bedside. The AD stated the activities staff lights the cigarettes for the residents when residents go out to smoke. The AD stated the facility admitted Resident 1 on 1/10/2022, and AD could not remember when the facility determined Resident 1 was a smoker. On 2/1/2022 at 2:55 pm, during an interview, LVN 1 stated on 1/29/2022, between 4:50 pm and 5:00 pm she was near Resident 1's room passing medications when she heard Resident 3 yell for help because Resident 1 was smoking in the room. Upon entering Resident 1's room, LVN 1 observed Resident 1's face was dark in color and had facial [CONDITION(S)]. LVN 1 called for help, two staff came to assist the resident. LVN 1 stated paramedics were called and transferred Resident 1 to GACH 1. On 2/2/2022 at 1:15 pm, during an interview, the Director of Nursing (DON) stated Resident 1 was not a smoker upon admission and as his medical condition improved, the resident resumed smoking. The DON confirmed the licensed nurses did not complete a smoking assessment for Resident 1 once the facility became aware the resident started smoking again. The DON stated residents were not supposed to have lighters at bedside. On 2/2/2022 at 2:40 pm, during an interview, the Administrator stated a smoking assessment should have been completed for Resident 1 and residents were not allowed to keep lighters at bedside as indicated in the facility's smoking policy. The Administrator did not know when Resident 1 resumed smoking while in the facility. On 2/2/2022 at 3:15 pm, an interview with Resident 3 was conducted. Resident 3 was oriented to person, time, and place. Resident 3 stated on 1/28/2022, during the night, he smelled smoke in their room and informed nursing staff about Resident 1 was smoking in the room. Certified Nurse Assistant 1 (CNA 1) came into the room and took away Resident 1's cigarettes. Resident 3 stated on 1/29/2022, around 5:00 pm, he smelled smoke in their room, and he heard a loud sound, like a popping sound, he opened the privacy curtain and saw Resident 1 standing with a black colored face and he could smell burning. Resident 3 stated he asked Resident 1 if he was okay and then called for the nurse. Resident 3 stated LVN 1 came into the room and assisted Resident 1. Resident 3 stated that he was fearful for his life if the oxygen tank blew up. Resident 3 stated a visitor brought a black bag with contents in it for Resident 1 but was unsure exactly what was in the bag. On 3/4/2022 at 8:40 am, during a telephone interview, CNA 1 stated she worked the night of 1/28/2022 to 1/29/2022 and after midnight (1/29/2022) I was smelling cigarette smoke and noticed it was coming from Resident 1's room. CNA 1 stated she took the cigarettes from resident 1, kept them at the front desk, and informed everyone working that night shift. CNA 1 stated she reported the incident to the morning charge nurse. CNA 1 could not remember who the morning charge nurse was. CNA 1 stated she would have confiscated the lighter if she saw it. A review of the facility's policy and procedures (P&P) titled, Smoking Policy revised 7/2017, indicated This facility shall establish and maintain safe resident smoking practices. Prior to, and upon admission, residents shall be informed of the facility smoking policy, including designated smoking area, and the extent to which the facility can accommodate their smoking or nonsmoking preferences. Smoking is only permitted in designated resident smoking areas, which are located outside of the building . Oxygen use is prohibited in smoking area . Residents without independent (self-perform) smoking privileges may not have or keep any smoking articles, including cigarettes, tobacco, etc., except when they are under direct supervision .This facility maintains the right to confiscate smoking articles found in violation of our smoking policies. A review of the facility's P&P titled, Oxygen Administration revised 10/2010, indicated to Remove all potentially flammable items (e.g., oils, alcohol, smoking articles, etc.) from the immediate area where the oxygen is to be administered. A review of the facility's P&P titled Safety and Supervision of Residents Revised July 2017, indicated Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.

Based on interview and record review, the facility failed to ensure two staff assisted in transferring one of three sampled residents (Resident 3) from the chair to the bed using a Hoyer lift (mechanical lifting device). There was one staff involved in transferring Resident 3 to the bed using the Hoyer lift. The facility assessed Resident 3 as totally dependent (full staff performance every time) and needing two plus persons physical assist when it came to transfers (how resident moves between surfaces including to and from: bed, chair, and wheelchair). This deficient practice resulted in Resident 3 falling from the mechanical lift device and suffering from multiple back fractures on 2/15/20. Findings: A review of Resident 3's Admission Record, dated 3/4/20, indicated Resident 3 was originally admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 3's care plan, dated initiated on 8/23/16, indicated Resident 3 required two person assist for transfer with Hoyer lift using extra large sling. A review of Resident 3's Minimum Data Set (MDS - a comprehensive assessment and care planning tool), dated 12/5/19, indicated Resident 3 was cognitively intact (thought process). The MDS indicated Resident 3 was totally dependent and needing two plus persons physical assist when it came to transfers. A review of the Resident 3's Progress Notes, dated 2/15/20 at 8:30 a.m., indicated Registered Nurse (RN) 1 was notified by Certified Nursing Assistant (CNA) 4 that Resident 3 fell from a Hoyer lift (four feet) when the sling snapped. The progress notes indicated CNA 4 was trying to put Resident 3 back on the bed after a shower. The Progress Notes indicated RN 1 walked into the room and Resident 3 was on the floor. The Progress Notes indicated Resident 3 was complaining of lower back pain with pain scale of 10/10 (rating pain on a scale of 0 to 10, with zero meaning no pain and 10 meaning the worst possible pain). The Progress Notes indicated facility called and notified Medical Doctor (MD) 4 who ordered Resident 3 to be transferred out to the General Acute Care Hospital (GACH). A review of CNA 4's written statement, dated 2/15/20, indicated she was transferring Resident 3 from the chair to the bed when the feet part of the sling of the Hoyer Lift snapped causing Resident 3 to slide out of the sling and landed on his butt. A review of Resident 3's Nursing Home to Hospital Transfer Form, dated 2/15/20, indicated Resident 3 was transferred to the GACH due to a fall. A review of Resident 3's (CT) scan (sophisticated X-ray device that can reveal anatomic details of internal organs that cannot be seen in conventional X-ray) of the lumbar spine (five vertebral bodies (L1-L5) that extend from the lower [MEDICATION NAME] spine (chest) to the sacrum (bottom of the spine)), dated 2/15/20, indicated the following impression: 1. Acute comminuted bilateral anterior sacral ala fractures (breaks of the bone). 2. There are also acute appearing right L4 and L5 [MEDICATION NAME] process fractures (a break in one or more wing-like bones on the right and left side of each vertebra in the spine). A review of a physician's orders [REDACTED]. FYI (for your information) assess skin for any skin breakdown, redness, sore A review of Occupational Therapy Treatment Encounter Note(s), written by OT 1, dated 4/1/20, indicated, Back/spinal brace was fitted to patient while supine in bed . During an interview on 3/4/20 at 9:10 a.m., the Director of Nursing (DON) stated CNA 4 was transferring Resident 3 to the bed without any help using the Hoyer lift when the foot part of the Hoyer sling fell causing Resident 3 to fall and got severe fractures. The DON stated that staff were taught that Hoyer lift transfers needed 2 staff and not one staff. During an interview on 3/4/20 at 10:55 a.m., CNA 2 stated that two people were needed to transfer a resident when using the Hoyer lift. During an interview on 3/4/20 at 11:00 a.m., CNA 1 stated there should be two staff assisting when using the lifts. During an interview on 3/5/20 at 10:14 a.m. the Interim Administrator (IADM) stated CNA 4 used the Hoyer lift to move Resident 3 by herself. The IADM stated the facility policy requires two staff to use a Hoyer lift to move a resident. IADM stated there should have been two staff using the Hoyer lift to move Resident 3. During an interview on 4/14/20 at 2:45 p.m., Resident 3, who was lying in bed, stated there was only one staff helping in the transfer to his bed using the Hoyer lift when he slipped and fell . Resident 3 stated it was terrible and very painful. Resident 3 stated that when readmitted back to the facility, staff needed to weigh him every week for four weeks and it was just excruciating. Resident 3 stated that weighing was now once a month and was coming in a couple of months and he was dreading it. Resident 3 stated he was able to sleep at night for four to five hours but then the pain woke him up and he had to take a pain pill almost every four to five hours. Resident 3 stated he did not like taking medications generally and now he had one more pill to take. Resident 3 stated he did not have a surgery and the doctors told him that his fractures were going to take a very long time to heal. During an interview with MD 3 on 4/17/20 at 10:11 am, MD 3 stated, Yes, Resident 3's fractures are serious . Yes, he (Resident 3 ) needs occupational therapy . The fractures will take approximately six weeks to heal and Resident 3 has had significant pain. He is getting pain medication but not opiods . Yes, he is getting [MEDICATION NAME] (a pain medication) . I (MD 3)ordered him (Resident 3) a back brace for his (Resident 3's) comfort . (A backbrace stabilizes the bones of the spine to allow for greater back comfort) . A backbrace can cause skin irritation and skin breakdown so the nurses have to assess him (Resident 3) regularly for that. A review of the facility's policy and procedure titled, Lifting Machine, Using a Mechanical, revised on July 2017, indicated At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. Mechanical lifts may be used for tasks that require: a. Lifting a resident from the floor; b. Transferring a resident from bed to chair; c. Lateral transfers; d. Lifting limbs; e. Toileting or bathing; or f. Repositioning.

Based on observation, interview, and record review, the facility failed to have a functional pharmaceutical system that ensures accurate accountability of each resident's medication that affected four of 18 sample residents (5, 6, 8, 18) with a systems failure that could potentially affect all residents receiving medications. This includes the delivery and receipt of drugs, use of emergency supply kit (E-kit), use of Heparin multi dose vials, labeling of drugs, and documentation of medications given. Resident 8 would have received expired Heparin (vial expired November 1, 2012) if the Evaluator had not intervened. A reconciliation of records revealed Resident 8 had potentially received expired Heparin from November 1, 2012, to December 15, 2012. Also, Resident 8's Heparin vial had a manufacturer's expiration date of November 1, 2012, inconsistent with the attached pharmacy label expiration date of October 9, 2013. Resident 5, who had clostridium dificcile (stool infection), had two doses of Flagyl (December 14 and 15, 2012, at 2 a.m.) that were not accounted for as to where the medication came from. Additionally, Resident 5's Flagyl medication was delivered by the pharmacy to the facility on [DATE]. However, the facility staff could not locate the medications (bubble pack cards) until December 15, 2012, two days after delivery. Resident 18 had no record of Heparin supply delivered from September 1, 2012, to October 4, 2012, (34 days, 68 doses) of unaccounted supply. The record of medication given was inconsistent with the supply. Resident 6 had an order for [REDACTED]. The licensed nurse was documenting treatment was provided when there was no medication available. The deficient practices placed all residents receiving medications at risk for adverse side effects of the medication, medical complications, the resident not receiving the medication as ordered, and medication errors. A situation of immediate jeopardy was declared by the survey team on December 16, 2012, at 3 p.m. The facility's administrator and director of nurses (DON) were immediately notified of these serious findings and began corrective actions such as notification of the physician regarding medication errors for Resident 8, in servicing of staff, medication pass observation, and reassessment of current pharmacy systems. The Immediate Jeopardy was lifted on December 17, 2012, at 7 p.m., following the inspection of the medication cart, interview with staff and review of the facility's submitted allegation of removal of the IJ. This was reviewed with the administrator and the DON. The S/S was reduced to an F. Findings: a. According to the admission record Resident 8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) an assessment and care screening tool, dated November 23, 2012, indicated the resident's cognitive status for daily decision-making was severely impaired and was totally dependent on the staff for all activities of daily living. Resident 8 had a physician's orders [REDACTED]. On December 15, 2012, at 1:25 p.m., during the noon medication pass observation Licensed Vocational Nurse (LVN 3) withdrew one milliliter (ml) of clear liquid from the Heparin vial. During the inspection of the Heparin vial, the attached pharmacy label indicated Heparin Sodium 5,000 units per ml. was filled on October 9, 2012, quantity 90 of 90 ml and expires October 9, 2013. However, the Heparin vial indicated the LOT # 95-463-DK and the manufacturer's expiration date of November 1, 2012. There was a discrepancy on the attached pharmacy label which indicated that the Heparin vial would expire October 9, 2013. During the same observation, there was another vial with LOT # 95-463-DK that was also expired on November 1, 2012. The Heparin vial indicated that it was delivered by the pharmacy to the facility on [DATE], but it was incorporated with eight other vials of Heparin that were delivered by the pharmacy to the facility on [DATE], with different LOT # 20-205-DK with an expiration date of August 1, 2014. During an interview with the facility's pharmacy consultant on December 17, 2012, at 12 p.m., she stated the licensed nurses should use the earliest expiration date. She further stated that the practice of the pharmacy is to label the Heparin vials with an expiration date one year earlier than the manufacturer's expiration date. She was unable to explain why the two vials of Heparin had an earlier manufacturer's expiration date than the attached pharmacy label expiration date. b1. Also, on December 15, 2012, at 1:25 p.m., during the noon medication pass the bottom of the Heparin vial that LVN 3 used to withdrew the 1 ml Heparin, indicated that it was opened on December 10, 2012. On December 15, 2012, at 4 p.m., Registered Nurse (RN 1) verified that the heparin vial was a multi dose vial with 10 ml (10 doses) and there were 9 mls left in the vial on December 15, 2012, at 1:25 p.m. RN 1 stated one vial of Heparin would be good for 10 doses (three days and one dose for the next day), which should have been emptied December 13, 2012. RN 1 stated that licensed nurses should open and use one vial at a time for accuracy and/or accountability of each dosage given to the resident. However, during the inspection of the medication cart all of the Heparin vials for Resident 8 were not open. RN 1 was unable to explain the discrepancy on where the licensed nurses got the Heparin that was given to Resident 8 from December 10 to December 15, 2012. c. According to the admission record Resident 5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Assessment (MDS) an assessment and care screening tool, dated November 28, 2012, indicated the resident cognitive skills for daily decision-making was moderately impaired and required extensive assistance from the staff with activities of daily living. The resident had a physician's orders [REDACTED]. On December 15, 2012, at 8:55 a.m., during medication pass observation Licensed Vocational Nurse 2 (LVN 2) stated that she did not have the medication available. LVN 2 stated she had to get the Flagyl medication in the emergency supply kit for three consecutive days. During an interview with registered nurse (RN 2) supervisor on December 15, 2012, at 11:25 a.m., regarding the facility's procedure for using the emergency supply kit, she stated when the physician orders [REDACTED]. Then the licensed nurse who receives the order should call and fax the new order to the pharmacy and follow up to ensure the medication was delivered. She further stated that she called and was told by the pharmacy that the Flagyl for Resident 5 was delivered to the facility on [DATE]. However, from December 12 to December 15, 2012, LVN 2 removed the Flagyl from the emergency supply kit for Resident 5. There was no indication and or documented evidence the licensed nurses followed up with the pharmacy to locate the Flagyl medication. Also, RN 2 was unable to find the delivery receipt of Flagyl for December 13, 2012. The facility had no consistent system of record keeping for pharmacy delivery receipts to ensure accuracy of drug reconciliation for the safety of residents. A review of the Consolidated Delivery Sheets faxed by the pharmacy to the facility on [DATE], at 2:28 p.m. indicated the Flagyl 500 milligrams (mgs) 21 tablets was delivered to the facility and received by a licensed nurse on December 13, 2012, at 9 p.m. During an interview with RN 2 on December 15, 2012, at 3 p.m., she stated they had checked the medication cart and the medication room, and was unable to find the Flagyl medication that was delivered by the pharmacy to the facility on [DATE]. However, the licensed nurses had to use the emergency supply kit for three days to get the Flagyl medication, instead of calling and verifying with the pharmacy if the medication was delivered or not. On December 15, 2012, at 5:35 p.m., RN 2 provided three separate unused bubble pack cards of Flagyl for observation. RN 2 stated the bubble pack card was misplaced on the wrong "cart." A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] A review of the emergency supply kit log book with registered nurse (RN 1) from December 12 to 15, 2012, indicated seven yellow slips (pharmacy billing slip) of two tablets of Flagyl 250 mg were taken from the emergency kit on December 12 at 6 p.m., December 13, 2012, at 2 a.m., December 13, 2012, at 10 a.m., December 13, 2012, at 6:30 p.m., December 14, 2012, at 10 a.m., and December 14, 2012, at 6 p.m. The Flagyl that was signed/initialed as given on December 14, 2012, at 2 a.m., and December 15, 2012 at 2 a.m., had no record that it was taken from the emergency supply kit. On December 17, 2012, at 11:05 a.m., during an interview with the licensed vocational nurse (LVN 4) who initialed the MAR indicated [REDACTED]. LVN 4 stated he filled out the pharmacy billing slip. However, he was unable to explain what happened to the pharmacy billing slip to indicate that the two doses of Flagy medication were taken from the emergency supply kit. According to the facility policy and procedure titled "Emergency Drug Supply" dated January 2009, it stipulated the emergency drug supplies will NOT be used to provide doses for existing orders or to refill medications. The emergency drug supply will be opened to meet the needs of residents with new medication orders. The use of emergency drug supply will be recorded in the emergency drug supply logbook. An entry will be made in the emergency drug supply logbook whenever the individual break the seal. The nurse will fill out the billing slip found in the emergency drug supply and return it to the drug supply. The nurse will notify the pharmacy of the use of the emergency drug supply by facsimile or telephone and record the order on the pharmacy order sheet, including the use of the drug supply. At shift change the staff will observe and record the status of all emergency drug supplies. However, during inspection of the emergency supply kit logbook with the registered nurse (RN 1) and RN 2, there was no documented evidence that the facility documents whenever the emergency supply kit seal was broken. There was also no records when the pharmacy was notified that the emergency supply kit was opened, and there was no records the licensed nurses were checking the status of the emergency supply kit during shift change. d1. According to the admission record Resident 18 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) an assessment and care screening tool, dated November 21, 2012, indicated the resident cognitive status for daily decision-making was severely impaired and required extensive assistance from the staff with activities of daily living except eating. The resident had a physician's orders [REDACTED]. A review of the Consolidated Delivery Sheets indicated the following delivery of Heparin Sodium since Resident 18 was admitted to the facility: 1. July 7, 2012, Heparin Sodium 5,000units/ml = 30 ml (three vials). 2. July 24, 2012, Heparin Sodium 5,000units/ml = 30 ml (three vials). 3. August 17, 2012, Heparin Sodium 5,000units/ml = 30 ml (three vials). 4. October 5, 2012, Heparin Sodium 5,000units/ml = 30 ml (three vials). 5. October 10, 2012, Heparin Sodium 5,000units/ml = 30 ml (three vials). 6. November 12, 2012, Heparin Sodium 5,000units/ml = 30 ml (three vials). 7. December 5, 2012, Heparin Sodium 5,000units/ml = 30 ml (three vials). There was no documentation that the pharmacy delivered any Heparin from September 2012 to October 5, 2012. On December 16, 2012, at 6:25 p.m., during an interview with Registered Nurse 1 (RN 1) he stated he called the pharmacy and it was confirmed there was no Heparin delivered for Resident 18 from September 2012 to October 5, 2012. RN 1 also reviewed the emergency supply kit logbook and there was no documentation that Heparin was taken from the emergency supply kit. Concurrent review and calculation of the Heparin supply delivered by the pharmacy to the facility on [DATE], and the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. d2. Also, a review of Resident 18's current Heparin supply revealed the attached pharmacy label in a Ziploc bag indicated Heparin Sodium 5,000 units/ml in a 10 ml vial (30 of 30 ml, three vials), filled December 5, 2012 and had an expiration date of August 2014. During the investigation, there were still three Heparin vials left, two of the vials were closed and one vial had an open date of December 7, 2012. The physician's orders [REDACTED]. On December 17, 2012, at 4:35 p.m., during the drug reconciliation the director of nurses stated the Heparin vial that was opened on December 7, 2012, had approximately 2.5 ml left in the vial, which should have been completed December 12, 2012. The DON was unable to explain why the Heparin vial still had 2.5 ml, and what Heparin supply was used for Resident 18 from December 12 to 14, 2012, for approximately eight doses. e. According to the admission record Resident 6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident had a physician's orders [REDACTED]. The care plan dated December 13, 2012, indicated Resident 6 had rashes on her back. During treatment cart inspection on December 17, 2012, at 8:40 a.m., the attached pharmacy label indicated that the Nystatin cream was delivered December 15, 2012, even though the order was received December 13, 2012. In addition, the Nystatin tube had an open date of December 13, 2012, which was a discrepancy with the attached pharmacy label delivery date of December 15, 2012. During an interview with the licensed vocational nurse (LVN 7) on December 17, 2012, at 11 a.m., she stated she just signed/initialed the Treatment Administration Record (TAR) without providing the treatment to Resident 6 on December 13 through 15, 2012.

Based on observation, interview and record review, the facility failed to ensure that they were free of a medication error rate of greater than five percent (%). A morning medication pass observation with a subsequent noon medication pass observation on [DATE], revealed nine medication errors in a sample size of 52 opportunities for error resulting in a cumulative error rate of 15.78 % for four of 18 sampled residents (1,7,8,9), and one randomly selected resident (22). Included in the 15.78 % medication error rate were observations of significant medication errors. Resident 8 would have received expired [MEDICATION NAME] (blood thinner) (vial expired [DATE]) if the Evaluator had not intervened. A reconciliation of records revealed Resident 8 had potentially received expired [MEDICATION NAME] from [DATE] to [DATE]. Resident 7 was given Reyataz (used to treat human immunodeficiency virus ,[MEDICAL CONDITION].) 300 milligrams at the wrong time, and without food; the [MEDICATION NAME] (prevention [MEDICAL CONDITION].and Vitamin C medications were omitted; and the wrong dose of Omega [DATE] (supplement used to treat high cholesterol) 500 mg was given instead of 1000 mg. Resident 9's [MEDICATION NAME] (used to promote good bacteria in the intestine) was omitted (not given). A situation of immediate jeopardy was declared by the survey team on [DATE], at 3 p.m. The facility's administrator and director of nurses (DON) were immediately notified of these serious findings and began corrective actions such as notification of the physician regarding medication errors for Resident 8, in servicing of staff, medication pass observation, and reassessment of current pharmacy systems. The Immediate Jeopardy was lifted on [DATE], at 7 p.m., following the inspection of the medication cart, interview with staff and review of the facility's submitted allegation of removal of the IJ. This was reviewed with the administrator and the DON. The S/S was reduced to an E. Findings: a. On [DATE], at 1:25 p.m., during the noon medication pass observation for Resident 8, Licensed Vocational Nurse 3 (LVN 3) cleaned the vial of [MEDICATION NAME] and withdrew one milliliter (ml) of clear liquid from the [MEDICATION NAME] vial. During the inspection of the [MEDICATION NAME] vial, the attached pharmacy label indicated [MEDICATION NAME] Sodium 5,000 units per ml. was delivered [DATE], quantity 90 of 90 ml (9 vials), expired [DATE]. The label attached to the vial indicated that it was opened [DATE]. Further inspection of the [MEDICATION NAME] vial indicated there was 10 ml in a vial for multi dose use with 8 ml left in the vial. The [MEDICATION NAME] vial had the LOT # ,[DATE]-DK and the manufacturer's expiration date was [DATE]. LVN 3 was waiting for the evaluator to return the [MEDICATION NAME] vial, with a 1 ml syringe in her hand filled with the expired [MEDICATION NAME]. The Evaluator asked LVN 3 if she really wanted to administer the [MEDICATION NAME]. LVN 3 paused and the Evaluator pointed to the manufacturer's expiration date on the vial. LVN 3 stated the facility does not go by the manufacturer's expiration date ([DATE]). LVN 3 further stated while checking the vial that they go by the attached pharmacy label expiration date ([DATE]). The Evaluator asked LVN 3 if she was sure of her answer, and LVN 3 paused and stated the [MEDICATION NAME] vial was expired. LVN 3 was asked if she had used the [MEDICATION NAME] vial before and she stated that she had used it to give the morning dose to the resident. A review of Resident 8's physician's orders [REDACTED]. During an interview with LVN 3 on [DATE], at 2:30 p.m., she stated that she had used the same [MEDICATION NAME] vial when she administered the 9 a.m. dose of [MEDICATION NAME] to Resident 8. She further stated that she read the expiration attached on the pharmacy label not the manufacturer's expiration date on the vial. b. On [DATE], at 9:35 a.m., during morning medication pass observation of Resident 7, Licensed Vocational Nurse (LVN 1) poured/prepared and administered the following medications: [REDACTED] 1. [MEDICATION NAME] 10 milligrams (mg) one tablet 2. Reyataz 300 mg one capsule 3. Multivitamin with mineral one tablet 4. Fish Oil 500 mg one tablet 5. [MEDICATION NAME] 0.025% nose spray 6. [MEDICATION NAME] 0.5 mg tablet Subsequent review of the clinical record on [DATE], revealed a physician's orders [REDACTED]. There was also a physician's orders [REDACTED]. Another physician's orders [REDACTED]. During medication pass observation a wrong dose of 500 mg was administered to Resident 7, instead of 1000 mg. On [DATE], there was an order for [REDACTED]. On [DATE], at 12 p.m., during an interview with LVN 1 while reviewing the resident's medication orders and the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. c. On [DATE], at 10:50 a.m., during the medication pass observation, Licensed Vocational Nurse (LVN 2) poured/prepared and administered the following medications to Resident 9: 1. [MEDICATION NAME] 200 mg one tablet 2. [MEDICATION NAME] 10 mg one tablet 3. Calcitrol 0.5 mg one tablet 4. Multivitamin one tablet 5. Vitamin C 500 mg one tablet 6. [MEDICATION NAME] 325 mg one tablet 7. [MEDICATION NAME] 25 mg one tablet 8. Artificial tear one drop each eye 9. [MEDICATION NAME] 2.5 mg/3 ml one unit A review of the resident physician's orders [REDACTED]. According to the facility policy and procedure titled "Guidelines for Medication Administration" dated [DATE], indicated to observed the right resident, right drug, right dose, right time and right route. Read the label on the medication container three times before administering the medication. Cross refer to F333: Residents are free of any significant medication errors Cross refer to F425: Pharmaceutical Services d. On [DATE], at 10 a.m. and 1:35 p.m., during the medication pass observations, the following was noted: Licensed Vocational Nurse 12 (LVN 12) was observed to prepare medications for Resident 1. The medications were [MEDICATION NAME] (50mg/5ml) 25 ml, MVI with minerals 30 ml, Vitamin C 5 ml, Zinc Sulfate 220 mg, Metropolol 25 mg, Prostat 40 ml and Artificial Tears one (1) drop on each eyes. The above medications were administered to the resident via gastrostomy ([DEVICE]) tube except the eye drop. A review of the resident's clinical record revealed a physician's order [REDACTED]. There was a physician order [REDACTED]. These medications were not observed administered during the medication pass observation. During a concurrent interview with LVN 12, she stated she was not aware the cranberry pill was not administered. e. Licensed Vocational Nurse 13 (LVN 13) was observed to prepare medications for Resident 22. The medications were [MEDICATION NAME] solution 15 ml and Artificial Tears four (4) drops on each eye. The LVN 13 applied four (4) drops of the Artificial Tear on the right eye one drop after the other. She waited for five (5) minutes and applied four (4) drops of the medication on the left eye without waiting in between drops.. A review of the facility's policy on Eye Drop Medication stipulated to wait 3 to 5 minutes between administrations of all eye drops, including multiple drops of the same medication.

Based on observation, interview and record review, the facility failed to ensure that they were free of a medication error rate of greater than five percent (%). A morning medication pass observation with a subsequent noon medication pass observation on [DATE], revealed nine medication errors in a sample size of 52 opportunities for error resulting in a cumulative error rate of 15.78 % for four of 18 sampled residents (1,7,8,9), and one randomly selected resident (22). Included in the 15.78 % medication error rate were observations of significant medication errors. Resident 8 would have received expired [MEDICATION NAME] (blood thinner) (vial expired [DATE]) if the Evaluator had not intervened. A reconciliation of records revealed Resident 8 had potentially received expired [MEDICATION NAME] from [DATE] to [DATE]. Resident 7 was given Reyataz (used to treat human immunodeficiency virus ,[MEDICAL CONDITION].) 300 milligrams at the wrong time, and without food; the [MEDICATION NAME] (prevention [MEDICAL CONDITION].and Vitamin C medications were omitted; and the wrong dose of Omega [DATE] (supplement used to treat high cholesterol) 500 mg was given instead of 1000 mg. Resident 9's [MEDICATION NAME] (used to promote good bacteria in the intestine) was omitted (not given). A situation of immediate jeopardy was declared by the survey team on [DATE], at 3 p.m. The facility's administrator and director of nurses (DON) were immediately notified of these serious findings and began corrective actions such as notification of the physician regarding medication errors for Resident 8, in servicing of staff, medication pass observation, and reassessment of current pharmacy systems. The Immediate Jeopardy was lifted on [DATE], at 7 p.m., following the inspection of the medication cart, interview with staff and review of the facility's submitted allegation of removal of the IJ. This was reviewed with the administrator and the DON. The S/S was reduced to an E. Findings: a. On [DATE], at 1:25 p.m., during the noon medication pass observation for Resident 8, Licensed Vocational Nurse 3 (LVN 3) cleaned the vial of [MEDICATION NAME] and withdrew one milliliter (ml) of clear liquid from the [MEDICATION NAME] vial. During the inspection of the [MEDICATION NAME] vial, the attached pharmacy label indicated [MEDICATION NAME] Sodium 5,000 units per ml. was delivered [DATE], quantity 90 of 90 ml (9 vials), expired [DATE]. The label attached to the vial indicated that it was opened [DATE]. Further inspection of the [MEDICATION NAME] vial indicated there was 10 ml in a vial for multi dose use with 8 ml left in the vial. The [MEDICATION NAME] vial had the LOT # ,[DATE]-DK and the manufacturer's expiration date was [DATE]. LVN 3 was waiting for the evaluator to return the [MEDICATION NAME] vial, with a 1 ml syringe in her hand filled with the expired [MEDICATION NAME]. The Evaluator asked LVN 3 if she really wanted to administer the [MEDICATION NAME]. LVN 3 paused and the Evaluator pointed to the manufacturer's expiration date on the vial. LVN 3 stated the facility does not go by the manufacturer's expiration date ([DATE]). LVN 3 further stated while checking the vial that they go by the attached pharmacy label expiration date ([DATE]). The Evaluator asked LVN 3 if she was sure of her answer, and LVN 3 paused and stated the [MEDICATION NAME] vial was expired. LVN 3 was asked if she had used the [MEDICATION NAME] vial before and she stated that she had used it to give the morning dose to the resident. A review of Resident 8's physician's orders [REDACTED]. During an interview with LVN 3 on [DATE], at 2:30 p.m., she stated that she had used the same [MEDICATION NAME] vial when she administered the 9 a.m. dose of [MEDICATION NAME] to Resident 8. She further stated that she read the expiration attached on the pharmacy label not the manufacturer's expiration date on the vial. b. On [DATE], at 9:35 a.m., during morning medication pass observation of Resident 7, Licensed Vocational Nurse (LVN 1) poured/prepared and administered the following medications: [REDACTED] 1. [MEDICATION NAME] 10 milligrams (mg) one tablet 2. Reyataz 300 mg one capsule 3. Multivitamin with mineral one tablet 4. Fish Oil 500 mg one tablet 5. [MEDICATION NAME] 0.025% nose spray 6. [MEDICATION NAME] 0.5 mg tablet Subsequent review of the clinical record on [DATE], revealed a physician's orders [REDACTED]. There was also a physician's orders [REDACTED]. Another physician's orders [REDACTED]. During medication pass observation a wrong dose of 500 mg was administered to Resident 7, instead of 1000 mg. On [DATE], there was an order for [REDACTED]. On [DATE], at 12 p.m., during an interview with LVN 1 while reviewing the resident's medication orders and the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. c. On [DATE], at 10:50 a.m., during the medication pass observation, Licensed Vocational Nurse (LVN 2) poured/prepared and administered the following medications to Resident 9: 1. [MEDICATION NAME] 200 mg one tablet 2. [MEDICATION NAME] 10 mg one tablet 3. Calcitrol 0.5 mg one tablet 4. Multivitamin one tablet 5. Vitamin C 500 mg one tablet 6. [MEDICATION NAME] 325 mg one tablet 7. [MEDICATION NAME] 25 mg one tablet 8. Artificial tear one drop each eye 9. [MEDICATION NAME] 2.5 mg/3 ml one unit A review of the resident physician's orders [REDACTED]. According to the facility policy and procedure titled "Guidelines for Medication Administration" dated [DATE], indicated to observed the right resident, right drug, right dose, right time and right route. Read the label on the medication container three times before administering the medication. Cross refer to F333: Residents are free of any significant medication errors Cross refer to F425: Pharmaceutical Services